Intro to Nursing Exam #2
The nurse is caring for a patient who has undergone a nephrectomy. The nurse documents the nursing care provided to the patient. Which interventions are written accurately? Select all that apply.
7:00 AM preprandial blood sugar level = 120 mg/dL 6:00 AM urine output = 800 mL; straw-colored urine, no clots
The nurse is assessing the character of a patient's migraine headache and asks, "Do you feel nauseated when you have a headache?" "Yes," the patient responds. Which type of finding is nausea?
A concomitant symptom
The nurse is planning a discharge for a patient. The nurse understands that the plan is designed based on the patient's activities of daily living (ADL). What factors should the nurse consider when making the plan? Select all that apply.
A paralyzed patient will need permanent assistance for ADLs. The patient should be encouraged to participate in ADLs The family members should be allowed to assist the patient.
Which patient is more prone to ulcer formation on the skin?
A patient using moisturizers
A goal describes a desired change in a patient's condition or behavior. For which patient is a short-term goal appropriate?
A patient who has acute pain related to incisional trauma
A patient is diagnosed with urinary stress incontinence. The nurse identifies it as which type of diagnosis?
Actual diagnosis
What should be the priority nursing intervention in a patient who has recently undergone a knee surgery?
Administering analgesics as prescribed to the patient
A patient develops skin rashes and hives after administration of penicillin. What is this phenomenon?
Adverse reaction
A night shift nurse has taken over for the nurse from the previous shift. There are four new patients, and the nurse needs to interview them to complete the nursing histories. When should the nurse plan to interview these patients?
After reviewing the information given in the change-of-shift report
The nurse is going through biographical information collected by the admitting office staff. What patient information is usually included in the biographical information? Select all that apply.
Age Occupation Martial status Health care insurance status
A patient who is cognitively impaired and has dementia requires hygiene care. The patient often displays aggressive behavior, such as screaming and hitting during the bath. Which techniques would make the bathing experience less stressful for both the nurse and the patient? Select all that apply.
Allow the patient to perform as much of the care as possible. Try an alternative to traditional bathing, such as the bag bath.
The nurse finds that a patient who had radical prostatectomy has incision pain, fever, and nausea. Based on the findings, the nurse concludes that the patient has infection at the surgical site. Which critical thinking skill has the nurse applied?
Analysis
The nurse is preparing a care plan for a patient who has a pressure ulcer on the coccyx. Which part of the plan is included to provide comfort to the patient?
Applying a moisture barrier ointment over the ulcer
The nurse is caring for a patient who weighs 220 pounds and is immobilized. The nurse wants to reposition the patient and transfer him to a chair. What is the appropriate action required of the nurse?
Ask for additional nurses and lift when help is available.
The nurse caring for a patient with pneumonia sits the patient up in bed and suctions his airway. After suctioning, the patient describes some discomfort in his abdomen. The nurse auscultates the patient's lung sounds and gives him a glass of water. Which option is an evaluative measure used by the nurse?
Auscultating the lung sounds
During an interview, a patient tells the nurse that he used to consume alcohol, smoke cigarettes, and take drugs. The nurse says, "I understand. Go on." This encourages the patient to share more about his or her habits and health problems. What technique of communication is the nurse using?
Back channeling
The student nurse is assigned to check the blood pressure of a patient. The student refers to the manual before checking the blood pressure. Which level of thinking does this illustrate?
Basic
Which action performed by the nurse is inappropriate while implementing care to patients in a health care facility?
Being judgmental and confident while providing care
Which sign is an early indication of pressure that resolves without tissue loss if the pressure is eliminated?
Blanchable erythema
Understand and apply nutrients that assist in wound healing
Calories: fuel for cell energy "protein protection" Protein: fibroplasia, angiogenesis, collagen formation and wound remodeling, immune function Vitamin C: collagen synthesis, capillary wall integrity, fibroblast function, immunological function, antioxidant Vitamin A: epithelialization, wound closure, inflammatory response, angiogenesis, collagen formation Zinc: collagen formation, protein synthesis, cell membrane and host defense Fluid: essential fluid environment for all cell function
The registered nurse is overseeing a nursing student who is providing a dressing change to a patient who had a cesarean section. Which nursing action indicates a need for further learning?
Choosing a dressing that keeps the periwound moist
Which action by the nurse indicates the application of self-regulation skill in clinical practice?
Choosing an alternative way based on experience while caring for a patient to achieve better outcomes
When cleaning a wound, which action is incorrect?
