Nursing assessment (Fundamentals)

What is wrong with this nursing order? "3/10/2015. Provide measures to relieve anxiety at every patient contact. J. King, RN" 1) Lacks a target time 2) Does not contain a verb 3) Should not be signed 4) Is vaguely worded

Is vaguely worded

Which of the following is a benefit of standardized care plans, as defined in your text? Standardized care plans: 1) Apply to every patient on a particular unit 2) Include both medical and nursing orders 3) Specify patient outcomes for each day 4) Help ensure that important interventions are not overlooked

) Help ensure that important interventions are not overlooked

Which of the following aids the nurse in best meeting the unique needs of a patient? 1) Kardex 2) Critical pathway 3) Individualized patient care plan 4) Standardized (model) patient care plan

) Individualized patient care plan

Which of the following nursing diagnoses is written in correct format? Assume the facts are correct in all of them. 1) Readiness for Enhanced Nutrition 2) Pain related to stating, "On a scale of 1 to 5, it's a 5." 3) Impaired Mobility related to pain A.M.B. hip fracture 4) Risk for Infection related to compromised immunity A.M.B. fever

) Readiness for Enhanced Nutrition

Which of the following is an example of theoretical knowledge? 1) A nurse uses sterile technique to catheterize a patient. 2) Room air has an oxygen concentration of approximately 21%. 3) Glucose-monitoring machines should be calibrated daily. 4) An irregular apical heart rate should be compared with the radial pulse.

) Room air has an oxygen concentration of approximately 21%.

Why is implementation known as the action phase of the nursing process? Because it is the stage in which the nurse: 1) Reassesses to see whether goals have been met 2) Performs or delegates the planned interventions 3) Documents the care that has been given 4) Prioritizes interventions

Performs or delegates the planned interventions

How can the nurse help promote client participation and adherence to a treatment regimen? 1) Be certain the care plan considers cultural and spiritual needs. 2) Explain that the treatments were prescribed by a physician. 3) Acknowledge that treatment is difficult, but that other patients do manage it. 4) Provide detailed written instructions about the client's disease process.

Be certain the care plan considers cultural and spiritual needs

Which intervention depends almost entirely on the client's adhering to the therapy? 1) Inserting an intravenous catheter 2) Turning a client every 2 hours 3) Shortening a surgical drain 4) Following a low-fat, low-calorie diet

Following a low-fat, low-calorie diet

A patient underwent surgery 3 days ago for colorectal cancer. The patient's critical pathway states that he should participate in a teaching session with the wound ostomy nurse to learn colostomy self-care. The patient appears depressed and refuses to look at the colostomy or even make eye contact. How should the nurse proceed? 1) Postpone the teaching session until the patient is more receptive. 2) Follow the critical pathway for patient teaching. 3) Administer a prescribed antidepressant and notify the healthcare provider. 4) Explain to the patient the importance of skin care around the ostomy site.

Postpone the teaching session until the patient is more receptive.

Nursing interventions are performed for the purpose of assessing health status, preventing and treating illness or disease, and promoting health.

True

Nursing interventions are performed for the purpose of assessing health status, preventing and treating illness or disease, and promoting health. True False

True

True or False: Informed consent requires the written consent of a study participant._______

True

Which intervention depends almost entirely on the client's adhering to the therapy? a. Shortening a surgical drain b. Turning a client every 2 hours c. Inserting an intravenous catheter d. Following a low-fat, low-calorie diet

d. Following a low-fat, low-calorie diet

Which of the following correctly illustrates an assessment of the environment and equipment? a. Take a thorough look at the patient b. Does the patient have any questions? c. Who else is in the room with the patient? d. Is the oxygen running?

d. Is the oxygen running?

