Unit 3 Flashcards
What is the definition of standing orders?
Preprinted document containing medical orders for specific patients with identified clinical problems
What are the clinical practice guidelines and protocols?
Foundation of scientific knowledge
Recommendations on how patients with a given condition should be managed everything else being equal
What are the two types of interventions of scope of practice?
Direct care interventions
Indirect care interventions
What are the initiations after interventions based on nursing interventions scope of practice?
Nurse-initiated
Health care provider-initiated
Other provider intimated
Is DNR a standing order?
No
What are the standards of practice?
For all reviewed on a regular basis
Emphasize a timely plan following patient safety goals
What are the qualities and safety education for nurses (QSEN)?
-standard competencies in knowledge, skills, and attitudes for the preparation of future nurses
-Goal of QSEN: to prepare nurses so that they can continuously improve the quality and safety of the health care systems within which they work
What is critical thinking outcomes?
Allows you to consider the complexity of interventions, changing priorities, alternative approaches, and the amount of time available to act
What are the three examples of implementation
1 avoiding adverse events
2 reassessing a patient
3 reviewing and revising the existing nursing care plan
What are the examples of implementation process?
1 time management
2 equipment
3 personnel
4 environment>safe
5 patient> physical and psychological comfort
In the implementation process, what are some examples of anticipating and preventing complications?
Risk from illness and treatment
Identifying area of assistance> need for additional personnel, review of policy or procedure
What are the necessities of implementation skills?
Cognitive skills> scientific knowledge base
Interpersonal communication>building trust
Psychomotor skills>clincial skills (IV)
What are examples of direct care
Activities of daily living
Instrumental activities of daily living
Lifesaving measures
Teaching
Preventative interventions
Controlling adverse reactions
What are examples of indirect care
Communicating nursing interventions
Delegating, supervising
Documentation
What are the methods for prioritizing?
High, intermediate, low based on the ABC’s
Maslows hierarchy
What are the ideas to establish priorities
Methods for prioritizing
Consider patients situation
Avoid classifying only physiological nursing diagnoses as high priority
Priorities in practice (plan of action)
T/F every outcome should have an evaluation
T
What kind of goals should nurses create for planning outcomes?
SMART goals
Specific
Measureable
Attainable
Realistic
Timed
What is Identification in clinical judgment outcomes>
Prioritizing outcomes
Role of health care team in outcomes
Describe the Evaluation step in Clincal Judgement
Examine the results
Compare achieved effects
Recognize errors
Understand and reflect on situation and correct errors
What are the elements of evaluation
Knowledge
Experience
Standards and attitudes for evaluation
Environment
What is the evaluation process
Recognize errors or unmet outcomes
Correct errors
Revising the care plan
(Discontinuing a care plan, redefined diagnoses, revising expected outcomes, revising interventions)
What are the 4 nursing sensitive preventable adverse outcomes?
Severe pressure injuries
Falls and trauma
Catheter-associated urinary tract infections
Central line-associated blood stream infections
What are the components of critical thinking in nursing?
Knowledge base
Experience
Environment
Attitudes
Application of critical thinking to make best clinical decision is-use the nursing process in the development of client care
Critical thinking involves:
Knowing as much as possible about each patient
The ability to sort information into patterns and recognize changes
Decision making under pressure
What is the cognitive skills process?
Recognize cues
Analyze cues
Prioritize hypotheses
Generate solutions
Taking actions
Evaluate outcomes
Describe the layers of the clinical judgement model
Layer 0- Cient needs, clinical decision
Layer 1 clinical judgement
Layer 2-form hypotheses, refine hypotheses, evaluation,
Layer 3- recognize cues, analyze cues, prioritize hypotheses, generate solutions, take actions, evaluate outcomes
Layer four- environmental factors, individual factors.
What is the difference between the Clincal judgement model layer 3, and the nursing process
Layer 3–Recognize cues, analyze cues, prioritize hypotheses, generate solutions, take actions, evaluate outcomes
Nursing Process—Assessment, analysis, planning, implementation, evaluation
What does a nursing care plan do?