Cleaning from the surrounding skin to the site of incision
Before consulting with a physician about a patient's need for urinary catheterization, the nurse considers the fact that the patient has urinary retention and has been unable to void on her own. The nurse knows that evidence for alternative measures to promote voiding exists, but none has been effective, and that before surgery the patient was voiding normally. This scenario is an example of which implementation skill?
Cognitive
Nursing interventions have different categories. Which nursing intervention is an interdependent intervention?
Collaborative intervention
Nursing intervention plays a vital role in achieving desired outcomes. What are the categories of nursing interventions? Select all that apply.
Collaborative interventions Nurse-initiated interventions Physician-initiated interventions
Which actions should the nurse perform when asked to administer a procedure with which she is unfamiliar? Select all that apply.
Collect all equipment necessary for the procedure. Seek information about the procedure. Get help from a nurse experienced in the procedure.
The nurse is in charge of performing the indirect care activities of the hospital. Which is an activity the nurse performs?
Collecting and transporting labeled specimens
The registered nurse is overseeing a nursing student who is collecting samples of wound drainage for culture. Which nursing action indicates a need for further learning?
Collecting wound culture samples from old drainage
A patient on a surgical unit develops sudden shortness of breath and a drop in blood pressure. The staff responds, but the patient dies 30 minutes later. The manager of the nursing unit calls a meeting of the nursing staff involved in the emergency response. The staff discusses what occurred over the 30-minute time frame, the actions taken, and whether other steps should have been implemented. In this situation, what are the nurses doing?
Conducting reflective practice
While assessing a patient, the nurse finds maceration on the skin. What could be the reason for this condition?
Constant exposure to moisture
The nurse checks a physician's order and notes that a new medication was ordered. The nurse is unfamiliar with the medication. The nurse's colleague explains that the medication is an anticoagulant used for postoperative patients with risk for blood clots. Before giving the medication, what is the nurse's best action?
Consult with a pharmacist to obtain knowledge about the purpose of the drug, the action, and the potential side effects.
The nurse is caring for a patient who has sustained a knee injury during a football game. The knee requires arthroplasty. The nurse finds that the patient is anxious about his ability to play after the surgery. The nurse determines the patient has anxiety and selects it as a diagnostic label; the nurse clusters its defining characteristics. The goal is for the patient to express acceptance of his health status by the day of discharge. Which interventions performed by the nurse are collaborative interventions? Select all that apply.
Consulting with a physiotherapist for postoperative exercises Consulting with the home health department to ensure the patient will have home health visits Consulting with the unit discharge coordinator who will help the patient plan for his return home
An 86-year-old patient visits the primary health care provider with a complaint of dry and itchy skin. What could be the cause of this condition?
Decreased production of lubricating substances
Which condition is caused by tooth decay?
Dental caries
The nurse is assessing a diabetic patient using Gordon's model of functional health patterns. Which pattern is not a functional pattern in Gordon's model?
Dependence-independence pattern
The primary healthcare provider prescribes interventions to the nurse to treat the medical diagnosis of the patient. To which category does such an intervention belong?
Dependent nursing interventions
Which condition impairs the healing function of skin?
Diabetes mellitus
The nurse talks with a patient who lost a sister 2 weeks ago. The patient is unable to sleep, feels very fatigued during the day, and is having trouble at work. The nurse asks the patient to clarify the type of trouble. The patient explains she can't concentrate or even solve simple problems. The nurse records the results of the assessment, describing the patient as having ineffective coping. Of what is this is an example?
Diagnostic reasoning
Which will help the nurse apply critical thinking skills in the day-to-day routine in an acute care setting? Select all that apply.
Discipline Responsibility Perseverance
A patient has a nursing diagnosis of immobility secondary to a fractured ankle. As a part of the care plan, the nurse plans to assist the patient to walk and provides instruction on the use of crutches. Later, the nurse finds that the patient is already able to walk with the crutches. What should the nurse do now?
Discontinue the current interventions and develop new ones.
The nurse is interviewing a patient on admission. Which questions from the nurse are examples of closed-ended questions? Select all that apply.
Do you have pain now? You have a severe headache, right? You are frightened that the diagnosis will be cancer, aren't you?
Which is characteristic of abnormal healing of a primary wound?
Drainage for more than 3 days after closure
The nurse is preparing for change-of-shift rounds with the nurse who will assume care for his or her patients. Which statements or actions by the nurse are characteristics of ineffective hand-off communication?
During walking rounds, the nurse talks about the problem the patient care technicians created by not assisting the patient to ambulate.
Which nursing interventions fall under the category of nurse-initiated interventions? Select all that apply.
Elevating an edematous extremity Repositioning the patient to relieve pain Informing about the side effects of medications
Which interventions can be classified as nurse-initiated interventions? Select all that apply.