Which of the following is a dependent intervention? a. Rubbing the patient's back to facilitate relaxation b. Measuring the patient's blood pressure c. Assessing the patient's needs related to discharge d. Administering prescribed medications to a patient

d. Administering prescribed medications to a patient

Which is the best example of a well-stated desired outcome? The patient will: a. Use the incentive spirometer while awake b. Increase the distance he walks each time he ambulates c. Verbalize the side effects of his new medication d. State pain is <4 on a 0-10 scale within 1 hour of receiving pain medication

d. State pain is <4 on a 0-10 scale within 1 hour of receiving pain medication

(Complete this statement.) Nursing research is based on the ____________________ method.

scientific

(Complete this statement.) A 23-year-old athlete decides to donate bone marrow for a child who requires a bone marrow transplant to fight leukemia. According to Maslow's later work, this athlete is fulfilling his need for ____________________.

self-transcendence

The nurse intends to identify nursing diagnoses for a patient. She can best do this by using a data-collection form organized according to (select all that apply): 1) A body systems model 2) A head-to-toe framework 3) Maslow's Hierarchy of Needs 4) Gordon's functional health patterns

1) A body systems model 4) Gordon's functional health patterns

Using a "patient preferences" framework, which of the following nursing diagnoses would probably have the highest priority for a patient who fractured his leg yesterday and now is wearing a cast? 1) Acute Pain 2) Disturbed Body Image 3) Ineffective Peripheral Perfusion 4) Impaired Physical Mobility

1) Acute Pain

In which of the following ways do collaborative problems differ from nursing diagnoses? Choose all correct answers. 1) All patients who have a certain disease are at risk for developing the same problem. 2) Collaborative problems are always potential problems. 3) The complications can be prevented with nursing interventions alone. 4) The problem statement does not need to be approved by a medical provider.

1) All patients who have a certain disease are at risk for developing the same problem. 2) Collaborative problems are always potential problems.

Critical thinking and the nursing process have which of the following in common? Both: 1) Are important to use in nursing practice 2) Use an ordered series of steps 3) Are patient-specific processes 4) Were developed specifically for nursing Answer:

1) Are important to use in nursing practice

As the nurse is inserting a urinary catheter she observes blood in the urine returned in the tubing. Which two nursing process phases does this demonstrate? 1. Assessment 2. Diagnosis 3. Implementation 4. Planning: Interventions

1) Assessment 2) Implementation

A young adult client is in the hospital after a motor vehicle accident. He is in a body cast and essentially immobile, but he is otherwise stable. Which activity or activities can the nurse delegate to a nursing assistant? Choose all that apply. 1) Bathing the client 2) Taking the client's vital signs 3) Choosing nursing interventions 4) Prioritizing interventions

1) Bathing the client 2) Taking the client's vital signs

What is the most basic reason that self-knowledge is important for nurses? Because it helps the nurse to: 1) Identify personal biases that may affect his thinking and actions. 2) Identify the most effective interventions for a patient. 3) Communicate more efficiently with colleagues, patients, and families. 4) Learn and remember new procedures and techniques. Answer:

1) Identify personal biases that may affect his thinking and actions

How are critical-thinking skills and critical-thinking attitudes similar? Both are: 1) Influences on the nurse's problem-solving and decision making 2) Like feelings rather than cognitive activities 3) Cognitive activities rather than feelings 4) Applicable in all aspects of a person's life

1) Influences on the nurse's problem-solving and decision making

all nursing diagnoses that commonly occur with a medical diagnosis. They do not describe care for a particular patient. Which of the following functions both as a care plan and a documentation form? Choose all correct answers. 1) Integrated plan of care (IPOC) 2) Critical pathway 3) Individualized patient care plan 4) Standardized (model) care plan

1) Integrated plan of care (IPOC) 2) Critical pathway

An 80-year-old resident in a long-term-care facility comes to the emergency department with dehydration. The nurse writes a diagnosis of Deficient Fluid Volume related to excessive fluid loss. An individualized nursing goal identified for this client is "The client will maintain urine output of at least 30 mL/hour." Which nursing interventions would directly help achieve or evaluate the stated goal? Choose all that are correct. 1) Measure and record urine output every hour; report an output of less than 30 mL/hour. 2) Monitor skin turgor and moistness of mucous membranes every shift. 3) Administer intravenous (IV) fluids as prescribed. 4) Keep oral fluids within the patient's reach and encourage the patient to drink.

1) Measure and record urine output every hour; report an output of less than 30 mL/hour. 3) Administer intravenous (IV) fluids as prescribed. 4) Keep oral fluids within the patient's reach and encourage the patient to drink.

