Nursing Interventions/Mgmt/Math/Informatics/Assessment Flashcards
The nurse attempts to determine whether learning outcomes were met after teaching a family about the importance of proper medication administration and by the practice of using weekly medication boxes with each day’s medications. Which learning outcome dimension is the nurse evaluating?
- Knowledge.
- Skills.
- Attitudes/Values.
- Behaviors.
2
The four learning outcome dimension include knowledge, skills, attitudes/values, and behaviors. The nurse is evaluating the skills of the family members by determining whether cognitive knowledge can be applied to healthy behaviors. The family members will still have to practice this skill to routinely implement the behavior, so the proper administration of prescribed medications is done.
What is the most important action for the nurse who is implementing a standing order?
- Compare the order with the client’s current status.
- Confirm the order with the healthcare provider.
- Transcribe the order into the record.
- Verify the order with another nurse.
1
The implementation of standing orders requires the nurse to use clinical judgment. Comparing the client’s current status with the order is one way to apply clinical judgment.
The nurse is reviewing the medication calcium acetate (Phoslo) with a client who receives dialysis three times per week. Which statement by the client indicates a need for additional client teaching?
- My dose of medication is based on my calcium levels.
- I should try to avoid dark green leafy vegetable such as spinach.
- My phosphate levels indicate the effectiveness of the medication.
- I should take this medication one hour before eating my meals or snacks.
4
For phosphate binding purposes, calcium acetate (Phoslo) should be taken one hour after each meal and snack and again at bedtime.
A client diagnosed with active pulmonary tuberculosis has been taking prescribed rifampin and isoniazid for the past two weeks. The client reports feeling tired all the time, loss of appetite and urine having a dark appearance. The nurse notices icterus in the client’s sclera and gums. Which lab test should the nurse request the healthcare provider to prescribe?
- Purified protein derivative skin test.
- Complete blood cell count with differential.
- Liver function test to include ALT, AST and bilirubin.
- Serum folate and vitamin B12.
3
A liver function test to include ALT, AST and bilirubin should be prescribed. Clients who are older than 35 years old and female should be monitored periodically because they are at increased risk of developing fatal hepatitis as a result of the treatment with rifampin and isoniazid, both used to manage tuberculosis.
The nurse assesses a pregnant client who has received oxytocin. Upon assessment, the nurse finds uterine tachysystole with nonreassuring fetal heart rhythm. Which action should the nurse take first?
- Stop the oxytocin.
- Administer 1000ml IV bolus of NS.
- Reposition the client in semi-fowler’s position.
- Prepare the client to deliver.
1
Uterine tachysystole is a condition of excessive uterine contractions and is considered an emergency causing potential to the fetus and an increase risk of uterine rupture. The first priority for the nurse is to reduce uterine contractions by stopping the oxytocin infusion.
A client is admitted for a thyroid scan to rule out Graves Disease. The nurse has delegated care of this client to an unlicensed assistive personnel (UAP). Which is the most important data that the UAP should report to the nurse immediately?
- Apical pulse of 110 beats per minute.
- Blood glucose reading of 150mg/dl.
- Presence of tremors and blurred vision.
- Temperature change from 99.1 to 100.1°F (37.3-37.8°C).
4
For the client with Graves disease (hyperthyroidism), an increase in temperature may indicate worsening of the condition and the onset of a thyroid storm. An increase of 1° F should be reported immediately.
The nurse is educating a pregnant client about breastfeeding. Which information should the nurse provide regarding effective breastfeeding of a healthy neonate?
- Breastfeeding should begin within the first hour of life.
- Breast milk should be supplemented with formula.
- Newborns should nurse every 2 to 3 hours.
- Pacifier should be used between feedings.
1
The nurse should educate clients on the benefits and best practices of establishing breastfeeding during the neonatal period. Exclusive breastfeeding provides adequate nutrition to a healthy neonate and should be encouraged within the first hour of life.
The nurse is tasked to develop a nursing employment outlook report. Which health care sector is expected to have the largest increase of open nursing positions?
- Acute care facilities.
- Outpatient centers.
- Long-term care facilities.
- Home health agencies.
4
The nurse leader must possess a thorough knowledge of recruitment in order to forecast needs and prevent shortages. Home health agencies are predicted to have the largest increase in open positions and needs due to the aging population and the shift in focus from institutionalization to home healthcare.
A client with asthma reports a pain level of 7 out of 10. The health care provider orders morphine 2 mg IV for pain. Which action should the nurse implement?
- Question the health care provider’s order.