Elevating an edematous extremity Repositioning the patient to achieve pain relief Instructing a patient about the effects of medications
The nurse is caring for a patient who has an edematous right leg. Which actions performed for the patient are nurse-initiated interventions? Select all that apply.
Elevating the edematous leg Repositioning the patient to achieve pain relief
A patient is admitted to the hospital for severe dehydration. The nurse asks the patient about bowel movements, urine output, and sweating. On the basis of Gordon's functional health patterns, which pattern is the nurse assessing?
Elimination pattern
Under the supervision of the registered nurse, the nursing student is repositioning a patient to reduce the risk of pressure ulcers. Which nursing action indicates a need for further learning?
Encouraging the patient to sit on a donut-shaped cushion
In which part of the skin do the normal flora reside?
Epidermis
Which errors may occur when the nurse makes the nursing diagnosis prior to grouping all data?
Errors in data clustering
A patient complains of pain when swallowing solid food. The nurse asks the patient if he or she has a history of substance abuse that has caused this pain. What kind of diagnostic error does the nurse make in this scenario?
Errors in data collection
What is the measurable criterion used to evaluate goal achievement?
Expected outcome
A second-year nursing student works in a surgical unit. A 56-year-old male patient admitted to the unit underwent a prostatectomy. The patient expresses to the nursing student that he is experiencing some pain and discomfort. The nursing student examines the patient's wound. The patient also tells the nurse that another nurse visited him a while ago but was rude and did not pay any attention to him. The student nurse apologizes to the patient and ensures that the patient's needs are fulfilled. The student speaks to the co-worker and manages the situation. Which attitude for critical thinking did the nursing student display here?
Fairness
The nurse is assessing a patient with bowel infection secondary to a colostomy. During the assessment, the nurse learns that the patient has not followed the care recommendations received when the patient was discharged from the hospital. Which critical thinking attitudes are appropriate for the nurse to exhibit when dealing with this patient? Select all that apply.
Fairness Integrity Confidence
The nurse wants to experiment with a new intervention on a patient. How should the nurse confirm the effectiveness of this intervention in an ethical manner? Select all that apply.
Follow evidence-based practice. Focus on the patient's values and beliefs related to the new intervention.
The nurse assesses a patient who comes to the pulmonary clinic: "I see that it's been over 6 months since you've been in, but your appointment was for every 2 months. Tell me about that. Also, I see from your last visit that the doctor recommended routine exercise. Can you tell me how successful you have been following this plan?" The nurse's assessment covers which of Gordon's functional health patterns?
Health perception and health management pattern
A group of nurses is organizing an educational session to teach the population of a particular community about the roots of cardiovascular disease and its impact on the human body. Which type of nursing diagnosis is being followed in this scenario?
Health promotion nursing diagnosis
What is a clinical judgment that concerns motivation and desire to increase well-being and actualize human health potential?
Health promotion nursing diagnosis
The nurse is assessing a patient with gastroenteritis. Which data collected by the nurse are objective data? Select all that apply.
Hemoglobin of 11.2 g/dL Elevated white blood cell count (WBC) Axillary temperature of 98.6° F
The student nurse uses the scientific method when doing a research project, which is required to obtain a graduate degree. Arrange the steps of the scientific method in the correct order.
Identification of the problem Collection of data Formulation of a hypothesis Testing the question or hypothesis Evaluation of the test or study results
Which is an example of an interpreting error in nursing diagnostics?
Inaccurate understanding of cues
A nursing student is learning how to design a care plan for patients in community-based settings. Which functions should the nursing student include in his or her care plan? Select all that apply.
Include his or her evaluation of expected outcomes. Educate the patient about necessary care techniques. Teach the family to integrate care within family activities.
What is the reason for the development of acne in adolescents?
Increased inflammation of sebaceous glands
Which components can restrict the student nurse's ability to move from a basic level to a complex level of critical thinking? Select all that apply.
Inexperience Inflexible attitude Weak competency
Dependent nursing requires a primary healthcare provider's order. What are examples of dependent nursing interventions? Select all that apply.
Inserting a Foley catheter Dressing a surgical incision wound Administering an intravenous drug
A patient is admitted to the hospital with a diagnosis of inguinal hernia. The nurse performs a comprehensive nursing assessment. What is the purpose of this activity? Select all that apply.
Interpret and validate the data collected. Establish a database about the patient's needs and health problems. Collect data with which to plan and evaluate care.
A patient with limited mobility develops a sacral pressure ulcer. Which nursing interventions are appropriate for reducing the risk for infection? Select all that apply.