Identifies client problems in need of nursing care
Predicts outcomes sensitive to nursing care
Lists intervention that will result in expected outcomes
Communicate planned care to health care team
Ensure continuity of care
T/F family caregivers and significant others input is under assessment
T
What is the difference between nursing diagnosis and medical diagnoses?
Nursing treats human response to illness or health needs rather than diagnosing or treating an illness or condition that caused the response
What is Etiology?
What is causing the problem?
No medical diagnoses
List all causes
What are considerations when planning outcomes?
Choose highest priority goals (ABC’s, Maslow’s)
Avoid classifying only physiological goals as high priority
Explain the SBAR
Situation- I am calling because, I am concerned that… Blood pressure is low/high, temp is___
Background- pt was admitted on___ THey had operation___, pt condition has changed in the last___
Assessment- I think the problem is___ and I have ___I don’t know what is wrong but I am worried
Recommendation-I need you to___Come to see the patient in the next__
When selecting interventions, consider:
Desired patient outcomes
Characteristics of the nursing diagnosis
Research based knowledge for interventions
Feasibility of carrying out the intervention
Acceptability to the patient
A client continues to report pain of 9 out of 10 and is not due for next dose. When should the critical thinking nurse do first?
A. Explain to the client that nothing else has been ordered
B offer to contact the dr
C discuss the surgical procedure pt had and reason for pain
D explore other options for pain relief
D
What does the nursing care plan do?
Identifies client problems in need of nursing care
Products outcomes sensitive to nursing care
Lists intervention that will result in expected outcomes
Purpose
What does Critical thinking do in assessment
Collection of information from a primary source and secondary sources
The interpretation and validation of data to determine whether more data are needed or the database is complete
What are the components of the nursing health history?
Biographical info
Chief concern
Patient expectations
Present illness
Past health history
What is standard language
Provides common language for nurses to communicate with one another
Ensures nursing care is documented
Defines nursing body of knowledge and scope of practice
Contributes to nursing autonomy
Third party reimbursement for nursing care that can be proven to be beneficial and cost effective
What are the different types of diagnosis
Problem focused
Risk for diagnosis>problem that may develop
Health promotion>the desire or motivation to improve health status through positive behavior change
What is the 3 part statement of a nursing diagnosis
P= problem (diagnostic label) followed by “related to”
E=etiology (related to factors) after “as manifested by”
S = Signs and symptoms
What are the 4 diagnostic errors
Errors in data collection
Errors in data clustering
Errors in analysis and interpretation of data
Errors in diagnostic statement
What are the 3 Cs of documentation
Clear, concise, comprehensive
What is SOAPIE
Subjective, objective, assessment, plan, intervention, evaluation
When documenting pain, what are the five parts that should be included
Intensity, type, location, pain strategies, and medication outcomes
How do we make mealtime easier? Dementia Alzheimer’s care
Offer a few options at a time
What is the mist difficult activities of daily living? Dementia Alzheimer’s care
Bathing
What should you do if the Alzheimer’s pt becomes agitated during an activity?
Allow time for the pt to rest
Come back
Discontinue the activity
If an Alzheimer’s pt suddenly becomes incontinent what should you consider? Also w other pts
Document and call the doctor
How can a nurse make the all of dressing, easier for the Alzheimer’s patient
Make clothing in order
Give one piece of clothing at a time
WHat would be good tips to give a new CNA working with Alzheimer’s patients?
Speak directly to client
Simple questions
Present self in front
If an Alzheimer’s pt has become anxious and stressed about leaving the facility, what can staff do?
Offer a different approach (adapt)
Is the number of people with Alzheimer’s expected to increase or decrease in the US by 2024
Increase
- A nurse completes the following steps during her shift of care. Which are the steps of nursing assessment? (Select all that apply.)
- The review of patient data in the medical record
- Confirming a patient’s self-report of abdominal pain by inspecting the abdomen
- Reporting results of an ongoing assessment to a nurse working the next scheduled shift
- Analyzing a set of signs revealing lower leg weakness and unsteady gait with a pattern of
mobility alteration - Conducting an interview of a family caregiver
Match the assessment activity on the left with the type of assessment on the right.