A patient with high blood pressure receives a daily oral medication to control his blood pressure. However, he has been vomiting for the past 24 hours. The nurse knows that oral medications are absorbed in the gastrointestinal tract, and that without the drug, the patient's blood pressure may become dangerously high. So the nurse notifies the primary provider to see whether the drug can be given by another route (e.g., intravenously or rectally). The nurse's thinking and actions illustrate which of the following? 1) Nursing is an applied discipline. 2) Nursing uses knowledge from other fields. 3) Nursing is fast paced. 4) Nursing requires ethical knowledge.

1) Nursing is an applied discipline 2) Nursing uses knowledge from other fields

The nurse is recording assessment data. She writes, "The patient seems worried about his surgery. Other than that, he had a good night." Which errors did the nurse make? Select all that apply. 1) Used a vague generality 2) Did not use the patient's exact words 3) Used a "waffle" word (e.g., seems) 4) Recorded an inference rather than a cue

1) Used a vague generality 3) Used a "waffle" word (e.g., seems)

Which is true of unit standards of care? Unit standards of care are (select all that apply): 1) Written for a specific medical diagnosis or treatments 2) Organized according to nursing diagnoses 3) A description of minimal level of care a patient is expected to receive 4) Not part of the care plan that is included in the patient's chart

1) Written for a specific medical diagnosis or treatment 3) A description of minimal level of care a patient is expected to receive

The client has a nursing diagnosis of Impaired Physical Mobility. Which of the following is a Nursing Outcomes Classification (NOC) outcome label to use with this diagnosis? 1) Increases his physical activity 2) Activities of daily living 3) Demonstrates appropriate use of adaptive equipment 4) Verbalizes feeling of increased strength

2) Activities of daily living

The nurse has written this diagnosis for a patient: Ineffective Airway Clearance related to weak cough secondary to incisional pain. Which of the following outcomes is essential for the nurse to include in the care plan? 1) Effective cough 2) Airways clear to auscultation 3) Pain less than 4 on a scale of 1 to 10 4) Demonstrates splinting of incision

2) Airways clear to auscultation

In which step of the nursing process does the nurse analyze data and identify client problems? 1) Assessment 2) Diagnosis 3) Planning outcomes 4) Evaluation

2) Diagnosis

An 85-year-old patient with hypertension (elevated blood pressure) was admitted to the hospital with dehydration. He has pressure sores on his back and hip. Which of the following tasks could the registered nurse delegate to nursing assistive personnel? Select all that apply. 1) Evaluating the healing of the pressure sores 2) Helping the patient to turn and reposition in bed 3) Coordinating the patient's care with the dietitian 4) Taking the patient's blood pressure and reporting changes in skin condition

2) Helping the patient to turn and reposition in bed 4) Taking the patient's blood pressure and reporting changes in skin condition

A patient is admitted with shortness of breath. The nurse specifically wants to know when the problem began, how often it occurs, what makes it worse, and what the patient has done to relieve it. What should the nurse do to obtain this information? 1. Complete a comprehensive admission assessment. 2. Interview the patient about the history of her present illness. 3. Perform a review of body systems and functional abilities. 4. Ask the patient about her expectations for care.

2) Interview the patient about the history of her present illness

Which statement about the nursing process is correct? 1) It was developed from the ANA Standards of Care. 2) It is a problem-solving method to guide nursing activities. 3) It is a linear process with separate, distinct steps. 4) It involves care that only the nurse will give.

2) It is a problem-solving method to guide nursing activities.

Which of the following is appropriate to the registered nurse's role in nursing diagnosis? 1) Decide when to delegate diagnosing to the LPN/LVN. 2) Make clinical judgments about the patient data. 3) Validate all nursing diagnoses with the primary care provider. 4) Use only NANDA-I standardized language to state problems.

2) Make clinical judgments about the patient data.