Irrigating and cleansing the wound with saline twice a day Packing the open wound with antibiotic solution-moistened gauze
Which pressure ulcer site is found immediately distal to the buttock?
Ischium
What is the benefit of an accurate nursing diagnosis?
It helps ensure effective and efficient nursing interventions.
Setting a time frame for outcomes of care serves which purpose?
It indicates when the patient is expected to respond in the desired manner.
The nurse asks a patient how she feels about her impending surgery for breast cancer. Before the discussion, the nurse reviewed the textbook description of loss and grief and therapeutic communication principles. Which critical thinking component did the nurse use while reviewing the literature?
Knowledge application
Which support surface is useful for treating and preventing pulmonary, venous stasis, and urinary complications associated with immobility?
Lateral rotation surface
The nurse is caring for a patient who has sustained a knee injury during a football game. The knee requires arthroplasty. The nurse finds that the patient is anxious about his ability to play after the surgery. The nurse determines the patient has anxiety and selects it as a diagnostic label; the nurse clusters its defining characteristics. The goal is for the patient to express acceptance of his health status by the day of discharge. Which nurse-initiated interventions should the nurse perform to achieve the goal? Select all that apply.
Listen attentively to the patient. Use a calm and reassuring approach. Provide factual information regarding the recovery.
A patient tells the night-shift nurse that the day-shift nurse did not administer pain medications. As a critical thinker, which action should the nurse take?
Listen to the patient but also confirm with the day-shift nurse.
What is the name of the crescent-shaped white area present in the nail body?
Lunula
Which blood cells are known as garbage cells? 1
Macrophages
A group of nursing students is being taught to avoid errors in writing nursing interventions. Which statements are correctly stated nursing interventions? Select all that apply.
Measure blood glucose before each meal: 7:00 AM, 11:00 AM, and 5:00 PM. Turn the patient every 2 hours from supine to prone to right side.
An elderly debilitated patient is confined to bed. The patient has reduced libido, is unable to eat, and is incontinent of urine. Which intervention would be the priority for this patient?
Measures to improve skin integrity
The nurse is caring for a 50-year-old patient. The patient has had the gall bladder removed, and it is the second postoperative day. The nurse finds that the patient is uncomfortable and in pain. After collecting data from the patient, the nurse examines the patient and collects subjective as well as objective data. Which data should the nurse categorize as objective data? Select all that apply.
Minimal oozing at the incision site Fever of 104o F
A 43-year-old women who is obese reports frequent burning and numbness of the feet. The patient also has foot pain when standing for a long time. Which condition would the nurse suspect?
Morton's neuroma
What is a common foot problem that affects middle-aged women?
Morton's neuroma
A mother finds her 26-year-old daughter unconscious at home. Her daughter is breathing and regains consciousness but appears confused. She takes her to the hospital along with her 1-year-old granddaughter. Who would be the primary source of information in this case?
Mother
The nurse is preparing a nursing care plan for a patient with a hernia. What are the basic concepts that a nursing care plan should emphasize? Select all that apply.
Nursing diagnoses Specific nursing interventions Goals and expected outcomes
Following an initial assessment of a patient, the nurse is charting the nursing goals and expected patient outcomes. What characteristics of nursing goals and expected outcomes should the nurse keep in mind when charting? Select all that apply.
Observable Measurable Patient centered
A patient with diabetes has come to the nurse with symptoms suggestive of hypoglycemia. Which would be the first appropriate nursing intervention?
Offer foods rich in glucose.
Which type of question is used when starting the assessment of a patient?
Open-ended
The nurse tries to apply the concept of critical thinking in clinical practice. Which are characteristics of critical thinking? Select all that apply.
Open-mindedness, continual inquiry, and perseverance. Recognition of an issue, analysis of related information, and formation of conclusions. Imagination and exploration of alternatives, consideration of ethical principles, and informed decision making.
Which symptom often changes a patient's gait?
Pain
While assessing a patient, the nurse observes that the patient has a dry cornea. What may be the cause of this condition?
Paralysis of the trigeminal nerve
A patient has been in the hospital for 2 days because of newly diagnosed diabetes. His medical condition is unstable, and the medical staff is having difficulty controlling his blood sugar. The physician expects that the patient will remain hospitalized at least 3 more days. The nurse identifies one nursing diagnosis as deficient knowledge regarding insulin administration related to inexperience with disease management. Which patient care goals are long-term goals?
Patient will achieve glucose control.
Which expected outcome is written in measurable terms?
Patient will report pain acuity less than 4 on a scale of 0 to 10.