A. Problem focused
nurse’s shift
B. Comprehensive
- Assessment conducted at beginning of a
- Review of a patient’s chief complaint
- Completion of admitting history at time
of patient admission to a hospital - Completion of the Long Term Care Minimum
Data Set during an elderly patient admission to a nursing home
A
A
B
B
A nurse initiates a brief interview with a patient who has come to the medical clinic because of self-reported hoarseness, sore throat, and chest congestion. The nurse observes that the patient has a slumped posture and is using intercostal muscles to breathe. The nurse auscultates the patient’s lungs and hears crackles in the left lower lobe. The patient’s respiratory rate is 20 per minute compared with an average of 16 per minute during previous clinic visits. The patient tells the nurse, “It is hard for me to get a breath.” Which of the following data sets are examples of subjective data? (Select all that apply.)
1. Heart rate of 20 per minute and chest congestion
2. Lung sounds revealing crackles and use of intercostal muscles to breathe
3. Patient statement, “It’s hard for me to get a breath”
4. Slumped posture and previous respiratory rate of 16 per minute
5. Patient report of sore throat and hoarseness
3, 5
. The nurse asks a patient the following series of questions: “Describe for me how much you exercise each day.” “How do you tolerate the exercise?” “Is the amount of exercise you get each day the same, less, or more than what you did a year ago?” This series of questions would likely occur during which phase of a patient-centered interview?
1. Orientation
2. Working phase
3. Data interpretation
4. Termination
2
- A young male patient enters the emergency department with fever and signs of a possible sexually transmitted infection. The nurse enters the patient’s cubicle and begins to enter a history on the computer screen. Before beginning the nurse introduces himself and tells the patient all information will be held confidentially. The nurse starts data collection by establishing eye contact with the patient and then looks at the computer prompts to select a series of questions. As the nurse fills out questions on the computer, the patient asks a question about his treatment. The nurse states, “Let me get through these questions first.” Which action interferes with the nurse’s ability to use connection as a communication skill.
- Introducing self to patient
- Using the computer as a prompt for questions
- Making the nurse’s questions a priority
- Assuring the patient all information is confidential
3
A nurse observes a patient walking down the hall with a shuffling gait. When the patient returns to bed, the nurse checks the strength in both of the patient’s legs. The nurse applies the information gained to suspect that the patient has a mobility problem. This conclusion is an example of:
1. Reflection.
2. Clinical inference.
3. Cue.
4. Validation.
2
Place the following steps of the assessment process in the correct order.
1. Compare data with another source to determine data accuracy.
2. As a pattern forms, probe and frame further questions.
3. Interview a patient, observe behavior, and gather physical assessment findings.
4. Cluster cues that relate together, make inferences, and identify emerging patterns.
5. Differentiate important data from the total data you collect.
3 5 4 2 1
In preparing to collect a nursing history for a patient admitted for elective surgery, which of the following data are part of the review of present illness in the nursing health history?
1. Current medications
2. Patient expectations of planned surgery
3. Review of patient’s family support system
4. History of allergies
5. Patient’s explanation for what might be the cause of symptoms that require surgery
5
A nurse is conducting a patient-centered interview. Place the statements from the interview in the correct order, beginning with the first statement a nurse would ask.
1. “You say you’ve lost weight. Tell me how much weight you’ve lost in the past month.”
2. “My name is Terry. I’ll be the nurse taking care of you today.”
3. “I have no further questions. Is there anything else you wish to ask me?”
4. “Tell me what brought you to the hospital.”
5. “So, to summarize, you’ve lost about 6 pounds in the past month, and your appetite has been poor—correct?”
2 4 1 5 3
Which of the following approaches are recommended when gathering assessment data from an 82-year-old male patient entering a primary care clinic for the first time? (Select all that apply.)
