Exam I Flashcards
Which action indicates a nurse is using critical thinking for implementation of nursing care to patients?
A.Determines whether an intervention is correct and appropriate for the given situation.
B.Reads over the steps and performs a procedure despite lack of clinical competency.
C.Establishes goals for a particular patient without assessment.
D.Evaluates the effectiveness of interventions.
A.Determines whether an intervention is correct and appropriate for the given situation.
A nurse is planning care for a client who has acute dysphagia. Which of the following nurse interventions should be included in the plan of care?
A. Providing a straw for consumption of liquids
B. Encouraging larger bites
C. Placing the client in semi-Fowlers position during meals
D. Instructing the client to tilt head forward when swallowing
D. Instructing the client to tilt head forward when swallowing
PERRLA
Pupils Equal Round Reactive to Light Accommodation (what one eye does, the other does)
Activity / Exercise
- Physical Activity Daily/Weekly?
- Lifestyle? Sedentary/active?
- Changes in Musculoskeletal system?
- Gait?
- Assistive Devices?
- Self Care Ability: Dressing/Bathing
OD/OS
eyes
A nurse in a clinic is interviewing a client who will undergo diagnostic testing. The nurse should ask about allergies during which phase of the process? A. Planning B. Evaluation C. Assessment D. Implementation
C. Assessment
DNR
Do Not Resuscitate
ORIF
open reduction and internal fixation
A nurse performs an assessment on a patient. Which assessment data will the nurse use as an etiology forAcute pain?
A.Discomfort while changing position
B.Reports pain as a 7 on a 0 to 10 scale
C.Disruption of tissue integrity
D.Dull headache
C.Disruption of tissue integrity
A nurse is planning care for a client who has terminal cancer and has a prescription for morphine. Which of the following interventions should the nurse include in the plan of care?
A. Instruct the client to take diphenoxylate/atropine 5 mg PO twice a day.
B. Instruct the client to actively cough to prevent a buildup of secretions in the airway.
C. Instruct the client to stop taking the morphine if itching develops.
D. Instruct the client to keep room lights dim during waking hours.
B. Instruct the client to actively cough to prevent a buildup of secretions in the airway.
BMP
basal metabolic panel (lab test)
Cognitive / Perceptual
- Level of Consciousness
- Orientation
- Mood
- Affect
- Memory Changes?
- Visual/Auditory Changes?
- Pain?
A nurse is caring for a client who is prescribed bedrest. The plan of care indicates that the client should perform isometric exercises every 2 hr. Which of the following actions should the nurse take as directed by the plan of care?
A. Ask the client to move her arms and legs while applying slight resistance.
B. Move the client’s limbs through their complete range of motion.
C. Have the client move each limb independently through its complete range of motion.
D. Instruct the client to tighten muscle groups for a short period, and then relax.
D. Instruct the client to tighten muscle groups for a short period, and then relax.
NPO
Nothing by mouth
Nutritional/ Metabolic
- Height and Weight
- RX Diet or Diet Restrictions
- Vitamins or Supplements
- Eating/Swallowing Difficulties
- Feeding Tubes or Modifications
Hgb/HcT
hemoglobin and hematocrit
Self-Concept
- Appearance (well groomed?)
- Hygiene
- Anxiety
- Eye contact
- View of Self
- Body Image
When a nurse conducts an assessment, data about a patient often comes from which of the following sources? (Select all that apply.)
A. An observation of how a patient turns and moves in bed
B. The unit policy and procedure manual
C. The care recommendations of a physical therapist
D. The results of a diagnostic x-ray film
E. Your experiences in caring for other patients with similar problems
A. An observation of how a patient turns and moves in bed
C. The care recommendations of a physical therapist
D. The results of a diagnostic x-ray film
Sexuality / Reproductive
- LMP
- Pregnancies
- Sexual History
- STD/STI
- Last Prostrate Exam
- Concerns?
HOB
Head of Bed
Health Perception / Management
- Past Medical History
- Past Surgical History
- Immunizations
- Alcohol/Drug Use/Smoking
- Allergies
- Code Status
The nurse is evaluating whether a patient’s turning schedule was effective in preventing the formation of pressure ulcers. Which finding indicates success of the turning schedule?
A.Staff documentation of turning the patient every 2 hours
B.Presence of redness only on the heels of the patient
C.Patient understands the need for regular turning
D.Absence of skin breakdown
D.Absence of skin breakdown
WDL
Within defined limits
WNL but covered legally
Ad lib
at liberty or as tolerated
pc
after meals
PRN
as needed
CBC
Complete Blood Count
H&P
History and Physical
A nurse is evaluating the outcomes for an outpatient client who has depression. Which of the following client statements indicates a need for further evaluation?
A. “I had a great trip to the Smokey Mountains.”
B. “Going back to work has been okay.”
C. “I just don’t like going to the movies like I used to.”
D. “I can’t wait to have my family together next weekend.”
C. “I just don’t like going to the movies like I used to.”
What information goes into the health history?
Known medical conditions, medications (including herbals and OTC), allergies, coping skills, stressors, history of surgeries, dentition, sexually active?, roles/resposibilities, nutrition, drugs/alcohol, sleep, values/beliefs, mental status, activity/exercise, problems with elimination
A nurse is assessing a client who is being admitted to the PACU following an abdominal hysterectomy. Which of the following assessments is the nurse's priority? A. Oxygen saturation B. Abdominal dressing C. Urinary output D. Pain level
A. Oxygen saturation
ABCD (skin)
Asymmetry
Border irregularity
Color
Diameter
a.c.
before meals
ABC (triage)
Airway
Breathing
Circulation
RR
Respiratory rate
IU
international Unit
K/KCL
potassium
HS
at bedtime
CC
Chief complaint
po
by mouth
c/o
complaint of
A nurse is reviewing a patient’s care plan. Which information will the nurse identify as a nursing intervention?