A patient is being discharged today. In preparation, the nurse removes the intravenous (IV) line from the right arm and documents that the site was clean and dry with no signs of redness or tenderness. On discharge, the nurse reviews the care plan for goals met. Which goals can be evaluated with what you know about this patient?
Patient's IV site will remain free of phlebitis.
A patient is recovering from surgery for removal of an ovarian tumor. It is 1 day after her surgery. Because she has an abdominal incision, dressing, and a history of diabetes, the nurse identified a risk of the patient contracting an infection. Which option is an appropriate goal statement for the diagnosis?
Patient's wound will remain free of infection by discharge.
Which structure helps to hold a tooth firmly in place?
Periodontal membrane
The nurse is preparing to administer an intravenous (IV) antibiotic to a patient who has been admitted to the hospital with pneumonia. What should the nurse do when arranging supplies and equipment for this nursing procedure? Select all that apply.
Place the supplies in a convenient location. Check whether the equipment is working properly. Decide what supplies will be needed for the procedure
According to the Braden Scale for predicting pressure ulcer risk, which factor most puts the patient at risk for developing a pressure ulcer?
Poor nutrition
The nurse administers a polio vaccine to an infant. What is this level of prevention called?
Primary
The nurse is talking with a patient who is visiting a neighborhood health clinic. The patient came to the clinic for repeated symptoms of a sinus infection. During their discussion, the nurse checks the patient's medical record and realizes that he is due for a tetanus shot. Administering the shot is an example of what type of preventative intervention?
Primary
Understand and apply the differences between healing by primary, secondary and tertiary intention
Primary- Wound that is closed- stapled or sutured Secondary- Wound edges not approximated or closed, ex. Pressure ulcers Tertiary- Wound is left open for several days and then approximated- ex, infection
Following an assessment, the nurse is formulating a nursing diagnosis using the PES format. What does the P in the acronym PES stand for?
Problem
The nurse checks a patient's intravenous (IV) line in his right arm and sees inflammation where the catheter enters the skin. The nurse uses a finger to apply light pressure (i.e., palpation) just above the IV site. The patient tells the nurse the area is tender. The nurse checks to see if the IV line is running at the correct rate. This is an example of what type of assessment?
Problem focused
What is the role of vitamin A in wound healing?
Promotes wound closure
The nurse enters a patient's room, and the patient asks if he can get out of bed and transfer to a chair. The nurse takes precautions to use safe patient handling techniques and transfers the patient. Which type of physical care technique is this an example of?
Protecting a patient from injury
A pregnant patient with epilepsy was prescribed phenytoin, which is teratogenic. Which critical action should the nurse take?
Question the prescription.
A patient signals the nurse by turning on the call light. The nurse enters the room and finds the patient's drainage tube disconnected, 100 mL of fluid in the intravenous (IV) line, and the patient asking to be turned. Which action does the nurse perform first?
Reconnect the drainage tubing.
A patient is admitted to the hospital for abdominal pain. The patient is instructed not to eat or drink anything by mouth for the next 24 hours. The patient also complains of nausea and vomiting. The healthcare provider orders an antiemetic drug for the patient. Following the administration of the drug, the patient develops adverse reactions. What should the nurse do? Select all that apply.
Record the reaction. Stop further administration of the drug. Call the healthcare provider.
Which method should the student nurse use to reflect on and analyze the student's own thoughts, actions, and knowledge?
Reflective journaling
Which term describes data that appear to show some type of patterned relationship with a nursing diagnosis?
Related factors
A patient with arthritis informs the nurse that the knee pain is worse during rest and while climbing stairs. The pain improves when the patient is walking. The patient takes ibuprofen and acetaminophen for pain relief. What are the precipitating factors in this case? Select all that apply.
Rest Climbing up the stairs
The nurse is delivering a lecture on "Health and Hygiene" to a group of teenagers. One teenager says, "I have so many pimples on my face, it makes my face look horrible. Can I ever get rid of this problem?" The nurse says, "Pimples are a common problem in adolescents. They are often due to the inflammatory condition of some glands." Which gland is the nurse talking about?
Sebaceous gland
The nurse is completing a shift and is handing over patient care to the next nurse on duty. What should the nurse do during the bedside handover?
Share information about the patient's condition.
A patient is complaining of severe abdominal pain in the right iliac region. The nurse is completing the nursing history. What information should the nurse elicit to help arrive at the probable cause of abdominal pain?
Some questions about the digestive system
The nurse is new to a postoperative ward. The nurse finds it difficult to care for the immediate needs of a patient. Which measures should the nurse take to improve caregiving? Select all that apply.
Spend more time in initial assessment. Observe the patient's behavior and measure physical findings. Constantly assess and monitor patients for health needs.
