Nursing Intro Exam 2 Flashcards
In the planning phase you will …?
- determine a short term goal
- create nursing interventions to help or reach that goal
- rationalize why we selected those interventions
How do we determine interventions?
- care plan books
- thinking outside of the box
What is the role of the pt in completing a goal?
- must partner with pt when setting their goal (ask what they want to achieve!)
- allow pt to fully participate in POC
- pt will be aware of identified needs
- pt can accept and embrace mutually agreed-on goals
What is a goal?
A broad statement describing a desired change in a pt’s behavior
What is an expected outcome/SMART goal?
A measurable change that must be achieved to reach the broad goal
Measurable change- pt behavior, physical state, perception
Who makes the goals for the pt?
The nurse
When making a goal …
- be creative and determine what your individual can or cant manage and achieve
- keep your goal small and measurable
- goals are about the pt not the nurse!
What is the S in a SMART goal?
Specific: well defined, clear/understandable to outsider
What is the M in a SMART goal?
Measurable: able to know when this goal is accomplished
What is the A in a SMART goal?
Attainable: achievable, acceptable
What is the R in a SMART goal?
Realistic: relevant, reasonable, can be completed within availability of resources
What is the T in a SMART goal?
Timely: included a time of day and day of week for goal to be achieved
What are some examples of nursing SMART goals?
- resident will ambulated 15ft (from baseline 10ft) using walker and one-person standby assist by 1400 on 2/27/20.
- resident will exhibit SPO2 of 80 or higher from 0700 to 1400 on 2/27/20.
- resident will describe 3 ways to prevent falls by 1400 on 2/20/20.
What are some examples of un- SMART nursing goals?
- resident will breathe better with less shortness of breath by 1400 on 8/27/20
- resident will ambulated farther than 8/26 on 8/27
- resident will have intake of 200mL from 0700-1400
What is a short term goal?
Outcome that will occur within 1-8 weeks (usually less than 1 week)
What is a long term goal?
Outcome that will occur within several weeks- months (usually 3-6 months out)
What are interventions?
what you, the nurse, will do to help your pt reach their SMART goal
Interventions CANNOT be …
a task or skill that you already perform on a daily basis i.e in your nursing scope of practice
Ex: turning pt, listening to lung sounds, etc.
You should always make your interventions _____ to your pt
specific
What are some intervention pieces we should avoid?
- education interventions for memory impaired individuals
- avoid “encouraging” interventions
- avoid “assessment” interventions (unless performing more frequently than normal/necessary)
What is a rationale?
When you rationalize WHY you chose a specific intervention and explain HOW it will help your pt reach their goal
If you use a intervention/rationale from another source what must you include?
an in-text citation
When creating nursing interventions nurses need to …
- know the scientific rationale for the interventions
- possess the necessary psychomotor and interpersonal skills
- be able to function within a setting to use health care resources effectively
What is a nurse-initiated intervention?
independent nursing interventions - actions that a nurse initiates
*no need for supervision or direction from others
What is a health care provider initiated intervention?
Dependent nursing interventions - required an order from a physician or other health care professional
- based in health care providers response to treating/ managing a medical diagnosis
ex: administering meds
What is a collaborative intervention?
Interdependent nursing interventions- requires combined knowledge, skill, and experience of multiple health care professionals
ex: PT, RT, OT, speech, dietary
When preparing for a physician- initiated or collaborative interventions …
DO NOT automatically implement the therapy, but determine whether it is appropriate for the pt
What is a direct care intervention?
interactions involving the pt and nurse
ex: ambulation, teaching how to perform wound care
What is an indirect intervention?
an intervention NOT involving the pt
ex: documenting response to pain meds
What are six factors to consider when selecting interventions?
- Desired pt outcomes
- Characteristics of the nursing diagnosis
- Research-based knowledge for the intervention
- Feasibility of the interventions
- Acceptability to the pt
- Nurse’s competency
What is consultation?
A process by which you seek the expertise of a specialist such as your nursing instructor, a physician, or a clinical nurse educator to identify ways to handle problems in pt management or in planning and implementation of therapies.
Consultation can occur at any step in the nursing process but most often during ___?
planning and implementations
When and how to consult
How: begin with your understanding of the pt’s problem
- direct the consultation to the right professional
- provide the consultant with relevant info about the problem are: summary, methods used to date, outcomes
- do not influence consultants
- be available to discuss the consultants findings
- incorporate the suggestions
When does implementation begin?
