Week 4 Sherpath Flashcards
Which actions are involved in the planning step of the nursing process?
Select all that apply.
Assessing the patient
Prioritizing nursing diagnoses
Developing patient-centered goals
Creating a personalized plan of care
Evaluating the patient’s response to interventions
Prioritizing nursing diagnoses
Developing patient-centered goals
Creating a personalized plan of care
At which point would the nurse begin the planning stage of the nursing process?
At patient discharge
When the patient requires care
When the patient and nurse first interact
Upon patient admission to the hospital
When the patient and nurse first interact
Which type of planning would the office nurse perform when contacting a patient with information about what to expect before, during, and after a scheduled surgery?
Discharge planning
Home care planning
Preadmission planning
Inpatient care planning
Preadmission planning
Which goal is an example of a long-term goal for the patient?
The patient will achieve wound healing in 3 weeks.
The patient will have a pain level of less than 3 for 48 hours.
The patient will demonstrate an increase in activity tolerance in 1 week.
The patient’s wound will decrease in dimension in 2 days.
The patient will achieve wound healing in 3 weeks.
Which duration reflects an appropriate time frame for achievement of a short-term goal?
1 week
2 weeks
1 month
6 months
1 week
Which rationale explains the importance of outcome identification to the achievement of patient goals?
Determines goal validity
Indicates goal attainment
Standardizes patient goals
Tells the nurse which goals to measure
Indicates goal attainment
If the nurse collaborates with the patient when setting goals, which behaviors is the patient more likely to demonstrate?
Select all that apply.
Be aware of priority needs.
Accept realistic goals.
Allow the nurse to control care.
Be more successful in achieving goals.
Comply with interventions and behavior changes.
Be aware of priority needs.
Accept realistic goals.
Be more successful in achieving goals.
Comply with interventions and behavior changes.
Which statement about nursing interventions is accurate?
Interventions are another term for health care provider orders.
The nurse selects standardized interventions to promote safety.
Interventions are activities that assist the patient in achieving goals.
The nurse and the health care provider select the appropriate interventions for the patient.
Interventions are activities that assist the patient in achieving goals.
Which components would the nurse include in a comprehensive plan of care?
Select all that apply.
Evaluation
Interventions
Measurable goals
Medical diagnosis
Nursing diagnosis
Evaluation
Interventions
Measurable goals
Nursing diagnosis
Which part of the plan of care contains the statement, “Patient will display complete healing of surgical area within 3 weeks”?
Evaluation
Interventions
Measurable goal
Nursing diagnosis
Measurable goal
Which statement describes the plan of care?
Development of the plan of care is the first component in the planning step of the nursing process.
The Joint Commission requires the plan of care to be part of the electronic health record.
The plan of care summarizes the patient’s condition, goals, and planned interventions.
The plan of care is most effective when standardized to incorporate evidence-based practice.
The plan of care summarizes the patient’s condition, goals, and planned interventions.
Which information would the nurse expect to find on a conceptual care map (CCM)?
Select all that apply.
Medications
Pathophysiology
Medical history
Health care provider orders
Nursing plan of care
Medications
Medical history
Health care provider orders
Nursing plan of care
For a patient scheduled for knee surgery, which statement identifies when the planning step of the nursing process begins?
After the surgery is complete
When the patient is admitted to the hospital
Just before being discharged from the hospital
When the nurse contacts the patient to schedule surgery
When the nurse contacts the patient to schedule surgery
Match the nursing diagnosis to its prioritization.
Life-threatening
Clinically urgent
Routine
Answered choices
Impaired Airway Clearance
Impaired Sleep
Impaired Tissue Integrity
Life-threatening
Impaired Airway Clearance
Clinically urgent
Impaired Tissue Integrity
Routine
Impaired Sleep
Which nursing diagnosis would be ranked as the highest priority?
Constipation
Pressure Ulcer
Impaired Gas Exchange
Impaired Tissue Integrity
Impaired Gas Exchange
Which statement is an example of a long-term patient goal?
Dress independently within 6 months.
Demonstrate deep-breathing techniques by end of shift.
Report an increase in appetite within 1 week.
Identify interventions to reduce risk for infection in 2 days.
Dress independently within 6 months.
When a patient who needs to lose 60 lb (27 kg) wants to change the nurse’s recommended goal from exercising for 30 minutes a day, four times per week to exercising for 15 minutes per day, two times a week, which action would the nurse take?
Ask why the patient does not want to lose weight.
Allow the patient to set any goal the patient wants.
Tell the patient the goal will not work.
Discuss personal factors influencing the patient’s perspective.
Discuss personal factors influencing the patient’s perspective.
Which action would the nurse implement to promote patient success through goal attainment?
Ask what the patient would like to achieve.
Identify the goal, and tell the patient what it is.
Tell the patient the goal was ordered by the health care provider.
Identify one goal reflecting the nurse’s priority and another that reflects the patient’s priority.
Ask what the patient would like to achieve.
Which role would the nurse associate with selection of interventions during the planning step of the nursing process?