- Administer the medication.
- Reassess the pain level.
- Measure the client’s respirations.
1
Morphine can exacerbate the symptoms of asthma, so this medication should be used with caution in clients with asthma. The nurse should question the health care provider’s order.
The nurse is teaching a group of adolescents about dealing with bullying. Which is the best strategy for teaching interpersonal skills?
- Worksheets.
- Discussion.
- Role-playing.
- Demonstration.
3
Role-playing can be effective in teaching parenting, relationship, and other interpersonal skills.
A nurse is educating a client about nutrition and celiac disease. Which should the nurse tell the client to avoid?
- Fruit.
- Cheese.
- Bread.
- Wine.
3
A client with celiac disease should maintain a gluten-free diet. Foods such as bread, cookies, cereal, and other products made with wheat, barley, or rye should be avoided.
The nurse is assessing a 4-year old child. Which best descirbe this chiild’s concept of illness?
- Possesses magical thoughts of how and why illness occurs.
- Demonstrates deep understanding of the cause of illness.
- Has a very concrete and rigid idea, but no abstract understanding.
- Little comprehension due to lack of life experiences, but can list the symptoms.
1
Possesses magical thoughts of how and why illness occurs.
A client with a body mass index (BMI) of 27 asks the nurse how much weight she should gain during her pregnancy with a single fetus. Which range should the nurse recommend?
a) 28-to-40 lbs (12.7 to 18.1 kg).
b) 25-to-35 lbs (11.3 to 15.9 kg).
c) 15-to-25 lbs (6.8 to 11.3 kg).
d) 11-to-20 lbs (4.9 to 9.1 kg).
3
With a body mass index (BMI) of 27, the client is considered overweight. A woman who is overweight should aim to gain 15 to 25 lbs (6.8 to 11.3 kg) during a single-fetus pregnancy.
The nurse is reviewing basic dietary guidelines with a client who is newly diagnosed with diabetes. Which statement by the client regarding macronutrients indicates a need for further education?
- “I should limit my carbohydrate intake to 80 grams a day.”
- “I should try to eat salmon or tuna a few times a week.”
- “Eating enough protein is important for improving my insulin response.”
- “My total fat intake should be limited to about 50 or 60 grams a day.”
1
Individuals with diabetes should be advised to consume at least 45% of their total calories from carbohydrates, with a minimum of 130 g per day. The nurse should explain to the client that consuming 80 grams of carbohydrates per day is not sufficient.
Cataracts Nursing Outcomes
Outcomes
The patient will verbalize questions and concerns regarding cataracts and the recommended surgical treatment.
The patient will have cataract surgery, when appropriate.
The patient will not fall.
The patient will assist with self-care to the fullest extent possible, as evidenced by fulfilling needs for cleanliness, grooming, and toileting.
The patient will report reduced anxiety, as evidenced by a relaxed state and learning about cataract surgery.
The nurse is interviewing for an open position at one of the city’s older hospital . Which factor should make the nurse most suspicious that retention efforts may be lacking at this facility?
- There are many open positions.
- The equipment is outdated.
- There are minimal educational opportunities.
- The pay scale is comparatively low.
1
Evidence indicates that nursing shortages and low staff satisfaction is directly related to a facility’s inability or unwillingness to retain existing staff. Therefore, a large number of open positions in an established facility is the best evidence that reflects of poor retention efforts on the part of the facility.
Which is true about the nurse delegating a task to an unlicensed assistive personnel (UAP)?
- The nurse retains accountability for client care.
- Clinical judgment is transferred to the UAP.
- Responsibility for the task is retained by the nurse.
- Clinical assessment is shared between the nurse and the UAP.
1
When delegating a task to a UAP, the nurse will always maintain accountability for client care.
The home health nurse completes documentation during a home client visit. Which is critical documentation to ensure continuity of care and continued reimbursement?
- Assessment completed.
- Education presented.
- Homebound status.
- Skilled care performed.
3
Home health documentation requires notation of assessment, services, and skilled care, education, observations, and evaluation requirements for reimbursement. Critical documentation for services is notation of homebound status at each visit or the client is ineligible for benefits.
The home health nurse completes documentation during a home client visit. Which is critical documentation to ensure continuity of care and continued reimbursement?
- Assessment completed.
- Education presented.
- Homebound status.
- Skilled care performed.
3
Home health documentation requires notation of assessment, services, and skilled care, education, observations, and evaluation requirements for reimbursement. Critical documentation for services is notation of homebound status at each visit or the client is ineligible for benefits.