The nurse writes a nursing diagnosis of Risk for Deficient Fluid volume for a 45-year-old patient admitted with acute pancreatitis. What type of nursing diagnosis has the nurse written for this patient? 1) Actual 2) Potential 3) Possible 4) Wellness

2) Potential

The nurse is preparing to admit a patient from the emergency department. The patient has chronic lung disease and has used tobacco for 30+ years. The nurse used to smoke a pack of cigarettes a day and worked very hard to quit smoking. She thinks to herself, "I know I tend to disapprove of people who use tobacco, especially when they have a serious lung condition; I figure if I can stop smoking, they should be able to. I must remember how difficult that is, and be very careful not to let be judgmental of this patient." This best illustrates: 1) Theoretical knowledge 2) Self-knowledge 3) Using reliable resources 4) Use of the nursing process

2) Self-knowledge

Which is the best example of a well-stated desired outcome? The patient will: 1) Use the incentive spirometer while awake 2) State pain < 4 on a scale of 1 to 10 within 1 hour after receiving pain medication 3) Increase the distance he walks each time he ambulates 4) Verbalize the side effects of his new medication

2) State pain < 4 on a scale of 1 to 10 within 1 hour after receiving pain medication

Which of the following is an example of data that should be validated? 1) The urinalysis report indicates there are white blood cells in the urine. 2) The client states she feels feverish; you measure the oral temperature at 98°F. 3) The client has clear breath sounds; you count a respiratory rate of 18 breaths/min. 4) The chest x-ray report indicates the client has pneumonia in the right lower lobe. Answer:

2) The client states she feels feverish; you measure the oral temperature at 98°F.

Which of the following are cues? Select all that apply. 1) Taking a brisk walk five times a week 2) Using laxatives to have a bowel movement 3) Needing more sleep than usual 4) Decreasing the amount of fat in the diet 5) Weighing less than indicated by developmental norms

2) Using laxatives... 3) Needing more sleep... 5) Weighing less than indicated by developmental norms

Arrange the steps of the nursing process in the sequence in which they generally occur. A. Assessment B. Evaluation C. Planning outcomes D. Planning interventions E. Diagnosis

3) A, E, C, D, B

Which of the following explains why it is important to have the correct etiology for a nursing diagnosis? The etiology: 1) Is the cause of the problem. 2) Cannot always be observed. 3) Directs nursing interventions. 4) Is an inference.

3) Directs nursing interventions

How is a critical pathway different from a standardized care plan? A critical pathway: 1) Does not include medical orders 2) Provides individualized goals and interventions 3) Specifies patient outcomes and interventions for each day, or other period of time 4) Is usually a preprinted document for a particular diagnosis or condition

3) Specifies patient outcomes and interventions for each day, or other period of time

What is missing from this goal statement? "The patient will walk to the doorway with the help of one person." 1) Action verb 2) Special conditions 3) Target time 4) Nothing is wrong with it.

3) Target time

As the nurse is inserting a urinary catheter she observes blood in the urine returned in the tubing. Which principle of assessment does this best illustrate? 1. Assessment must be accurate because the remainder of the nursing process depends on it. 2. Nursing assessments focus on patient responses rather than disease processes. 3. Assessment is a responsibility of professional nurses and cannot be delegated. 4. Assessment is related to and overlaps with other steps of the nursing process.

4) Assessment is related to and overlaps with other steps of the nursing process.

A clinic client has not been keeping his scheduled follow-up appointments. In talking with him about that, the nurse asks, "Do you have a car or other transportation to bring you to the clinic?" Which critical-thinking process does that question illustrate? 1) Inquiry based on credible sources 2) Reflective skepticism 3) Analyzing assumptions 4) Contextual awareness Answer:

4) Contextual awareness

Which of the following is the most obvious example of defining characteristics of the diagnosis Deficient Fluid Volume? 1) Increased metabolic rate 2) Effects of medications 3) History of falls 4) Decreased urine output

4) Decreased urine output

After assessing a patient, the nurse is analyzing and synthesizing the data she obtained. She thinks, "I know the patient must sit up to breathe; his respirations are shallow and fast; and he is pale. What does this mean? What are some possible explanations for these symptoms?" Which of the following critical-thinking attitudes is the nurse illustrating? 1) Fair-mindedness 2) Independent thinking 3) Intellectual courage 4) Intellectual curiosity

4) Intellectual curiosity

Using the mnemonic H E L P (from Volume 1 of your textbook), which of the following correctly illustrates the letter H—Help? 1) Is the oxygen running? 2) Who else is in the room with the patient? 3) Are there any spills? 4) Is the patient in pain?