1. Recognize normal changes associated with aging.
2. Avoid direct eye contact.
3. Lean forward and smile as you pose questions.
4. Allow for pauses as patient tells his story.
1 3
Mr. Chuck Rhodes is admitted to the medical-surgical unit for unrelenting abdominal pain. Mr. Rhodes is a 37-year-old fireman. He has been intermittently vomiting for the past 2 days. His wife has accompanied him to the hospital. Mr. Rhodes has never been hospitalized. Crystal is the student nurse who has been assigned to admit Mr. Rhodes. Crystal is in her first clinical rotation. Crystal goes into Mr. Rhodes’ room, introduces herself, and explains that she will be collecting information that is needed for his admission. Mr. Rhodes is agreeable and asks Crystal to call him Chuck.
- Crystal starts the data collection. What would she want to accomplish during the interview? (Select all that apply.)
A. Establish a caring, therapeutic relationship with Chuck and his wife.
B. Determine what Chuck’s goals and expectations are regarding hospitalization.
C. Gain insight about Chuck’s concerns and worries.
D. Determine Chuck’s medical diagnosis.
E. Obtain cues about which parts of the interview may require further investigation.
Abce
- During the initial interview, Crystal notices that Chuck is grimacing and will not make eye contact with her. She wants to get more information. Which question is most appropriate to help Crystal in her assessment?
A. Do you hurt?
B. Do you feel like you are going to vomit?
C. How are you feeling now?
D. Do you need pain medicine?
C
- Crystal is assessing Chuck using Gordon’s functional health patterns. This is an example of which approach to comprehensive assessment?
Nursing Diagnosis
. A nursing student is working with a faculty member to identify a nursing diagnosis for an assigned patient. The student has assessed that the patient is undergoing radiation treatment, has liquid stool, and the skin is clean and intact. The student selects the nursing diagnosis Impaired Skin Integrity. The faculty member explains that the student has made a diagnostic error for which of the following reasons?
1. Incorrect clustering of data
2. Wrong diagnosis
3. Condition is a collaborative problem
4. Premature ending assessment
2
. A nurse conducts an assessment of a 42-year-old woman at a health clinic. The woman is married and lives in a condo with her husband. She reports having frequent voiding and pain when she passes urine. The nurse asks whether she has to go to the bathroom at night, and the patient responds, “Yes, usually twice or more.” The patient had an episode of diarrhea 1 week ago. She weighs 300 lb and reports having difficulty cleansing herself after voiding or passing stool. Which of the following demonstrate assessment findings that cluster to indicate the nursing diagnosis Impaired Urination. (Select all that apply.)
1. Age 42
2. Dysuria
3. Difficulty performing perineal hygiene
4. Nocturia
5. Episode of diarrhea
2 4
Review the following nursing diagnoses and identify the diagnoses that are stated correctly. (Select all that apply.)
1. Offer frequent skin care because of Impaired Skin Integrity
2. Risk of Infection
3. Chronic Pain related to osteoarthritis
4. Activity Intolerance related to physical deconditioning
5. Lack of Knowledge related to laser surgery
2 4
Which of the following best describe a collaborative health problem? (Select all that apply.)
1. An actual or potential physiological complication that nurses monitor to detect the onset of changes in a patient’s health status
2. The language medical practitioners use to communicate a patient’s health problem and associated treatments and response
3. A diagnostic label that classifies a patient’s response to illness so that all nurses can be familiar with a specific patient’s health care needs
4. A language used by health care providers to communicate and consider each other’s unique perspective, so they can better manage the multiple factors that influence the health of individuals
5. A diagnosis that provides clear direction as to the type of nursing interventions nurses are licensed to provide independently
1 4
Which of the following is a diagnostic error involving identification of a goal of care rather than a patient need?
1. Patient obtains social support care related to caregiver stress
2. Fear related to open-heart surgery
3. Acute Pain related to splinting of incision
4. Impaired Family Coping related to insufficient caregiver support
1
A nurse is assigned to a new patient admitted to the medical unit. The nurse collects a nursing history and interviews the patient. Place the following steps for making a nursing diagnosis in the correct order.