A.The patient will ambulate in the hallway twice this shift using crutches correctly.
B.Impaired physical mobility related to inability to bear weight on right leg.
C.Provide assistance while the patient walks in the hallway twice this shift with crutches.
D.The patient is unable to bear weight on right lower extremity.
C.Provide assistance while the patient walks in the hallway twice this shift with crutches.
A patient is admitted to the hospital with shortness of breath. As the nurse assesses this patient, the nurse is using the process of: A. evaluation. B. data collection. C. problem identification. D. testing a hypothesis.
Data Collection
Gtt
drop or gtts drops
What two things are assessed in the lungs?
Ventilation and Respiration
Ventilation = air in and out
Respiration = ability to utilize air (pulse ox)
LOC
Level of Consciousness
Coping / Stress
- Self Reported Stress Level
- Coping Mechanisms?
- Hospitalization concerns
AKA
Above the Knee Amputation
What type of information goes into the general survey?
Two identifiers, 360 safety check, general orientation, mood, visual appearance, body language, obvious physical signs, mental state
After assessing a patient, a nurse develops a standard formal nursing diagnosis. What is the rationale for the nurse’s actions?
A.To form a language that can be encoded only by nurses
B.To distinguish the nurse’s role from the physician’s role
C.To develop clinical judgment based on other’s intuition
D.To help nurses focus on the scope of medical practice
B.To distinguish the nurse’s role from the physician’s role
A novice nurse asks the preceptor to describe the primary purpose of evaluation. Which statement made by the nursing preceptor ismostaccurate?
A.“An evaluation helps you determine whether all nursing interventions were completed.”
B.“During evaluation, you determine when to downsize staffing on nursing units.”
C.“Nurses use evaluation to determine the effectiveness of nursing care.”
D.“Evaluation eliminates unnecessary paperwork and care planning.”
C.“Nurses use evaluation to determine the effectiveness of nursing care.”
SOB
shortness of breath
DOE
dyspnea on exertion
A nurse in a provider's office is orienting a newly licensed nurse on how to position a client for vaginal examination. The nurse should include in the teaching to place the client in which of the following positions? A. Lithotomy B. Dorsal recumbent C. Prone D. Lateral recumbent
A. Lithotomy
Sleep/ Rest
- Hours of Sleep per night?
- Consecutive/intermittent?
- Naps?
- Methods/Meds to promote sleep?
- Feel rested?
A nurse is teaching a client who has rheumatoid arthritis about increasing physical rest as part of her treatment plan. Which of the following outcomes of this intervention should the nurse document as a goal for this client?
A. Reduced joint stress
B. Maintenance of joint function
C. Suppression of the inflammation process
D. Decreased stiffness
A. Reduced joint stress
You are invited to attend the weekly unit patient care conference. The staff discusses patient care issues. This type of communication is:
A. public.
B. intrapersonal.
C. transpersonal.
D. small group.
Small group
Na
Sodium
Fx
Fracture
h/o
history of
A nurse is assessing a client who has a fracture of the femur. The nurse obtains vital signs on admission and again in 2 hours. Which of the following changes in assessment should indicate to the nurse that the client could be developing a serious complication?
A. Increased respiratory rate from 18 to 44/min.
B. Increased oral temperature from 36.6° C (97.8° F) to 37° C (98.6° F).
C. Increased blood pressure from 112/68 to 120/72 mm Hg.
D. Increased heart rate from 68 to 72/min.
A. Increased respiratory rate from 18 to 44/min.
I&D
Incision and Drainage
cc
cubic centimeters
NSR
Normal Sinus Rhythm
BID
Twice daily
Values / Beliefs
- Religious Preference?
- Spiritual Preference?
- Concerns?
LLQ/LUQ
left lower/upper quadrant of the abdomen
Which information concerning a goal indicates a nurse has a good understanding of its purpose?
A.It is a statement describing the patient’s accomplishments without a time restriction.
B.It is a realistic statement predicting any negative responses to treatments.
C.It is a broad statement describing a desired change in a patient’s behavior.
D.It is a measurable change in a patient’s physical state.
C.It is a broad statement describing a desired change in a patient’s behavior.
PT
Physical therapy
Roles / Relationships
- Lives with?
- Married/Single/Widowed/Divorced?
- Children?
- Employment?
- Social Activities?
NV
Nausea and vomiting
Elimination
- Changes in Bowel or Bladder?
- Date of last BM
- Urine output (self/urinal/brief?)
DDX
Differential diagnosis
A nurse is planning care for a patient with a nursing diagnosis ofImpaired skin integrity.The patient needs many nursing interventions, including a dressing change, several intravenous antibiotics, and a walk. Which factors does the nurse consider when prioritizing interventions? (Select all that apply.)
A.Rank all the patient’s nursing diagnoses in order of priority.
B.Do not change priorities once they’ve been established.
C.Set priorities based solely on physiological factors.
D.Consider time as an influencing factor.
E.Utilize critical thinking.
A.Rank all the patient’s nursing diagnoses in order of priority.
D.Consider time as an influencing factor.
E.Utilize critical thinking.