After POC is developed
Reminder!
- interventions are designed based on diagnoses
- interventions are what the nurse does to help the pt reach their goal
A.D.P
Assessment: pt is unable to bear weight on right lower extremity
Diagnosis: impaired physical mobility related to musculoskeletal impairments as evidenced by limited ROM in right lower extremity, complaints of weakness in right lower extremity, and reluctance to move right lower extremity
SMART goal: pt will ambulated 15ft with a one person assist three times a day by 1400 on 2/27/20
Interventions: pt will perform 3 sets of lower extremity ROM exercises each shift
Critical thinking in implementation includes …
- making appropriate conclusions about interventions to address a pt’s response to health conditions or life processes
- requires nurse to use or modify standard approaches, sometimes improvise new ones
- nurse must determine whether an intervention is correct and appropriate for the given situation
Tips for making decisions during implementation
- review the set of all possible nursing interventions for a pt’s problem
- review all possible consequences associated with each possible nursing action
- determine the probability of all possible consequences
- judge the value of the consequence to the pt
What do you need to prepare for implementation?
- decide to perform intervention
- pt
- time management
- equipment
- personnel
- environment
How can we prevent complications?
- identify risks to the pt
- adapt interventions to the situation
- evaluate the relative benefit of a treatment vs the risk
- initiate risk- prevention measures
When identifying areas of assistance …
- seek information about a procedure
- collect all necessary equipment
- ask another nurse provide assistance and guidance
What is a cognitive skill?
includes critical thinking and decision making skills
What is an interpersonal skill?
develop trusting relationships, express level of caring, communicate clearly with pt’s and families
What is a psychomotor skill?
requires integration of cognitive and motor activities (i.e giving a shot)
Direct care
- ADL’s
- instrumental ADL’s (shopping, cleaning, cooking, etc)
- physical care techniques
- lifesaving measures
- teaching, counseling, controlling adverse reactions, preventative measures
Indirect care
Nursing actions that manage the pt care environment and interdisciplinary collaborative actions that support the effectiveness of direct care interventions
- communicating nursing interventions
- delegating, supervising, evaluating
- documenting
When achieving pt goals …
- nurses implement care to meet pt goals
- multiple interventions may be needed
- priorities help nurses to anticipate and sequence nursing interventions
- pt adherence means that the pt and families invest time in carrying out required treatments
What is the final step of the nursing process?
Evaluation
What do you accomplish in this step?
- determine if your pt’s condition or well-being has improved
- perform evaluative measures to determine if that pt has met the expected outcomes
- NOT to determine if nursing interventions were completed
Once you deliver an ____, you continuously examine & evaluate results by gathering subjective and objective data from the pt, family, and health care team
Intervention
What do you do when you are examining results?
- review knowledge regarding a pt’s current condition, the treatment, and the resources available for recover
- by reflecting on previous experiences caring for similar pt’s, you are in a better position to know how to evaluate your pt
What are evaluative measures?
assessment skills and techniques (observation, physiology, measurements, pt interviewing)
- evaluating behavior
- self management
What is comparing achieved effects with goals and outcomes?
- compare clinical data, pt behavior measures, and pt self report measures collected before implementation with the evaluation findings gathered after administering nursing care
- evaluate whether the results of care match the expected outcomes and goals set for a pt
- be sure to differentiate between evaluation and other steps of nursing process
How do you interpret and summarize findings?
- clinical conditions can change rapidly
- make clinical judgements on basis of observations of a specific pt
- be detailed with evaluation measures (bc change may not be obvious)
When is the only time you discontinue a care plan?
- after nurse determines pt met expected goal
- discuss with pt prior to discontinuation
Modifying a care plan
- reassessment
- redefining diagnosis
- goals (if not met, identify why)
- interventions
- a change in one health care problem sometimes affects the goals for others
What are the standards for evaluation?
- resolve actual health problems
- prevent potential problems
- maintain a healthy state
Competencies include?
- being systematic
- using criterion-based evaluation
- collaborating
- using ongoing assessment data to revise care plan
- communicating results
When you collaborate and evaluate the effectiveness of interventions, you ask ?
- family
- healthcare team
When documenting your results you must?
describe interventions, evaluative measures used, outcomes, and continued plan of care
____ are responsible for making accurate and appropriate clinical decisions or judgements.
RNs
To make an appropriate clinical decision, one must use _____?
critical thinking
What separates a professional nurse from a technician?