4) Is the patient in pain?

What is the role of The Joint Commission in regard to patient assessment? The Joint Commission 1. States what assessments are collected by individuals with different credentials 2. Regulates the time frames for when assessments should be completed 3. Identifies how data are to be collected and documented 4. Sets standards for what and when to assess the patient

4) Sets standards for what and when to assess the patient.

Which of the following is an example of appropriate behavior when conducting a client interview? 1) Recording all the information on the agency-approved form during the interview 2) Asking the client, "Why did you think it was necessary to seek healthcare at this time?" 3) Using precise medical terminology when asking the client questions 4) Sitting, facing the client in a chair at the client's bedside, using active listening Answer:

4) Sitting, facing the client in a chair at the client's bedside, using active listening

Which organization's standards require that all patients be assessed specifically for pain? 1) American Nurses Association (ANA) 2) State nurse practice acts 3) National Council of State Boards of Nursing (NCSBN) 4) The Joint Commission

4) The Joint Commission

A nurse is in the process of generating and selecting nursing interventions for a patient. Number the following steps in the order in which they should occur. 1) Choose the best interventions for the patient. 2) Identify several interventions or actions. 3) Review the desired patient outcomes. 4) Review the nursing diagnosis. 5) Individualize standardized interventions to meet the patient's unique needs.

4, 3, 2, 1, 5

What is wrong with the format of this diagnostic statement: Possible Risk for Constipation related to irregular defecation habits A.M.B. verbalizing that "When I'm busy, I can't always take the time to go to the bathroom." 1) Possible nursing diagnoses do not have signs and symptoms. 2) A nursing diagnosis is either possible or it is a risk, not both. 3) Risk for Constipation is a medical diagnosis. 4) The etiology is actually a defining characteristic.

A nursing diagnosis is either possible or it is a risk, but not both

Which of the following is a collaborative intervention? 1) Rubbing patient's back to facilitate relaxation 2) Measuring the patient's blood pressure 3) Assessing the patient's educational needs related to discharge 4) Administering prescribed medications to a patient

Administering prescribed medications to a patient

The nurse develops a goal on the nursing care plan that states: 9/26/16, 0900—By 0800 tomorrow, will reach tube-feeding goal of 80 mL/hour. How can the nurse best collect data to evaluate this goal? (Note: Residual is the amount of undigested feeding remaining in the stomach; blood glucose levels are affected by calories ingested and digested.) 1) Weigh the client daily. 2) Monitor urine output hourly. 3) Obtain blood glucose levels every 6 hours. 4) Check feeding residual every 2 hours.

Check feeding residual every 2 hours.

Which of the following form propositions when linked together, and are considered "building blocks" of theories? 1) Concepts 2) Research data 3) Hypotheses 4) Numbers

Concepts

The nurse phones the laboratory to schedule a blood test for a hospitalized patient. She also schedules an x-ray for the same day. Both of these require the patient to be NPO (to have no food or liquids by mouth) for several hours prior to the tests. The nurse makes sure the patient has something to drink at the last possible moment before the patient is NPO. After the tests, when analyzing the urine output, she takes into consideration that the patient has had nothing to drink for 7 hours. This is a good example of: 1) Collaborating 2) Coordinating 3) Delegating care 4) Individualizing care

Coordinating

A patient is at risk for dehydration. Because of this, the nurse plans to monitor the patient's intake and output and to check skin turgor every 4 hours. Which of the following processes does this illustrate? 1) Deductive reasoning 2) Inductive reasoning 3) Intuition (inspiration) 4) Data analysis

Deductive reasoning

A patient has not achieved a desired outcome by the target date. What should the nurse do next when reviewing the care plan? 1) Reassess to see whether other outcomes have been met. 2) Implement new nursing interventions. 3) Write a new nursing diagnosis. 4) Determine whether the outcome was realistic.