Understand differences between pressure ulcers - stages 1-4 & no stage/non identifiable/necrotic
Stage 1: pressure ulcers are not open wounds, the skin can be red but does not blanch, in a dark skinned person the pressure ulcer is usually a different tone than the rest of the surrounding area. Temperature is often warm to touch. Stage 2: Ulcer breaks open, often times looks like a blister, scrape or a small crater in the skin. Area is often red and tender Stage 3: Full thickness/Skin loss, can see down to subcutaneous tissue, large and red Stage 4: Full thickness/tissue loss, can see down through to muscle/bone, very red and tender
Which type of ulcer can be dressed with a transparent or hydrocolloid dressing?
Stage I
Which stage of the pressure ulcer involves partial-thickness loss of the dermis and manifests as a red-pink, open ulcer without slough?
Stage II
The nurse is responsible for preparing discharge planning for the patient. Which statements are true about discharge planning? Select all that apply.
Start discharge planning at admission. Involve the family members.
Which statement is true regarding the oral cavity?
Stimulation of the sympathetic nervous system can completely inhibit the release of saliva.
Which nursing intervention is included in the standard care plan while caring for a critically ill patient?
Suggesting the patient use a chlorhexidine mouthwash regularly
Following an assessment, the nurse is formulating a nursing diagnosis using the PES format. What does the S in PES stand for?
Symptoms
The nurse is caring for a patient who has undergone nephrectomy. Which interventions performed by the nurse are independent nursing interventions? Select all that apply.
Teaching the patient about deep breathing exercises Assisting the patient in taking a bed bath Repositioning a patient for relief from pain
The nurse is conducting an interview of a patient who complains of chest pain. The nurse says, "I have just two more questions for you." In which stage of the interview is the nurse?
Terminating the interview
Which statement regarding the skin is true?
The dermis and the inner layer of the skin provide tensile strength.
A patient complains of epigastric pain. The nurse assumes the problem is gastritis and educates the patient about the condition. The patient is later diagnosed with mild myocardial infarction. Which statements indicate appropriate management of the situation? Select all that apply.
The nurse should provide a straightforward explanation to the patient for why the confusion occurred. The nurse should remember the need to be open-minded while looking at the patient's information during the initial diagnosis. The nurse should retroactively correlate the patient's data to see what was missed
The nurse finds that a patient who is scheduled for an appendectomy is crying and infers that the patient is crying due to anxiety over the surgery or the hospital admission. What appropriate action does the nurse take?
The nurse validates the inference by asking the patient about the crying behavior.
Which patient-related factors fall under health promotion nursing diagnosis? Select all that apply.
The patient is willing to eat nutritious foods. The patient is ready to increase his or her coping skills. The patient is ready to perform regular exercises.
The nurse is caring for a patient with pneumonia. According to the patient's care plan, a reduction of the respiratory rate (RR) from 33 breaths per minute to 20 breaths per minute (bpm), reduced cough, and reduced sputum production in 2 days would indicate successful intervention. On the first day, the nurse finds that the cough has reduced following nebulization and the RR is 25 bpm. What should the nurse's evaluation be?
The patient needs continued nebulization therapy.
Which action made by the patient is associated with the loss of the protective acid condition of the skin?
The patient uses alkaline soaps.
The nurse is caring for a 40-year-old patient undergoing chemotherapy. The patient complains of vomiting. Which statement is an appropriate goal statement for the patient's problem?
The patient will stop vomiting in 2 hours.
How should the nurse document the expected outcome statement after assessing the apical pulse in a patient?
The patient's apical pulse is 80 beats per minute.
While caring for a patient with partial dentures who has dental caries, the nurse observes that the patient's gums have lost vascularity and tissue elasticity. Which risk does the nurse suspect?
The patient's dentures cannot fit properly.
Which outcome allows you to measure a patient's response to care more precisely?
The patient's wound will reduce in size to less than 4 cm (1.5 in) by day 4.
Which statements are true regarding the oral cavity? Select all that apply.
The saliva facilitates bolus formation. Mouth breathing may impair saliva secretion in the mouth. The mucous membrane, continuous with the skin, lines the oral cavity.
The nurse gathers the following assessment data. Which cues form(s) a pattern suggesting a problem? Select all that apply.
The skin around the wound is tender to touch. Patient has increased drainage from surgical wound. Body temperature is 101° F (38.3° C).
Which statement is true regarding subcutaneous tissue?
The subcutaneous layer contains blood vessels, nerves, lymph, and loose connective tissue.