The ability to use critical thinking and have clinical decision making skills
The ability to think in a systematic and logical manner with openness to question and reflect on the reasoning process is?
critical thinking
When critical thinking we need to …
recognize that an issue exists, analyze information, evaluate information, and drawing conclusions
What is reflection?
- the ability to act on the basis of critical thinking that comes with experience
- turning over a subject in the mind and thinking about it seriously
What is the nursing process as a competency?
ADPIE
What do you need for a model components?
- specific knowledge base (drawn from nursing school education)
- experience (obtained through clinical situations)
- nursing process competency
- attitudes for clinical thinking
- professional standards
What is critical thinking synthesis?
critical thinking and the nursing process go hand in hand in making quality decisions about pt care
What are attitudes a nurse needs?
confidence independence fairness responsibility risk taking discipline perseverance creativity curiosity integrity humility
What is reflective journaling?
a tool used to clarify concepts through reflection by thinking back or recalling situations, express experiences in your own words
What is concept mapping?
A visual representation of pt problems and interventions that illustrates an interrelationship
What is involved when meeting with colleagues?
discussing and examining work experiences and validate decisions
The work of professional nursing is difficult as you see pt’s endure suffering from disease and painful therapies and as you try to manage care responsibilities in busy, fast-paced work settings. This can cause ___?
stress
Effective _____ is needed between RNs and NAP for giving feedback and clarifying tasks and pt status.
Communication
When pt’s clinical decisions change, warranting attention by RNs, clear directions are necessary to avoid ____?
missed care
Applying critical thinking can help an RN make the decision about when to appropriately ____ care
delegate
When caring for groups of pt’s …
- identify nursing diagnoses and collaborative problems of each pt
- decide with are most urgent
- consider the time it will take to care for those pt’s
- consider the resources that you have to manage each problem
- consider how to involve the pt as participants in care
- decide how to combine activities
- decide which nursing care procedures to delegate
- discuss complex cases with the health care team
Setting priorities for a pt’s nursing diagnoses or health problems is an important step in planning pt care. Which of the following statements describe elements to consider in planning care? (Select all that apply)
- Priority setting established a preferential order for nursing interventions
- In most cases wellness problems take priority over problem focused problems
- Recognition of symptom patterns helps in understanding when to plan interventions
- Longer term chronic needs require priority care over short term problems
- Priority setting involves creating a list of care tasks
«< answer
- Priority setting established a preferential order for nursing interventions
- Recognition of symptom patters helps in understanding when to plan interventions
Match the elements for correct identification of outcome statements with the SMART acronym terms below
SPECIFIC
A. Mutually set an outcome that a pt agrees to meet
B. Set an outcome that a pt can meet based upon his or her physiological, emotional, economic, and sociocultural resources
C. Be sure an outcome addressed only one pt 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 pt status
«< answer
C. Be sure an outcome addresses only one pt behavior or response
Match the elements for correct identification of outcome statements with the SMART acronym terms below
MEASURABLE
A. Mutually set an outcome that a pt agrees to meet
B. Set an outcome that a pt can meet based upon his or her physiological, emotional, economic, and sociocultural resources
C. Be sure an outcome addressed only one pt 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 pt status
«< answer
E. Use a term in an outcome statement that allows for observation as to whether a change takes place in a pt status
Match the elements for correct identification of outcome statements with the SMART acronym terms below
ATTAINABLE
A. Mutually set an outcome that a pt agrees to meet
B. Set an outcome that a pt can meet based upon his or her physiological, emotional, economic, and sociocultural resources
C. Be sure an outcome addressed only one pt 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 pt status
«< answer
A. Mutually set an outcome that a pt agrees to meet
Match the elements for correct identification of outcome statements with the SMART acronym terms below
REALISTIC
A. Mutually set an outcome that a pt agrees to meet
B. Set an outcome that a pt can meet based upon his or her physiological, emotional, economic, and sociocultural resources
C. Be sure an outcome addressed only one pt 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 pt status
«< answer
B. Set an outcome that a pt can meet based upon his or her physiological, emotional, economic, and sociocultural resources
Match the elements for correct identification of outcome statements with the SMART acronym terms below
TIMED
A. Mutually set an outcome that a pt agrees to meet
B. Set an outcome that a pt can meet based upon his or her physiological, emotional, economic, and sociocultural resources
C. Be sure an outcome addressed only one pt 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 pt status
«< answer
D. Include when an outcome is to be met
A nursing student is providing a hand off report to the RN assuming care of her pt. 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 pt 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 IV site and started a new bag of D51/2 NS. Which intervention is a dependent intervention?