Validation of nursing diagnoses
Evaluation of the patient’s goal attainment
Facilitation of clear communication of patient needs
Assistance for the patient in achieving goals and improving health
Assistance for the patient in achieving goals and improving health
Which strategies would the nurse use to promote individualization of the identified nursing interventions?
Select all that apply.
Consider patient assessment findings.
Ensure interventions align with patient acceptance.
Consult other professionals involved in the patient’s care.
Consider the underlying etiology and related factors.
Select interventions based on experience with other patients.
Consider patient assessment findings.
Ensure interventions align with patient acceptance.
Consult other professionals involved in the patient’s care.
Consider the underlying etiology and related factors.
Place the components of the planning step of the nursing process in the correct order.
Create a plan of care.
Prioritize nursing diagnoses.
Select interventions.
Establish goals and outcomes.
Prioritize nursing diagnoses.
Establish goals and outcomes.
Select interventions.
Create a plan of care
Match the component of the plan of care with the related information.
Heart rate (HR) 34 beats/min
Impaired Cardiac Function, supported by bradycardia
HR will return to 60 to 90 beats/min in 48 hours; monitor cardiac rhythm continuously
HR 70 to 79 beats/min × 48 hours; goal met; discontinue goal
Answer choices
Nursing diagnosis
Key assessment data
Measurable goal and intervention
Evaluation
Heart rate (HR) 34 beats/min
Key assessment data
Impaired Cardiac Function, supported by bradycardia
Nursing diagnosis
HR will return to 60 to 90 beats/min in 48 hours; monitor cardiac rhythm continuously
Measurable goal and intervention
HR 70 to 79 beats/min × 48 hours; goal met; discontinue goal
Evaluation
Which rationale supports the use of a conceptual care map (CCM) to develop a plan of care?
Provides criteria for the selection of interventions
Assists with the development of a standardized plan of care
Lists all of the patient’s medical history in a concise format
Provides a quick, yet comprehensive, overview of the patient’s status and plan
Provides a quick, yet comprehensive, overview of the patient’s status and plan
The nurse performs patient care interventions and documents interventions during which step of the nursing process?
Analysis
Planning
Evaluation
Implementation
Implementation
Which statement summarizes how the scope of nursing practice influences interventions?
It promotes evidence-based practice.
It focuses on a specific clinical situation.
It describes what actions a nurse can take.
It outlines recommended interventions for a patient problem.
It describes what actions a nurse can take.
Which statement accurately describes nursing documentation?
Missing documentation does not harm patients.
The nurse charts only direct-care interventions.
Nurses document interventions primarily in the plan of care.
Documentation conveys interventions and outcomes to other health care providers.
Documentation conveys interventions and outcomes to other health care providers.
The nurse would categorize interventions according to which formal descriptors?
Select all that apply.
Priority
Purpose
Time frame
Type of patient contact
Who initiates the intervention
Purpose
Type of patient contact
Who initiates the intervention
Match the intervention category to its description.
Manages and treats existing issues
Avoids patient problems
Involves personal contact with the patient
Benefits the patient without face-to-face contact
Answer choices
Prevention-oriented
Indirect-care
Problem-based
Direct-care
Manages and treats existing issues
Problem-based
Avoids patient problems
Prevention-oriented
Involves personal contact with the patient
Direct-care
Benefits the patient without face-to-face contact
Indirect-care
Match the type of intervention to its process.
Initiated and implemented by the nurse
Initiated by a health care provider prescription and conducted by the nurse
Initiated by the nurse and executed by other health care team members
Answer choices
Dependent nursing
Collaborative nursing
Independent nursing
Initiated and implemented by the nurse
Independent nursing
Initiated by a health care provider prescription and conducted by the nurse
Dependent nursing
Initiated by the nurse and executed by other health care team members
Collaborative nursing
Which activity reflects an indirect-care type of intervention?
Delegation
Physical care
Reassessment
Patient education
Delegation
Which activity occurs during the fourth step of the nursing process?
Analyzing patient data
Planning the patient’s care
Implementing interventions
Evaluating the patient’s response
Implementing interventions
According to the American Nurses Association (ANA) scope of nursing practice, which statements describe an intervention the nurse should be qualified and competent to perform?
Select all that apply.
The facilitation of healing
The prevention of illness and injury
The advocacy of patients and families
The optimization of patient health and abilities
The transfer of evidence-based practice to the clinical setting
The facilitation of healing
The prevention of illness and injury
The advocacy of patients and families
The optimization of patient health and abilities
Which statement describes how nurses use clinical practice guidelines (CPGs) in determining patient care interventions?
CPGs provide individualized patient care interventions.
The American Nurses Association (ANA) developed CPGs to describe nursing actions.
Nurses select interventions that they are qualified and competent to perform by applying CPGs.
Nurses apply CPGs to implement standardized interventions for a specific clinical situation.
Nurses apply CPGs to implement standardized interventions for a specific clinical situation.
Which action occurs after the nurse performs interventions?
Determining goals
Assessing the patient
Resolving the interventions
Documenting the interventions
Documenting the interventions
Which type of intervention benefits the patient but does not involve face-to-face contact with the patient?