While caring for a patient in the postsurgical unit, the nurse palpates the area around the surgical wound and asks the patient if there is tenderness. What is the rationale behind this nursing action?
To assess for the risk of periwound edema
While assessing a patient who has a pressure ulcer, the nurse finds black wound tissue. In which stage is this pressure ulcer?
Unstageable
A patient has undergone throat surgery and is unable to speak. The following day while performing routine care, the nurse finds it difficult to interact with the patient. How should the nurse manage this situation?
Use message boards to communicate with the patient.
A patient who received penicillin developed a rash on the right hand. The patient asked the nurse why the rash developed. How should the nurse explain this to the patient?
Use previous knowledge.
Which nutrient is an antioxidant that promotes wound healing?
Vitamin C
The nurse advises a patient to avoid the use of dry razors. Which condition is the nurse trying to prevent?
Weakening of the epidermis
A 40-year-old patient is admitted to the hospital with severe pain in the lower abdomen and is very uncomfortable. The student nurse is assigned to care for this patient. Which attitude of critical thinking should the student nurse adopt when approaching the patient?
confidence
The surgical unit has initiated the use of a pain-rating scale to assess patients' pain severity during their postoperative recovery. The registered nurse (RN) looks at the pain flow sheet to see the pain scores recorded for a patient over the last 24 hours. Use of the pain scale is an example of which intellectual standard?
consistent
A 40-year-old patient is admitted to the hospital with severe pain in the lower abdomen. The student nurse is assigned to care for this patient. After nursing interventions, the pain did not subside substantially. The nursing student then started looking for different approaches to the patient's pain relief. Which aspect of critical thinking did the student nurse display?
creativity
Probing communication
encourage a full description without trying to control the direction the story takes Example: "Is there anything else you can tell me?" "What else is bothering you?"
A patient had hip surgery 16 hours ago. During the previous shift the patient had 40 mL of drainage in the surgical drainage collection device over an 8-hour period. The nurse refers to the written plan of care and notes that the health care provider should be notified when drainage in the device exceeds 100 mL for the day. On entering the room, the nurse looks at the device and carefully notes the amount of drainage currently in it. What is this an example of?
evaluation
problem-oriented
focused on particular need or problem
The nurse is assessing patients in a medical unit. What priority level is assigned to the patient diagnosed with decreased gas exchange?
high priority
A patient who has a stage III pressure ulcer develops a body temperature of 103° F. While changing the wound dressing, the nurse finds purulent discharge with an odor coming from the wound. What will the nurse suspect is occurring in the patient?
infection
close-ended questions
limit answers to one or two words such as "yes" or "no" Example: "how often does the diarrhea occur?" "Do you have pain or cramping?"
In a supine position, which site is not at risk for a pressure ulcer?
medial knee
open-ended questions
more than one or two words Example: "what are your concerns about this?"
Understand how to measure a wound (include tunneling) Tunneling - measuring depth of wound directly under skin around edges, see how wound/infection has extended
o Width and length with a measuring device o Depth with a sterile cotton-tipped applicator- same way with tunneling
The nursing process is an essential component of nursing practice. When using a five-step nursing process, what is the third step?
planning
While assessing a patient, the nurse observes that the patient's intravenous (IV) line is not infusing at the ordered rate. The nurse assesses the patient for pain at the IV site, checks the flow regulator on the tubing, looks to see if the patient is lying on the tubing, checks the point of connection between the tubing and the IV catheter, and then checks the condition of the site where the IV catheter enters the patient's skin. After the nurse readjusts the flow rate, the infusion begins at the correct rate. Of what is this an example?
problem solving
What should a clinical interview ideally focus on?
the patient
A 65-year-old patient is scheduled for a cholecystectomy. The attending nurse observes that the patient is restless and has poor eye contact when speaking. The patient also asks the nurse a number of questions. What should the nurse interpret from this behavior?
the patient is anxious
A patient with an abdominal wound from a motor vehicle accident comes into the emergency room with evisceration. The nurse immediately places sterile gauze soaked in sterile saline over the extruding tissues. What is the rationale for this nursing action?
to prevent infection
The nurse received the "Employee of the Year" award for knowledge, courage, honesty, and objectivity. Which concept of critical thinking does the nurse possess, according to Facione and Facione (1996)?
truth seeking
Comprehensive approach
usually gathered upon admission, includes health history, baseline data Ex: gordon's model of functional health patterns
Which question does the nurse ask the patient with renal disorder while selecting nursing diagnoses relevant to the patient's culture?
"How does this health problem affect you and your family?"
A registered nurse teaches a nursing student about the implications of skin care. Which statement if made by the nursing student indicates a need for further learning?