1. Consider the context of patient’s health problem and select a related factor.
2. Review assessment data, noting objective and subjective clinical information.
3. Cluster clinical data elements that form a pattern.
4. Identify appropriate assessment findings for diagnosis.
5. Identify a nursing diagnosis.
4,1,2,5,3
A nurse interviews and conducts a physical examination of a patient that includes the following findings: reduced movement of lower leg, reduced range of motion in left knee, and difficulty turning in bed without assistance. This data set is an example of:
1. Collaborative data set.
2. Diagnostic label.
3. Related factors.
4. Data cluster.
D
A nurse reviews data gathered regarding a patient’s response to a diagnosis of cancer. The nurse notes that the patient is restless, avoids eye contact, has increased blood pressure, and expresses a sense of helplessness. The nurse compares the pattern of assessment findings for Anxiety with those of Fear and selects Anxiety as the correct diagnosis. This is an example of the nurse avoiding an error in? (Select all that apply.)
1. Data collection
2. Data clustering
3. Data interpretation
4. Making a diagnostic statement
5. Goal setting
2,3, 4
Fill in the Blank:
A(n)__________________________ diagnosis is one that applies when there is an increased potential or vulnerability for a patient to develop a problem.
Risk
Crystal, a student nurse, is caring for Mr. Chuck Rhodes, a 37-year-old firefighter who was admitted to the medical-surgical unit for unrelenting abdominal pain. He has been intermittently vomiting for the last 2 days and has been unable to eat any solid food. His wife has accompanied him. Mr. Rhodes has never been hospitalized. During her assessment, Mr. Rhodes rated his pain as a 9 on a scale of 0 to 10. Crystal is developing the nursing diagnosis. She reviews her assessments.
- Which of the following statements are true about nursing diagnosis? (Select all that apply.)
A. Nursing diagnoses are always based on a physiological problem.
B. Nursing diagnoses have two parts, which include the diagnostic label and the related factor.
C. Errors in nursing diagnosing can occur from inadequate assessment.
D. Nursing diagnoses are focused on the scope of nursing practice.
B, c, d
- Crystal establishes the following nursing diagnoses for Mr. Rhodes. Which one of these nursing diagnoses is best reflective of her assessments?
A. Nausea related to unknown cause of stomach pain
B. Imbalanced nutrition: less than body requirements related to decreased ability to ingest food as a result of vomiting
B
- Crystal now has established a nursing diagnosis. This is an example of which of the following types of nursing diagnoses?
A. Actual nursing diagnosis
B. Risk nursing diagnosis
C. Wellness nursing diagnosis
D. Health promotional nursing diagnosis
A
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.
1. Specific
2. Measurable
3. Attainable
4. Realistic
5. 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, 2E, 3A, 4B, 5D
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?
1. Providing hand-off report at change of shift
2. Enhancing the patient’s sleep hygiene
3. Administering IV fluids
4. 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.)
1. Policy for conducting hourly rounds
2. Staffing level
3. Interruption by staff nurse colleague
4. Type of hospital unit
5. 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 Categories
A. Strategy for Effective Hand-off
B. Strategy for ineffective hand-off
- Use a standard checklist for the report.
- Encourage questions and clarification.
- Offer specific information on how to reduce
patient’s risks. - Give report at time when shift has ended and other
nurses are requesting information. - Explain how patient’s discharge was delayed by
insufficient numbers of staff. - Organize time by preparing in advance what to report. neffective Hand-off
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 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?
1. Patient will be turned every 2 hours within 24 hours.
2. Patient will have normal formed stool within 48 hours.
3. Patient’s ability to turn self in bed improves.
4. 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 top with the appropriate outcome statements on the bottom.
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.
week.
1C, 2B, 3B, 4A
Mr. Rhodes, the patient who was being cared for by Crystal in the previous chapter case study, is diagnosed with appendicitis. The surgeon schedules his surgery for that afternoon at 1300. Crystal continues to develop his care plan. Mr. Rhodes has never had surgery and tells Crystal that the thought of surgery makes him very nervous.
- Crystal wants to add information to his care plan now that the surgery has been scheduled. Which one of the following is an important expected outcome for Mr. Rhodes regarding surgery?
