Chapter 18 Review Qs book Flashcards
Setting priorities for a patient’s nursing diagnoses or health problems is an important step in planning patient care. Which of the following statements describe elements to consider in planning care?
(Select all that apply.)
1. Priority setting establishes a preferential order for nursing interventions.
2. In most cases wellness problems take priority over problem-focused problems.
3. Recognition of symptom patterns helps in understanding when
to plan interventions.
4. Longer-term chronic needs require priority over short-term
problems.
5. Priority setting involves creating a list of care tasks.
1,3
Match the elements for correct identification of outcome statements with the SMART acronym terms below.
- Specific
- Measurable
- Attainable
- Realistic
- Timed
a. Mutually set an outcome that a patient
agrees to meet.
b. Set an outcome that a patient can meet
based upon his or her physiological,
emotional, economic, and sociocultural
resources.
c. Be sure an outcome addresses only one
patient behavior or response.
d. Include when an outcome is to be met.
e. Use a term in an outcome statement
that allows for observation as to whether a
change takes place in a patient’s status.
1c,2d,3b,4a
A nursing student is providing a hand-off report to the RN assuming her patient’s care. She explains, “I ambulated him twice during the shift; he tolerated walking to end of hall each time and back with no shortness of breath. Heart rate was 88 and regular
after exercise. The patient said he slept better last night after I closed his door and gave him a chance to have some uninterrupted sleep. I changed the dressing over his intravenous (IV) site and started a new bag of D5½NS. Which intervention is a
dependent intervention?
- Providing hand-off report at change of shift
- Enhancing the patient’s sleep hygiene
- Administering IV fluids
- Taking vital signs
3
A nurse is assigned to care for six patients at the beginning of the night shift. The nurse learns that the floor will be short by one registered nurse (RN) as a result of a call-in. A patient care technician from another area is coming to the nursing unit to assist. Because the unit requires hourly rounds on all patients, the nurse begins to make rounds on a patient who recently asked for a pain medication. The nurse is interrupted by another registered nurse who asks about another patient. Which factors in this nurse’s unit environment will affect the ability to set priorities? (Select all that
apply.)
- Policy for conducting hourly rounds
- Staffing level
- Interruption by staff nurse colleague
- Type of hospital unit
- Competency of patient care technician
2,3,5
A nursing student is providing a hand-off report to a registered nurse (RN) who is assuming her patient’s care at the end of the clinical day. The student states, “The patient had a good day. His intravenous (IV) fluid is infusing at 124 mL/hr with D5½NS infusing in left forearm. The IV site is intact, and no complaints of tenderness. I ambulated him twice during the shift; he tolerated walking to the visitors lounge and back with no shortness of breath, respirations 14, heart rate 88 after exercise. He uses his walker without difficulty, gait normal. The patient ate ¾ of his dinner with no gastrointestinal complaints. For the goal of improving the patient’s activity tolerance, which expected outcomes were shared in the hand-off? (Select all that apply.) 1. IV site not tender 2. Uses walker to walk 3. Walked to visitors lounge 4. No shortness of breath 5. Tolerated dinner meal
3,4
Which of the following factors should be considered when choosing an intervention for a patient’s plan of care? (Select all that apply.)
1. The specific patient outcome against which to judge effectiveness of interventions
2. The timing of care activities routinely conducted on the care
unit
3. The scientific evidence available in support of an intervention
4. The amount of time required for implementation in consideration of patient’s condition
5. The patient’s values and beliefs regarding the intervention
1,3,4,5
A nurse on a hospital unit is preparing to hand off care of a patient being discharged to a home health nurse. Match the activities on the left with the hand-off report categories on the right. Activities: 1. Use a standard checklist for the report. 2. Encourage questions and clarification. 3. Offer specific information on how to reduce patient’s risks. 4. Give report at time when shift has ended and other nurses are requesting information. 5. Explain how patient’s discharge was delayed by insufficient numbers of staff. 6. Organize time by preparing in advance what to report. Categories: A. Strategy for Effective Hand-off B. Strategy for Ineffective Hand-of
1A,2A,3A,4B,5B,6A
A patient diagnosed with colon cancer has been receiving chemotherapy for 6 weeks. The patient visits the outpatient infusion center twice a week for infusions. The nurse assigned to the patient is having difficulty accessing the patient’s intravenous (IV) port used to
administer the chemotherapy. Despite attempts to flush the port, it is obstructed. This also occurred 2 weeks earlier. What steps should the nurse follow to make a consultation with a member of the IV infusion team? (Select all that apply.)
1. Ask the IV nurse to come to the infusion center at a time when
the nurse starts care for a second patient.
2. Specifically identify the problem of port obstruction, and
attempt to flush the port to resolve the problem.
3. Explain to the IV nurse the frequency in which this port has
obstructed in the past.
4. Tell the IV nurse the problem is probably related to the physician who inserted the port.
5. Describe to the IV nurse the type and condition of the port currently in use.
2,3,5
A nurse assesses a 78-year-old patient who weighs 108.9 kg (240 lb) and is partially immobilized because of a stroke. The nurse turns the patient and finds that the skin over the sacrum is very red and the patient does not feel sensation in the area. The patient has had fecal incontinence on and off for the past 2 days.
The nurse identifies the nursing diagnosis of Risk for Impaired Skin Integrity. Which of the following outcomes is appropriate for the patient?
- Patient will be turned every 2 hours within 24 hours.
- Patient will have normal formed stool within 48 hours.
- Patient’s ability to turn self in bed improves.
- Erythema of skin will be mild to none within 48 hours.
4
An 82-year-old patient who resides in a nursing home has the following three nursing diagnoses: Risk for Fall, Impaired Physical Mobility related to pain, and Imbalanced Nutrition: Less Than Body Requirements related to reduced ability to feed self. The nursing staff identified several goals of care. Match the goals on the left with the appropriate outcome statements on the right. Goals: 1. \_\_\_\_\_ Patient will ambulate independently in 3 days. 2. \_\_\_\_\_ Patient will be injury free for 1 month. 3. \_\_\_\_\_ Patient will achieve 5-pound weight gain in 1 month. 4. \_\_\_\_\_ Patient will achieve pain relief by discharge. Outcomes: a. Patient expresses fewer nonverbal signs of discomfort within 24 hours. b. Patient increases caloric intake to 2500 calories daily. c. Patient walks 20 feet using a walker in 24 hours. d. Patient identifies barriers to remove in the home within 1 week.
1c,2,d,3b,4a