- Providing hand off report at change of shift
- Enhancing the pt’s sleep hygiene
- Administering IV fluids
- Taking vital signs
«< answer
- Administering IV fluids
A nurse is assigned to care for six pt’s at the beginning of the night shift. The nurse learns that the floor will be short by one RN as a result of a call-in. A pt care technician from another area is coming to the nursing unit to assist, because the unit requires hourly rounds on all pt’s, the nurse begins to make rounds on a pt who recently asked for a pain medication. The nurse is interrupted by another RN who asks about another pt. Which factors in this nurses units environment will affect the ability to set priorities? (Select all that applies)
- Policy for conducting hourly rounds
- Staffing level
- Interruption by staff nurse colleagues
- Type of hospital unit
- Competency of pt care technician
«< answer
- Staffing level
- Interruption by staff nurse colleagues
- Competency of pt care technician
A nursing student is providing a hand off report to a RN who is assuming her pt’s care at the end of the clinical day. The student states, “The pt had a good day. His IV fluid is infusing at 124 mL/hr with D51/2NS 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, respiration’s 14, heart rate 88 after exercise. He used his walker without difficulty, gait normal. The pt ate 3/4 of his dinner with no gastrointestinal complaints. For the goal of improving the pt’s activity tolerance, which expected outcomes were shared in the hand off? (Select all that apply)
- IV site not tender
- Uses walker to walk
- Walked to visitors lounge
- No shortness of breath
- Tolerated dinner meal
«< answer
- Walked to visitors lounge
4. No shortness of breath
Which of the following factors should be considered when choosing and intervention for a pt’s plan of care? (Select all that apply)
- The specific pt outcome against which to judge effectiveness of interventions
- The timing of care activities routinely conducted in the care unit
- The scientific evidence available in support of n intervention
- The amount of time required for implementation in consideration of pt’s condition
- The pt’s valued and beliefs regarding the intervention
«< answer
- The specific pt outcome against which to judge effectiveness of interventions
- The scientific evidence available in support of n intervention
- The amount of time required for implementation in consideration of pt’s condition
- The pt’s valued and beliefs regarding the intervention
A nurse on a hospital unit is preparing to hand off care of a pt being discharged to a home health nurse. Match the activities on the left with the hand off report categories on the right.
Activities (left side)
- Use a standard checklist for the report
- Encourage questions & clarification
- Offer specific info on how to reduce pt’s risk
- Give report at time when shift had ended and other nurses are requesting info
- Explain how pt’s discharge was delayed by insufficient numbers of staff
- Organize time by preparing in advance what to report
Categories (right side)
A. Strategy for effective hand off
B. Strategy for ineffective hand off
«< answer
A. Strategy for effective hand off
- Use a standard checklist for the report
- Encourage questions & clarification
- Offer specific info on how to reduce pt’s risk
B. Strategy for ineffective hand off
- Give report at time when shift had ended and other nurses are requesting info
- Explain how pt’s discharge was delayed by insufficient numbers of staff
- Organize time by preparing in advance what to report
A pt diagnosed with colon cancer has been receiving chemotherapy for 6 weeks. The pt visits the outpatient infusion center twice a week for infusions. The nurse assigned to the pt is having difficulty accessing the pt’s 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 team? (Select all that apply)
- Ask the IV nurse to come to the infusion center at a time when the nurse starts care for a second pt
- Specifically identify the problem of port obstruction, and attempt to flush the port to resolve the problem
- Explain to the IV nurse the frequency in which this port has obstructed in the past
- Tell the IV nurse the problem is probably related to the physician who inserted the port
- Describe to the IV nurse the type and condition of the port currently in use
«< answer
- Specifically identify the problem of port obstruction, and attempt to flush the port to resolve the problem
- Explain to the IV nurse the frequency in which this port has obstructed in the past
- Describe to the IV nurse the type and condition of the port currently in use
A nurse assesses a 78-year-old pt who weighs 108.9 kg (240 lb) and is partially immobilized because of a stroke. The nurse turns the pt and finds that the skin over the sacrum is very red and the pt does not feel sensation in the area. The pt identified the nursing diagnosis of Risk for Impaired Skin Integrity. Which of the following outcomes is appropriate for the pt?