A. Is able to describe the importance of postoperative exercises before going to surgery
B. Demonstrates use of the call bell if he needs something after surgery
C. Will not vomit after surgery
D. Learns about postoperative exercises to prevent blood clots
B
- Crystal has two nursing diagnoses on Mr. Rhodes’ care plan. Which of these is the priority for Crystal?
A. Imbalanced nutrition: less than body requirements related to decreased ability to ingest food as a result of vomiting
B. Deficient knowledge regarding postoperative care related to lack of exposure to information
B
- Which of the following interventions is written correctly for Crystal to add to Mr. Rhodes’ care plan?
A. Provide frequent mouth care
B. Keep NPO
C. Reposition in bed every 2 hours
D. Offer 30 ml of water hourly while awake
D
A nurse is assigned to five patients, including one who was recently admitted and one returning from a diagnostic procedure. It is currently mealtime. The other three patients 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.)
1. The nurse directs the assistive personnel to obtain a set of vital signs on the patient returning from the diagnostic procedure.
2. The nurse directs the patient care technician to go to the patient in pain and to reposition and offer comfort measures until the nurse can bring an ordered analgesic to the patient.
3. The nurse directs the patient care technician to set up meal trays for patients.
4. The nurse directs the patient care technician to gather a history from the newly admitted patient about his medications.
5. The nurse directs the patient care technician to assist one of the stable patients up in a chair for his meal.
2, 3, 5
A nurse working the evening shift has five patients and is teamed up with an assistive personnel. One of the assigned patients has just returned from surgery, three others are stable and resting, and one has requested a pain medication. The patient 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 patient is scheduled for a physical therapy visit in 2 hours. Which of the following demonstrate good clinical decision making during intervention? (Select all that apply.)
1. The nurse reviews the options for pain relief for the patient.
2. The nurse assesses whether the 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.
3. The nurse reviews the policy and procedure for the cold application.
4. The nurse considers how the patient might react if the pain medication is held until an hour before physical therapy.
5. The nurse delegates vital sign assessment of the patient returning from surgery to the assistive personnel.
1, 2, 4
A nurse working the evening shift has five patients and is teamed up with an assistive personnel. One of the assigned patients has just returned from surgery, one is newly admitted, and one has requested a pain medication. The patient who has returned from surgery just minutes ago has a large abdominal dressing, is still on oxygen by nasal cannula, and has an intravenous line. One of the other patients has just called out for assistance in setting up a meal tray. Another patient is stable and resting comfortably. Which patient is the nurse’s current greatest priority?
1. Patient in pain
2. Patient newly admitted
3. Patient who returned from surgery
4. Patient requesting assistance with meal tray
3
The nurse administers a tube feeding via a patient’s nasogastric tube. This is an example of which of the following?
1. Physical care technique
2. Activity of daily living
3. Indirect care measure
4. Lifesaving measure
A
Which principle is most important for a nurse to follow when using a clinical practice guideline for an assigned patient?
1. Knowing the source of the guideline
2. Reviewing the evidence used to develop the guideline
3. Individualizing how to apply the clinical guideline for a patient
4. Explaining to a patient the purpose of the guideline
3
A nurse is visiting a patient who lives alone at home. The nurse is assessing the patient’s adherence to medications. While talking with the family caregiver, the nurse learns that the patient has been missing doses. The nurse wants to perform interventions to improve the patient’s adherence. Which of the following will affect how this nurse will make clinical decisions about how to implement care for this patient? (Select all that apply.)
1. Reviewing the family caregiver’s availability during medication administration times
2. Determining the value the patient places on taking medications
3. Reviewing the number of medications and time each is to be taken
4. Determining all consequences associated with the patient missing specific medicines
5. Reviewing the therapeutic actions of the medications
1, 3, 4
The nurse enters a patient’s room and finds that the patient was incontinent of liquid stool. Because the patient has recurrent redness in the perineal area, the nurse worries about the risk of the patient developing a pressure injury. The nurse cleanses the patient, 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.)