Determine whether the outcome was realistic

A patient has a diagnosis Impaired Walking related to knee pain secondary to arthritis. The nurse has written the following set of nursing orders for that diagnosis. Provide passive range of motion to the affected knee 3 times per day. Assist the patient to walk to the bathroom and at least 3 times per day. Which of the following is a valid criticism of this set of orders? The orders 1) Are too long and complex. 2) Do not address the etiology of the nursing diagnosis. 3) Do not address the problem side of the nursing diagnosis. 4) Should not include the words "secondary to arthritis."

Do not address the etiology (knee pain) of the nursing diagnosis.

A nurse has an educational background that prepares her to manage research projects. Which nursing degree does this nurse most likely hold? 1) Associate degree 2) Baccalaureate degree 3) Master's degree 4) Doctoral degree

Doctoral degree

Which nursing intervention is considered an independent intervention? 1) Administering 1 liter of dextrose 5% in normal saline solution at 100 mL/hour 2) Encouraging the postoperative client to perform coughing and deep-breathing exercises 3) Explaining his diet to the client; then communicating the teaching with the dietitian 4) Administering morphine sulfate 2 mg IV to the client with postoperative pain

Encouraging the postoperative client to perform coughing and deep-breathing exercises

The nurse has written the following diagnosis: Diarrhea r/t frequent loose stools. Which of the following describes the error in that diagnostic statement? 1) Diagnostic statement does not include an etiology. 2) Etiology does not describe the cause of the problem. 3) Statement includes a medical diagnosis. 4) Problem is stated as a need rather than a response.

Etiology does not describe the cause of the problem.

In which phase of the nursing process does the nurse decide whether her actions have successfully treated the client's health problem?

Evaluation

In which phase of the nursing process does the nurse decide whether her actions have successfully treated the client's health problem? ________________

Evaluation

The nurse has just finished documenting that he removed a patient's nasogastric tube. Which is the next logical step in the nursing process? 1) Assessment 2) Planning 3) Evaluation 4) Diagnosis

Evaluation

A facility is using ___________ nursing care when scientifically sound research data are used to make nursing care decisions.

Evidence based

A facility is using ___________ nursing care when scientifically sound research data are used to make nursing care decisions. 1) Evidence-based 2) Standardized 3) Individualized 4) Theoretical

Evidence-based

The nurse has developed and implemented a care plan for a patient. Evaluation of the patient's responses ends the nursing process for this patient.

False

The nurse has developed and implemented a care plan for a patient. Evaluation of the patient's responses ends the nursing process for this patient. True False

False

A nurse has observed that quite a few patients on the unit develop pressure sores while in the agency. The nurse wonders whether there are better preventive measures than are currently being used and wishes to find the best evidence for perhaps changing at least one intervention. What should the nurse do next? 1) Identify a clinical nursing problem. 2) Formulate a PICOT question on the topic. 3) Search the nursing literature. 4) Evaluate the quality of the research in the literature.

Formulate a PICOT question on the topic

The nurse is beginning discharge planning for an older adult with left-side weakness. All of the following are important, but which action is most important in ensuring that the discharge plan is successful? 1) Start planning at admission. 2) Involve the family members. 3) Get patient input when making the plan. 4) Involve the multidisciplinary team.

Get patient input when making the plan.

in diagnostic reasoning, the nurse does all of the following when analyzing and interpreting data. Which task occurs first? 1) Cluster cues. 2) Identify data gaps and inconsistencies. 3) Identify significant data. 4) Make inferences.

Identify significant data.

In diagnostic reasoning, which of the following does the nurse usually do first? 1) Interpret patient data. 2) Draw conclusions about health status. 3) Verify problems with the patient. 4) Prioritize health problems.

Interpret patient data.

Using the mnemonic H E L P (from Volume 1 of your textbook), which of the following correctly illustrates the letter E—Equipment and Environment? 1) Is the oxygen running? 2) Who else is in the room with the patient? 3) Does the patient have any questions? 4) Take a thorough look at the patient.

Is the oxygen running?