"I should maximize friction by moving the patient frequently."
During a home health visit, the nurse prepares to instruct a patient in how to perform range-of-motion (ROM) exercises for an injured shoulder. The nurse verifies that the patient took an analgesic 30 minutes before the nurse arrived at the patient's home. After discussing the purpose for the exercises and demonstrating each one, the nurse has the patient perform them. After two attempts with only the second of three exercises, the patient stops and says, "This hurts too much. I don't see why I have to do this so many times." Which statement by the nurse illustrates the critical thinking attitude of integrity?
"I understand your reluctance, but the exercises are necessary for you to regain function in your shoulder. Let's go a bit more slowly and try to relax."
The nurse is teaching a group of nursing students about the application of a nursing diagnosis to nursing practice. Which statement made by a student indicates the need for further teaching?
"Nursing diagnosis improves the selection of nursing interventions by nurses in certain practice settings."
The nurse is teaching nursing students about medical diagnoses. Which statements by the students indicate effective learning? Select all that apply.
"Osteoarthritis is a medical diagnosis." "Medical diagnoses are based on the results of diagnostic tests." "A primary healthcare provider is licensed to describe medical diagnoses."
A registered nurse teaches a nursing student about the characteristics of hair. Which statement if made by the nursing student indicates a need for further teaching?
"Physiological factors directly affect the hair shaft."
Which question by the nurse while taking an interview can strengthen his or her connection with a postoperative patient?
"Tell me how you are managing your pain at home?"
The nurse is delivering a lecture on "Health and Hygiene" to a group of teenagers. One teenager says, "For the past few weeks, I have been perspiring a lot, especially in the underarm area. What should I do?" Which is the most appropriate response by the nurse?
"This is just a normal part of growing up."
Which instruction provided by the nurse would be most beneficial to a patient who underwent bariatric surgery?
"You should use adaptive bathing methods."
A patient reports cracks in the skin. Which suggestion would be beneficial for the patient?
"You should use emollients."
Which suggestion made by the nurse is appropriate for reducing mechanical irritation?
"You should use smooth linen cloths."
A patient is scheduled for a prostatectomy. The patient is worried that he may not be able to have sex after surgery. What is the nurse's most appropriate response?
"Your surgeon will talk to you about the surgery. Don't be afraid to ask this question."
Procedure for denture care
(1) Ask the patient to remove dentures and place them in the container, which may be a glass of water if no other container is available. (2) While the patient is cleaning his mouth, take his dentures to the sink. Give him tissues to wipe his mouth. 3) Place the basin in the sink and brush the dentures over the basin under running water. In event the denture is dropped, it will be cushioned by the water in the basin. After thorough brushing, rinse the dentures and place them in a basin of water while cleaning the denture container. (4) Return the dentures in the container to the patient. (5) When a denture is not in use, place it in a marked clean container filled with clean water. Patients should neither wrap a denture in tissue or other material nor store it in a pajama pocket, under the pillow, or in a drawer.
The nurse is conducting a patient-centered interview. Place the statements from the interview in the correct order.
1. "My name is Todd. I'll be the nurse taking care of you today. I'm going to ask you a series of questions to gather your health history." 2. "Tell me what brought you to the hospital." 3. "You say you've lost weight. Tell me how much weight you have lost in the last month." Correct 4. "So, to summarize, you've lost about 6 pounds in the last month, and your appetite has been poor, correct?" 5. "I have no further questions. Thank you for your patience."
A registered nurse teaches a nursing student about cultural beliefs and personal values that may influence hygiene. Which statement if made by the nursing student indicates the need for further teaching?
"All socioeconomic groups are sensitive to body odors."
The nurse is caring for a 50-year-old patient. The patient had his gall bladder removed, and it is the second postoperative day. The nurse finds that the patient is uncomfortable and is in pain. The nurse also notices some oozing from the site of surgery and decides to gather information from the patient about the pain. Which questions related to the complaint could the nurse ask? Select all that apply.
"Can you show me where exactly the pain is?" "Have you turned or moved since last night?" "On a scale of 0 to 10, how severe would you rate this pain?"
A registered nurse teaches a group of nursing students about critical thinking. Which statement if made by the nursing student indicates the need for further learning?
"Clinical judgments and decisions should be made before anticipating the information."
2 Part Nursing Diagnosis
2 part: uses the defining characteristics or signs and symptoms identified in the assessment Ex: impaired Bed Mobility r/t inability to turn self from side to side Readiness for Enhanced Hope r/t expresses the desire to enhance sense of meaning to life. Impaired Gas Exchange r/t alveolar capillary membrane changes