- Pt will be turned every 2 hrs within 48 hrs
- Pt will have normal formed stool within 48 hrs
- Pt’s ability to turn self in bed improves
- Erythema of skin will be mild to none within 48 hrs
«< answer
- Erythema of skin will be mild to none within 48 hrs
An 82-year- old pt 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 (left side)
- Pt will ambulated independently in 3 days
- Pt will be injury free for 1 month
- Pt will achieve 5 lb weight gain in 1 month
- Pt will achieve pain relief by discharge
Outcomes (right side)
A. Pt expresses fewer nonverbal signs of discomfort within 24 hrs
B. Pt increased caloric intake to 2500 calories daily
C. Pt walks 20 ft using a walker in 24 hrs
D. Pt identified barriers to remove in the home within 1 week.
«< answer
- = C
- = D
- = B
- = A
A nurse is assigned five pt’s, including one who was recently admitted and one returning from a diagnostic procedure. It is currently mealtime. The other three pt’s are stable but one has just requested a pain medication. The nurse is working with an assistive personnel. Which of the following are appropriate delegation actions on the part of the nurse? (Select all that apply)
- The nurse directs the assistive personnel to obtain a set of vital signs on the pt returning from the diagnostic procedure
- The nurse directs the pt care technicians to go to the pt in pain and to reposition and offer comfort measures until the nurse can bring an ordered analgesic to the pt
- The nurse directs the pt care technician to set up meal trays for pt’s
- The nurse directs the pt care technician to gather a history from the newly admitted pt about his medications
- The nurse directs the pt care technician to assist one of the stable pt’s ip in a chair for his meal
«< answer
- The nurse directs the pt care technicians to go to the pt in pain and to reposition and offer comfort measures until the nurse can bring an ordered analgesic to the pt
- The nurse directs the pt care technician to set up meal trays for pt’s
- The nurse directs the pt care technician to assist one of the stable pt’s ip in a chair for his meal
A nurse enters a pt’s room at the beginning of a shift to conduct an assessment of his condition following a blood transfusion. The nurse cared for the pt on the previous day as well. The pt has a number of issues he wished to share with the nurse, who takes time to explore each issue. The nurse also assessed the pt and finds no sxs of a reaction to the blood product. The nurse observed the pt the day prior and sees a change in his behavior, a reluctance to get out of bed and ambulate. Which of the following actions improve the nurses ability to make clinical decisions about this pt? (Select all that apply)
- Working the same shift each day
- Spending time during the pt assessment
- Knowing the early mobility protocol guidelines
- Caring for the pt on consecutive days
- Knowing the pattern of pt behavior about ambulation
«< answer
- Spending time during the pt assessment
- Caring for the pt on consecutive days
- Knowing the pattern of pt behavior about ambulation
Match the concepts for a critical thinker on the right with the application of the term on the left
(Left)
A. Anticipate how a pt might respond to a treatment
B. Organize assessment on the basis of pt priorities
C. Be objective in asking questions of a pt
D. Be tolerant of the pt’s views and beliefs
(Right)
- Truth seeking
- Open mindedness
- Analyticity
- Systematicity
«< answer
- = C
- = D
- = A
- = B
A nurse has seen many cancer pt’s struggle with pain management because that are afraid of becoming addicted to the medicine. Pain control is a priority for cancer care. By helping pt’s focus on their values and beliefs about pain control, a nurse can best make clinical decisions. This is an example of:
- Creativity
- Fairness
- Clinical reasoning
- Applying ethical criteria
«< answer
- Applying ethical criteria
The reflect model can improve learning after providing of care. Place the steps of this model in the correct order:
- Think about your thoughts and actions at the time of a situation
- Review the knowledge you gained from the experience
- Review the facts of the situation
- Set a schedule for completing your plan of action
- Consider options for handling a similar situation in the future
- Recall any feelings you had at the time of the situation
- Create a plan for future situations
«< answer
3, 1, 6, 2, 5, 7, 4
One element of clinical decision making is knowing the pt. Which of the following activities affect a nurses ability to know pt’s better? (Select all that apply)
- Caring for similar groups of pt’s over time
- Reading the evidence based practices appropriate to pt’s
- Learning how pt’s typically respond to their clinical situations
- Observe pt’s
- Engaging with pt’s experiencing illness
«< answer
- Caring for similar groups of pt’s over time
- Learning how pt’s typically respond to their clinical situations
- Observe pt’s
- Engaging with pt’s experiencing illness
A nurse is preparing medications for a pt. The nurse checks the name of the medication on the label with the name of the medication in the doctors order. At the bedside the nurse checks the pt’s name against the medication order as well. The nurse is following which critical thinking attitude?