1. The application of the skin barrier is a dependent care measure.
2. The call to the ostomy and wound care specialist is an indirect care measure.
3. The cleansing of the skin is a direct care measure.
4. The application of the skin barrier is an instrumental activity of daily living.
5. Inspecting the skin is a direct care activity.
2, 3
Match the category of direct care on the left with the specific direct care activity on the right.
1. Counseling ___
2. Lifesaving measure ____
3. Physical care technique ___
4. Activity of daily living ____
a. Assisting patient with oral care
b. Discussing a patient’s options in
choosing palliative care
c. Protecting a violent patient from injury
d. Using safe patient handling during
positioning of a patient
1B, 2C, 3D, 4A
Which measures does a nurse follow when being asked to perform an unfamiliar procedure? (Select all that apply.)
1. Checks scientific literature or policy and procedure
2. Determines whether additional assistance is needed
3. Collects all necessary equipment
4. Delegates the procedure to a more experienced nurse
5. Considers all possible consequences of the procedure
1, 2, 3, 5
A nurse is conferring with another nurse about the care of a patient with a stage II 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.)
1. Allows nurses to act more quickly and appropriately
2. Sets a level of clinical excellence for practice
3. Eliminates need to create an individualized care plan for the patient
4. Incorporates evidence-based interventions for stage II pressure injury
1, 2, 4
Mr. Rhodes, a firefighter, returns from surgery and has an uneventful evening and night. Crystal, the student nurse, will be caring for Mr. Rhodes this morning. She is planning her morning and determines from his care plan and orders that he will need to ambulate this morning, have his dressing changed, and then be discharged to home.
- Crystal looks at the preprinted orders that Mr. Rhodes’ physician uses for routine dressing changes on his patients who have had an appendectomy. These are examples of which type of standard nursing interventions?
Standing Order
- After Crystal changes Mr. Rhodes’ dressing, she sits down and documents the dressing change. Is documentation considered direct or indirect care?
Indirect care
- While changing Mr. Rhodes’ dressing, Crystal uses infection control measures. What type of nursing care is this?
A. Teaching
B. Lifesaving measures
C. Activities of daily living
D. Controlling for adverse reactions
D
A nurse admits a 32-year-old patient for treatment of acute asthma. The patient has labored breathing, a respiratory rate of 28 per minute, and lung sounds with bilateral wheezing. The nurse makes the patient comfortable and starts an ordered intravenous infusion to administer medication that will relax the patient’s airways. The patient tells the nurse after the first medication infusion, “I feel as if I can breathe better.” The nurse auscultates the patient’s lungs and notes decreased wheezing with a respiratory rate of 22 per minute. Which of the following is an evaluative measure? (Select all that apply.)
1. Asking patient to breathe deeply during auscultation
2. Counting respirations per minute
3. Asking the patient to describe how his breathing feels
4. Starting the intravenous infusion
5. Auscultating lung sounds
2, 3, 5
A patient has labored breathing, a respiratory rate of 28 per minute, and lung sounds that reveal wheezing bilaterally. The nurse starts an ordered intravenous infusion to administer medication that will relax the patient’s airways. When the nurse asks how the patient feels, he responds by saying, “I feel as if I can breathe better.” The nurse auscultates the patient’s lungs and notes decreased wheezing with a respiratory rate of 22 per minute. Which of the following evaluative measures may not reflect change in a patient’s condition?
1. Counting respirations per minute
2. Asking the patient to describe how his breathing feels
3. Observing breathing pattern
4. Auscultating lung sounds
2
Which of the following statements correctly describes the evaluation process? (Select all that apply.)
1. Evaluation involves reflection on the approach to care.
2. Evaluation involves determination of the completion of a nursing intervention.
3. Evaluation involves making clinical decisions.
4. Evaluation requires the use of assessment skills.
5. Evaluation is performed only when a patient’s condition changes.
1, 3, 4
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 patient is to achieve self-management of insulin medication. Identify appropriate evaluative measures for self-management for this patient. (Select all that apply.)
1. Quality of life
2. Patient satisfaction
3. Clinic follow-up visits
4. Adherence to self-administration of insulin
5. Description of side effects of medications
1, 3, 4
From the following list of indicators, determine which indicators are goals (G) and which indicators are outcomes (O).