A research article describes a multicenter study in which 5,000 healthy patients between the ages of 30 and 65 were given a medication. Effects were observed, which included change in blood pressure with the prescribed drug. Study findings indicate this medication is safe for healthy patients between the ages of 30 and 65 when given for a defined medical condition. What can you most reasonably infer from this information? 1) It was a qualitative study. 2) It was a quantitative study. 3) The study did not use a random sample. 4) The study did not include a broad enough age span.

It was a quantitative study.

A nurse spends time sitting with a dying patient. She holds the patient's hand and prays with her quietly. This action is most clearly an example of whose nursing theory? 1) Jean Watson 2) Imogene King 3) Ida Jean Orlando 4) Martha Rogers

Jean Watson

When writing an individualized patient care plan, which of the following should the nurse do first? 1) Transcribe medical orders to the appropriate documents. 2) Individualize standardized plans as needed. 3) Write basic care needs on the Kardex or in special sections of the care plan. 4) Make a working problem list with problems in priority order.

Make a working problem list with problems in priority order

Which nursing intervention is best individualized to meet the needs of a specific client? 1) Suction the client every 2 hours per unit policy. 2) Use incentive spirometry every hour while awake per postoperative protocols. 3) Institute swallowing precautions. 4) Move client out of bed to the chair daily; client prefers to be out of bed for dinner.

Move client out of bed to the chair daily; client prefers to be out of bed for dinner.

Which of the following is true of the Nursing Interventions Classification (NIC)? Select all that apply. 1) NIC interventions can be used in all specialty areas of nursing practice. 2) The American Nurses Association (ANA) has approved it for use. 3) It is used mainly by home health nurses. 4) It is designed primarily for use in hospitals.

NIC interventions can be used in all specialty areas of nursing practice. The American Nurses Association (ANA) has approved it for use.

What are the similarities between a risk nursing diagnosis and a possible nursing diagnosis? 1) Both are developed primarily from nursing intuition and experience. 2) Both require intervention from physicians. 3) Neither requires the client to have increased vulnerability. 4) Neither is made on the basis of client symptoms (defining characteristics).

Neither is made on the basis of client symptoms (defining characteristics)

Hildegard Peplau was a nursing theorist whose major contribution to nursing was: 1) Transcultural nursing 2) Health promotion 3) Nurse-patient relationship 4) Holistic comfort

Nurse-patient relationship.

Which standardized intervention vocabulary was designed specifically for community health nurses? 1) Omaha System 2) Clinical Care Classification 3) Nursing Interventions Classification 4) International Classification for Nursing Practice

Omaha System

Most nurses see nursing as focusing on the entire person and his response to cellular changes. This global perspective of nursing is known as a nursing: 1) Framework 2) Theory 3) Model 4) Paradigm

Paradigm

observable, verifiable data to describe, explain, or predict events. According to Maslow's Hierarchy of Needs, which patient need should the nurse address first? 1) Protecting the patient against falls 2) Protecting the patient from an abusive spouse 3) Promoting sleep and rest in the critically ill patient 4) Promoting self-esteem after a body image change

Promoting sleep and rest in the critically ill patient

What do standardized nursing care plans and individualized care plans have in common? They both: 1) Reflect critical thinking for a specific patient 2) Apply to needs common to a group of patients 3) Address a patient's individual needs 4) Provide detailed nursing interventions

Provide detailed nursing interventions

Which nurse is most clearly using evidence-based practice? One who uses an intervention: 1) He read about in a study in a nursing research journal 2) From the agency's critical pathway in the electronic health record 3) Published in the clinical practice guidelines of a national organization 4) That is individualized to meet a specific patient need

Published in the clinical practice guidelines of a national organization

How is qualitative research different from quantitative research? Qualitative research: 1) Is more valid when large numbers of participants are studied 2) Reports data in the form of words 3) Is less useful than quantitative research 4) Requires careful attention to methods and techniques

Reports data in the form of words

Which of the following nursing activities is a direct-care intervention? 1) Consulting with the nurse practitioner about a patient's medication 2) Telephoning the physician when a pain medication is not relieving the patient's pain 3) Checking and stocking the unit's resuscitation cart daily 4) Sitting with a patient who is anxious about his upcoming surgery

Sitting with a patient who is anxious about his upcoming surgery

The criterion reads: "Hallways clear and free of equipment (e.g., beds, wheelchairs)." This is an example of a criterion that would be appropriate in which type of evaluation? 1) Outcomes 2) Processes 3) Structures 4) Intermittent

Structures

Using the mnemonic H E L P (from Volume 1 of your textbook), which of the following correctly illustrates the letter L—Look? 1) Is the oxygen running? 2) Who else is in the room with the patient? 3) Are there any spills? 4) Take a thorough look at the patient.