- Responsibility
- Humility
- Accurate
- Fairness
«< answer
- Responsibility
A nurse has been caring for a pt with a chronic wound that has not been healing. The nurse talks with a nurse specialist in wound care to find alternative approaches from what the health care provider ordered for dressing and wound. The two decide that because if the pt’s allergy to tape a nonallergenic dressing will be used. The nurse obtains an order from the health care provider for the new dressing. After two days there is improvement in the wound. This is an example of which critical thinking standards? (Select all that apply)
- Clear
- Broad
- Relevant
- Risk taking
- Creativity
Answer - 3, 4, 5
A nurse is assigned to care for a woman who is expecting her first child. The nurse organizes herself and plans to gather data about the pt by applying Pender’s health promotion model, including the pt’s characteristics and experiences and situational influences. She plans to observe pt behavior and consider the pt’s psychosocial issues. Such data will offer a clear understanding to help the nurse identify the pt’s needs. This is an example of which of the following concepts? (Select all that apply)
- Diagnostic reasoning
- Deductive reasoning
- Inductive reasoning
- Assessment
- Problem solving
«< answer
- Deductive reasoning
4. Assessment
A nurse is caring for a pt who has poor pain control. The pt’s has a history of opioid abuse. During the day the pt made frequent requests for a pain medication. In order to make an effective clinical decision about the pt, the nurse needs to ask questions about the data available in the pt to make a thorough and thoughtful decision. The nurse asks herself, “How does my view about the pt’s pain tolerance compare with the pt’s, and does that pose a problem?” This is an example of:
- A question about assumptions
- A question about evidence
- A question about procedure
- A question about perspective
«< answer
- A question about perspective
Which of the following describes a nurses application of a specific knowledge base during critical thinking? ( select all that apply)
- Initiative in reading current evidence from the literature
- Application of nursing theory
- Reviewing a policy and procedure manual
- Considering a colleague’s view of a pt’s needs
- Previous time caring for a specific group of pt’s
«< answer
- Initiative in reading current evidence from the literature
- Application of nursing theory
A nurse working the evening shift has five pt’s and is teamed up with a NAP. One of the assigned pt’s has just returned from surgery, three others are stable and resting, and one has requested pain medication. The pt in pain has two analgesics ordered PRN for pain and has been using cold applications on his surgical site for pain relief. The last time an analgesic was given was 4 hours ago. The pt is scheduled for a physical therapy visit in 2 hours. Which of the following demonstrate good clinical decision making during interventions? (Select all that apply)
- The nurse reviews the options for pain relief for the pt
- The nurse assesses whether PRN medication, ordered every 4 to 6 hours and last given 4 hours ago, is effective and whether a new type of medication is needed.
- The nurse reviews the policy and procedure for the cold application.
- The nurse considers how the pt might react if the pain medication is held until an hour before physical therapy.
- The nurse delegates vital sign assessment of the pt returning from surgery to the assistive personnel.
«< answer
- The nurse reviews the options for pain relief for the pt
- The nurse assesses whether PRN medication, ordered every 4 to 6 hours and last given 4 hours ago, is effective and whether a new type of medication is needed.
- The nurse considers how the pt might react if the pain medication is held until an hour before physical therapy.
A nurse working the evening shift has five pt’s and is teamed up with an assistive personnel. One of the assigned pt’s has just returned from surgery, one is newly admitted, and one has requested a pain medication. The pt who has returned from surgery just minutes ago has a large abdominal dressing, is still on oxygen via nasal cannula, and has an IV line. One of the other pt’s has just called out for assistance in setting up a meal tray. Another pt is stable and resting comfortably. Which pt is the nurse’s cirrent greatest priority?
- Pt in pain
- Pt newly admitted
- Pt who returned from surgery
- Pt requesting assistance with meal tray
«< answer
- Pt who returned from surgery
The nurse administers a tube feeding via a pt’s nasogastric tube. This is an example of which of the following?
- Physical care technique
- Activity of daily living
- Indirect care measure
- Lifesaving measure
Which principle is most important for a nurse to follow when using a clinical practice guideline for an assigned pt?