1. _____ Will achieve pain relief
2. _____ Ambulates 10 feet down hallway
3. _____ Will remain free of infection
4. _____ Will be afebrile
5. _____ Reports pain severity reduced from 6 to a 4 on scale of 0 to 10
6. _____ Will gain improved mobility
1G, 2O, 3G, 4G, 5O, 6G
A nurse has been caring for a patient over 2 consecutive days. During that time the patient had an intravenous (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 patient 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 patient evaluation? (Select all that apply.)
1. Comparing patient response with previous response
2. Examining results of clinical data
3. Recognizing error
4. Self-reflection
5. Checking medical record for when IV was inserted.
1, 2
A nurse asks how a patient’s condition from a serious infection changed since yesterday while receiving a hand-off report. The nurse leaving the shift reports the patient has two priority nursing diagnoses—fluid imbalance and fever. The receiving nurse begins to provide care by measuring the patient’s body temperature, inspecting the condition of the skin, reviewing the intake and output record, and checking the summary notes describing the patient’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.)
1. Checking the summary notes
2. Asking the leaving RN about the patient’s condition.
3. Assigning the technician to measure intake and output
4. Comparing current outcomes with those set for the patient’s goals
5. Reflecting on patient’s progress
1, 2, 4, 5
A nurse in the recovery room is monitoring a patient who had a left knee replacement. The patient arrived in recovery 15 minutes ago. The nurse observes the patient to be restless, turning frequently, and groaning; the patient’s heart rate is 92 compared with 76 preoperatively. Blood pressure 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 patient’s situation?
1. The patient is recovering normally.
2. The symptoms reflecting restlessness
3. The patient’s blood pressure trend
4. The delay in administration of the analgesic
4
A nurse enters a patient’s room and begins a conversation. During this time the nurse evaluates how a patient is tolerating a new diet plan. The nurse decides to also evaluate the patient’s expectations of care. Which of the following is appropriate for evaluating a patient’s expectations of care?
1. On a scale of 0 to 10 rate your level of nausea.
2. The nurse weighs the patient.
3. The nurse asks, “Did you believe that you received the information you needed to follow your diet?”
4. The nurse states, “Tell me four different foods included in your diet.”
3
Which of the following statements correctly describe the evaluation process? (Select all that apply.)
1. Evaluation is an ongoing process.
2. Evaluation involves the gathering of data for recognizing errors or omissions in care.
3. Evaluation involves making clinical decisions.
4. Evaluation requires the use of assessment skills.
5. Evaluation is done only when a patient’s condition changes.
1, 2, 3, 4
Mr. Rhodes is getting ready to go home from the hospital after an appendectomy. Crystal, his student nurse, is getting things ready for the discharge. Crystal evaluates his goals from the care plan. His diagnosis was determined to be Imbalanced nutrition: less than body requirements related to decreased ability to ingest food as a result of vomiting. The goal that was established for the nursing diagnosis is the following: Patient will ingest 2000 calories/day of a regular diet by discharge.
- What evaluative measures are appropriate for Crystal to use for this goal? (Select all that apply.)
A. Measure caloric intake.
B. Weigh patient to monitor for weight gain or stabilization.
C. Patient will eat ice cream.
D. Patient reports no nausea after meals.
E. Patient has not vomited for past 24 hours.
A, B, D, E
- Crystal is further evaluating Mr. Rhodes’ care plan. She is confirming that all nurse-sensitive outcomes have been met. Which of the following are nurse-sensitive outcomes? (Select all that apply.)
A. Pain severity will be reduced.
B. Length of stay will be 4 days.
C. Skin is intact.
D. Patient completes hygiene independently.
A, C, D
- Crystal reviews Mr. Rhodes’ care plan with her instructor. Her instructor asks Crystal to explain why it is important to review the care plan for evaluating the outcomes. How should Crystal respond to this question?
Evaluation of the nursing plan allows the nurse to know he effectiveness of the interventions for a specific patient