Take a thorough look at the patient

What is the error in the following nursing order: "7-21-15—Using 2 persons, assist the patient from bed to chair 3 times per day. Jerry Xeno, RN"? 1) There is no action verb. 2) There are no times or limits. 3) Nurses do not need to sign nursing orders. 4) The order is too long and complex.

There are no times or limits.

In diagnostic reasoning, which of the following does the nurse usually do first? a. Interpret patient data b. Prioritize health data c. Verify problems with the patient d. Draw conclusions about health status

a. Interpret patient data

Which of the following is an example of data that should be validated? a. The client states he feels feverish; his oral temperature is 98°F b. The breath sounds are clear; respiration rate is 18 breaths per minute c. The chest xray indicates possible pneumonia in the left lower lung lobe d. Urinalysis report indicates there are white blood cells in the urine

a. The client states he feels feverish; his oral temperature is 98°F

As the nurse is inserting a urinary catheter she observes blood in the urine returned in the tubing. Which two nursing process phases does this demonstrate? SELECT ALL THAT APPLY a. Assessment b. Diagnosis c. Implementation d. Planning: Interventions

a. Assessment c. Implementation

Which nursing intervention is considered an independent intervention? a. Administering 1 liter of dextrose 5% in normal saline solution at 100 mL/hour b. Encourage the postoperative client to perform coughing and deep breathing exercises c. Explaining the diet to the client; then communicating the teaching to the dietitian d. Administering morphine 2 mg IV for postoperative pain

b. Encourage the postoperative client to perform coughing and deep breathing exercises

The nurse is preparing to admit a patient from the emergency department. The patient has chronic lung disease and has used tobacco for 30+ years. The nurse used to smoke a pack of cigarettes a day and worked very hard to quit smoking. She thinks to herself, "I know I tend to disapprove of people who use tobacco, especially when they have a serious lung condition; I figure if I can stop smoking, they should be able to. I must remember how difficult that is, and be very careful not to be judgmental of this patient." This best illustrates: a. Theoretical knowledge b. Self knowledge c. Using reliable resources d. Use of the nursing process

b. Self knowledge

What is missing from this goal statement? "The patient will walk to the doorway with the help of one person." a. Action verb b. Target time c. Special conditions d. Nothing is wrong with it

b. Target time

In which step of the nursing process does the nurse analyze data and identify client problems? a. Evaluation b. Diagnosis c. Assessment d. Intervention

b. Diagnosis

A young adult client is in the hospital after a motor vehicle accident. He is in a body cast and essentially immobile, but he is otherwise stable. Which activity or activities can the nurse delegate to a nursing assistant? SELECT ALL THAT APPLY a. Choosing nursing interventions b. Priorititizing interventions c. Bathing the client d. Taking the client's vitals

c. Bathing the client d. Taking the client's vitals

A patient has not achieved a desired outcome by the target date. What should the nurse do next when reviewing the care plan? a. Write a new nursing diagnosis b. Implement new nursing interventions c. Determine whether the outcome was realistic d. Reassess to see if other outcomes have been me

c. Determine whether the outcome was realistic

Which of the following aids the nurse in best meeting the unique needs of a patient? a. Kardex b. Critical Pathway c. Individualized patient care plan d. Standardized (Model) patient care plan

c. Individualized patient care plan

Which statement about the nursing process is correct? a. It was developed from the ANA Standards of Care b. It involves care that only a nurse will give c. It is a problem-solving method to guide nursing activities d. It is a linear process with separate, distinct steps

c. It is a problem-solving method to guide nursing activities