- Knowing the source of the guideline
- Reviewing the evidence used to develop the guideline
- Individualizing how to apply the clinical guideline for a pt
- Explaining to a pt the purpose of the guideline
«< answer
- Individualizing how to apply the clinical guideline for a pt
A nurse is visiting a pt who lives alone at home. The nurse is assessing the pt’s adherence to medications. While talking with the family caregiver, the nurse learns that the pt has been missing doses. The nurse wants to perform interventions to improve the pt’s adherence. Which of the following will affect how this nurse will make clinical decisions about how to implement care for the pt? (select all that apply)
- Reviewing the family caregiver’s availability during medication administration times.
- Determining the value the pt places on taking medications
- Reviewing the number of medications and time each is to be taken
- Determining all consequences associated with the pt missing specific medications
- Reviewing the therapeutic actions of the medications
«< answer
- Determining the value the pt places on taking medications
4. Determining all consequences associated with the pt missing specific medications
The nurse enters a pt’s room and finds that the pt was incontinent of liquid stool. Because the pt has recurrent redness in the perineal area, the nurse worries about the risk of the pt developing a pressure injury. The nurse cleanses the pt, inspects the skin, and applies a skin barrier ointment to the perineal area, The nurse consults the ostomy and wound care nurse specialist for recommended skin care measures. Which of the following correctly describe the nurse’s actions? (select all that apply)
- The application of the skin barrier is a dependent care measure
- The call to the ostomy and wound care specialist is an indirect care measure
- The cleansing of the skin is a direct care measure
- The application of the skin barrier is an instrumental activity of daily living
- Inspecting the skin is a direct care activity
«< answer
- The call to the ostomy and wound care specialist is an indirect care measure
- The cleansing of the skin is a direct care measure
Match the category of direct care on the left with the specific direct care activity on the right.
Left
- Counseling
- Lifesaving measure
- Physical care technique
- Activity of daily living
Right
A. Assisting pt with oral care
B. Discussing a pt’s options in choosing palliative care
C. Protecting a violent pt from injury
D. Using safe pt handling during positioning of a pt
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- = B
- =C
- =D
- =A
Which measures does a nurse follow when being asked to perform an unfamiliar procedure? (select all that apply)
- Checks scientific literature or policy and procedure
- Determines whether additional assistance is needed
- Collects all necessary equipment
- Delegates the procedure to a more experienced nurse
- Considers all possible consequences of the procedure
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- Checks scientific literature or policy and procedure
- Determines whether additional assistance is needed
- Collects all necessary equipment
- Considers all possible consequences of the procedure
A nurse is conferring with another nurse about the care of a pt with a stage 2 pressure injury. The two decide to review the clinical practice guideline of the hospital for pressure injury care. The use of a clinical practice guideline achieves which of the following? (select all that apply)
- Allows nurses to act more quickly and appropriately
- Sets a level of clinical excellence for practice
- Eliminates need to create an individualized care plan for the pt
- Incorporates evidence-based interventions for stage 2 pressure injury
- Provides for access to pt care information within the electronic health record
«< answer
- Allows nurses to act more quickly and appropriately
- Sets a level of clinical excellence for practice
- Incorporates evidence-based interventions for stage 2 pressure injury
A nurse admits a 32-year-old pt for treatment of acute asthma. The pt has labored breathing, a respiratory rate of 28 per minute, and lung sounds with bilateral wheezing. The nurse makes the pt comfortable and starts an ordered IV infusion to administer medication that will relax the pt’s airways. The pt tells the nurse after the first medication infusion, “I feel as if i can breath better”. The nurse auscultates the pt’s lungs and notes decreased wheezing with a respiratory rate of 22 per minutes. Which of the following is an evaluative measure? (select all that apply)
- Asking pt to breathe deeply during auscultation
- Counting respirations per minute
- Asking the pt to describe how his breathing feels
- Starting the IV infusion
- Auscultating lung sounds
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- Counting respirations per minute
- Asking the pt to describe how his breathing feels
- Auscultating lung sounds
A pt has labored breathing, a respiratory rate of 28 per minute, and lung sounds that reveal wheezing bilaterally. The nurse starts an ordered IV infusion to administer medication that will relax the pt’s airways. When the nurse asks how the pt feels, he responds by saying, “I feel as if i can breath better”. The nurse auscultates the pt’s lungs and notes decreased wheezing with a respiratory rate of 22 per minutes. Which of the following evaluative measures may not reflect change in a pt’s condition?