Direct
Indirect
Independent
Prevention-based
Indirect
Which intervention category is likely to have the highest priority?
Direct-care
Independent
Problem-oriented
Prevention-based
Problem-oriented
Match the intervention category to the intervention.
Monitoring a patient’s temperature and skin color for fever
Administering antibiotics for infection as prescribed by the health care provider
Delegating bathing and dressing to a nursing assistant
Answer choices
Collaborative
Dependent
Independent
Monitoring a patient’s temperature and skin color for fever
Independent
Administering antibiotics for infection as prescribed by the health care provider
Dependent
Delegating bathing and dressing to a nursing assistant
Collaborative
Which activities are direct-care interventions?
Select all that apply.
Advocacy
Research
Reassessment
Informal counseling
Activities of daily living (ADLs)
Reassessment
Informal counseling
Activities of daily living (ADLs)
Which action is an indirect-care intervention?
Informal counseling
Patient assessment
Activities of daily living (ADLs)
Communications with health care providers
Communications with health care providers
Which activities are independent nursing interventions?
Select all that apply.
Hand hygiene
Patient ambulation
Intravenous (IV) fluid management
Administration of medications
Teaching use of incentive spirometer
Hand hygiene
Patient ambulation
Teaching use of incentive spirometer
Which statement describes the evaluation step of the nursing process?
Evaluation is not a collaborative process.
Evaluation is the fourth step of the nursing process.
This step facilitates the selection of nursing diagnoses.
The nurse determines whether the goals were achieved.
The nurse determines whether the goals were achieved.
Which action would the nurse take when the patient’s goal states, “Skin will remain intact while in the hospital” and the nurse notices a new stage 2 pressure injury?
Document the goal as being met.
Delete the goal and write a new one.
Reflect on factors that prevented goal achievement.
Document the goal as being met once the skin has healed.
Reflect on factors that prevented goal achievement.
Which information would the nurse include in an evaluation statement?
Select all that apply.
Level of goal attainment
Revisions needed in the plan of care
Date when the goal will be reevaluated
The name of the person evaluating the goal
Factors contributing to goal achievement
Level of goal attainment
Revisions needed in the plan of care
Factors contributing to goal achievement
Which process occurs when the nurse uses data and specific methods to systematically increase the quality of patient care?
Planning
Evaluation
Nursing process
Quality improvement
Quality improvement
Sequentially arrange the steps taken by nurses to implement the quality improvement process in nursing.
Determine factors contributing to positive patient results.
Review data about nursing care.
Make changes in nursing practice.
Review data about nursing care.
Determine factors contributing to positive patient results.
Make changes in nursing practice.
According to The Joint Commission requirements, which time frame describes when the nurse would evaluate the plan of care?
Daily
Every shift
Continuously
Only if the patient’s condition changes
Continuously
During which step of the nursing process would the nurse review the patient’s plan of care and determine whether a goal was met?
Planning
Evaluation
Assessment
Implementation
Evaluation
Once a patient meets a goal, which action would the nurse take?
Discontinue the goal.
Discontinue the plan of care.
Revise the entire plan of care.
Decide whether to continue or discontinue the goal.
Decide whether to continue or discontinue the goal.
Consider the goal: Patient will ambulate 50 ft twice daily with assistance. Match the level of goal attainment with the evaluation statement.
Patient is consistently ambulating 50 ft twice daily.
Patient is ambulating between 20 and 50 ft twice daily.
Patient is on bed rest due to the development of a pulmonary embolus.
Answer choices
Goal is unmet.
Goal is met.
Goal is partially met.
Patient is consistently ambulating 50 ft twice daily.
Goal is met.
Patient is ambulating between 20 and 50 ft twice daily.
Goal is partially met.
Patient is on bed rest due to the development of a pulmonary embolus.
Goal is unmet.
A patient sets a goal to quit smoking within the next 30 days. After 30 days, the patient has not quit but reports that their smoking is reduced by 50%. The goal for the next 30 days is revised. Which outcome would the nurse document regarding goal attainment?
Goal met
Goal unmet
Goal partially met
Goal unattainable
Goal partially met
Which process occurs when the nursing staff of a small emergency department implements a process to reduce wait times?
Evaluation
Patient satisfaction
Quality improvement
Evidence-based practice
Quality improvement
Match the step of the Plan-Do-Study-Act (PDSA) improvement model to the nursing action that takes place during each step.
Consider what the data show, and revise the plan of care if needed
State the objective and develop a plan
Review results
Implement interventions
Answer choices
Study
Act
Do
Plan
Consider what the data show, and revise the plan of care if needed
Act
State the objective and develop a plan
Plan
Review results
Study
Implement interventions
Do
Which statement explains the importance of making modifications to the plan of care when a patient’s status changes?
Plan modification enhances communication among health care providers.
The Joint Commission requires modification to the plan of care.
Revision is a necessary component of providing safe patient care.
The hospital can be reimbursed for interventions provided when revision occurs.
Revision is a necessary component of providing safe patient care.