- Counting respirations per minute
- Asking the pt to describe how his breathing feels
- Observing breath patterns
- Auscultating lung sounds
«< answer
- Asking the pt to describe how his breathing feels
Which of the following statements correctly describes the evaluation process? (select all that apply)
- Evaluation involves reflection on the approach to care
- Evaluation involves determination of the completion of a nursing intervention
- Evaluation involves making clinical decisions
- Evaluation requires the use of assessment skills
- Evaluation is performed only when a pt’s condition changes
«< answer
- Evaluation involves reflection on the approach to care
- Evaluation involves making clinical decisions
- Evaluation requires the use of assessment skills
A nurse in a community health clinic has been caring for a young female teenager with diabetes for several months. The nurse’s goal of care for this pt is to achieve self-management of insulin medication. Identify appropriate evaluative measures for self-management for this pt. (select all that apply)
- Quality of life
- Pt satisfaction
- Clinic follow-up visits
- Adherence of self-administration of insulin
- Description of side effects of medications
«< answer
- Quality of life
- Clinic follow-up visits
- Adherence of self-administration of insulin
From the following list of indicators, determine which indicators are foals and which indicators are outcomes.
- Will achieve pain relief
- Ambulates 10 ft down hallway
- Will remain free of infection
- Will be afebrile
- Reports pain severity reduced from 6 to a 4 on scale of 0 to 10
- Will gain improved mobility
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- G
- O
- G
- G
- O
- G
A nurse has been caring for a pt over 2 consecutive days. During that time the pt had an IV catheter in the right forearm. At the end of shift on the second day the nurse inspects the catheter site, observes for redness, and asks whether the pt feels tenderness when the site is palpated. The nurse reviews the medical record from 24 hours ago and finds the catheter site was without redness or tenderness. Which of the activities below reflect the nurse’s ability to perform pt evaluation? (select all that apply)
- Comparing pt response with previous response
- Examining results of clinical data
- Recognizing error
- Self-reflection
- Checking medical record for when IV was inserted
«< answer
- Comparing pt response with previous response
2. Examining results of clinical data
A nurse asks how a pt’s condition from a serious infection changed since yesterday while receiving a hand off report. The nurse leaving the shift reports the pt has two priority nursing diagnoses - fluid imbalance and fever. The receiving nurse begins to provide care by measuring the pt’s body temperature, inspecting the condition of the skin, reviewing the intake and output record, and checking the summary notes describing the pt’s progress since the day before. The nurse asks a technician to measure intake and output during the shift. What critical thinking indicators reflect the nurse’s ability to perform evaluation? (select all that apply)
- Checking the summary notes
- Asking the leaving RN about the pt’s condition
- Assigning the technician to measure intake and output
- Comparing current outcomes with those set for the pt’s goals
- Reflecting on pt’s progress
«< answer
- Checking the summary notes
- Asking the leaving RN about the pt’s condition
- Comparing current outcomes with those set for the pt’s goals
- Reflecting on pt’s progress
A nurse in the recovery room is monitoring a pt who has a left knee replacement. The pt arrived in recovery 15 minutes ago. The nurse observes that pt to be restless, turning frequently, and groaning; the pt’s heart rate is 92 compared with 76 preoperatively. BP is stable since admission to the recovery room. The nurse reviews the medical orders for analgesic therapy. The nurse notes that the postop dose of an ordered analgesic has not yet been given. What is most likely to cause the nurse to reflect on the pt’s situation?
- The pt is recovering normally
- The symptoms reflecting restlessness
- The pt’s BP trend
- The delay in administration of the analgesic
«< answer
- The delay in administration of the analgesic
A nurse enters a pt’s room and begins a conversation. During this time the nurse evaluates how a pt is tolerating a new diet plan. The nurse decides to also evaluate the pt’s expectations of care. Which of the following is appropriate for evaluating a pt’s expectations of care?
- On a scale of 0-10 rate your level of nausea
- The nurse weighs the pt
- The nurse asks, “Did you believe that you received the information you needed to follow the diet?”
- The nurse states, “Tell me four different foods included in your diet.”
«< answer
- The nurse asks, “Did you believe that you received the information you needed to follow the diet?”
Which of the following statements correctly describe the evaluation process? (select all that apply)
- Evaluation is an ongoing process
- Evaluation involves the gathering of data for recognizing errors or omissions in care.
- Evaluation involves making clinical decisions
- Evaluation requires the use of assessment skills
- Evaluation is done only when a pt’s condition changes
«< answer
- Evaluation is an ongoing process
- Evaluation involves the gathering of data for recognizing errors or omissions in care.
- Evaluation involves making clinical decisions
- Evaluation requires the use of assessment skills
