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The nurse is caring for a patient who has been diagnosed with methicillin-resistant Staphylococcus aureus located in her incision. What transmission-based precautions will the nurse implement for the patient?
b.Private, negative-airflow room
c.Mask worn by the staff when entering the room
d.Mask worn by the staff and the patient when leaving the patient’s room
a. private room
A private room decreases the chance of another patient contracting the infection. The other precautions (i.e., private room with negative airflow, mask worn by staff when entering the room, and mask worn by staff and patient when leaving the patient’s room) are airborne precautions, which are not necessary in managing this patient.
A new patient is admitted to a medical unit with Clostridium difficile. Which type of precautions or isolation does the nurse know is appropriate for this patient?
c. contact precautions
Contact precautions are used with C. difficile because transmission of a contagious disease is possible through contact with the patient or with the equipment or items in the patient’s room. Airborne precautions are used when spread by small droplets that remain suspended in the air for a long period of time. Droplet precautions are used when a disease is spread by large droplets in the air. Protective isolation is used for patients who are immunosuppressed.
In which situations does the nurse wear clean gloves as part of standard precautions? (SATA)
a.In the care of a patient diagnosed with an infectious process
b.When the patient is diaphoretic
c.During care of each individual under treatment in the facility
d.In the presence of urine or stool
e.When taking the patient’s blood pressure
a, c, d
The nurse uses standard precautions for situations in which an infectious disease is known or when there is a possibility of contact with blood or body fluids (except perspiration). Gloves are not necessary when taking the blood pressure of a patient who is not in isolation and who does not have any other risk factors.
The nurse is providing patient education on infection prevention. Which definition of an infection does the nurse use as a teaching point?
a.An illness resulting from living in an unclean environment
b.A result of lack of knowledge about food preparation
c.A disease resulting from pathogens in or on the body
d.An acute or chronic illness resulting from traumatic injury
c. A disease resulting from pathogens in or on body
A disease resulting from pathogens in or on the body is the definition of an infection. An illness resulting from living in an unclean environment, from lack of knowledge about food preparation, or from trauma can lead to an infection but does not define an infection.
The nurse is caring for a patient who had abdominal surgery and has developed an infection in the wound while hospitalized. Which agent is most likely the cause of the infection?
The cause of an infection in the surgical wound in a hospitalized patient who has had abdominal surgery is most likely bacteria because it is present on the skin as normal flora. Fungi and spores are the focus of removal during the surgical preparation. Viruses are target specific and do not usually live on the skin.
A nurse is preparing to change a sterile dressing and has donned two sterile gloves. To maintain surgical asepsis, what else must the nurse do?
a.Minimize the amount of splashes on the sterile field
b.If a sneeze is imminent, cover the nose and mouth with a gloved hand.
c.With a moist saline sponge, use the dominant hand to clean the wound and then apply a dry dressing.
d.Regard the outer 1 inch of the sterile field as contaminated.
d. regard outer 1 in of sterile field as contaminated
Considering the outer 1 inch of the sterile field as contaminated is a principle of sterile technique. Moisture contaminates the sterile field. Sneezing or coughing would contaminate the sterile glove and would necessitate replacing the contaminated glove with a new sterile one. The hand used to clean the wound would never be used to apply a dry dressing. The hand would have to be re-gloved.
What is the proper order of removal of soiled personal protective equipment when the nurse leaves the patient’s room?
a.Gown, goggles, mask, gloves, and exit the room
b.Gloves, wash hands, remove gown, mask, and wash hands
c.Gloves, goggles, gown, mask, and wash hands
d.Goggles, mask, gloves, gown, and wash hands
c. gloves, goggles, gown, mask, and wash hands
Gloves are removed before the rest of personal protective equipment because they usually are the most contaminated. Protective eyewear or goggles are removed next via the earpieces. Gowns are removed by untying the waist and then the neck and grasping inside the neck. The mask is removed last because it prevents the spread of respiratory microorganisms. Hands should be washed thoroughly after the removing equipment and before leaving the room.
Of the following hospitalized patients, who is most at risk for acquiring a health–care-associated infection?
a.60-year-old who smokes two packs of cigarettes per day
b.40-year-old who has an indwelling urinary catheter in place
c.65-year-old who is a vegetarian and slightly underweight
d.60-year-old who has a white blood cell count of 6000
b. 40 y.o. who has an indwelling urinary catheter in place
Hospital-acquired infections are associated with indwelling urinary catheters. A normal white blood cell count, smoking cigarettes, or being a vegetarian has not been associated with hospital-acquired infections.
A patient develops food poisoning from contaminated food. What is the means of transmission for the infectious organism?a.Direct contact
Contaminated food is a vehicle for transmitting an infection. Direct contact requires close proximity between the susceptible host and an infected person. A vector is a nonhuman carrier. In airborne transmission, the organism is carried in droplet or dust particles.
Of the following assessment findings, which signs indicate to a nurse that a patient has a surgical site infection? (SATA)
a.Thick, white drainage in the Jackson-Pratt tubing
b.Redness or warmth at the affected site
c.Purulent drainage at the incision site
d.Temperature 100.4 F (38 C)
e.Tenderness and localized pain
f.Wound with well-approximated edges
g.Purulent drainage at the incision site
a, b, c, d, e, g
Purulent drainage at the site and thick, white drainage in the Jackson-Pratt tubing indicate the presence of white blood cells and microorganisms at the site of infection. Fever, localized pain, and redness are results of the inflammatory response to an infection. Well-approximated edges are a desired outcome of wound healing.
A hospitalized patient experiences a sharp, stabbing pain while visiting with his spouse. Both the patient and his wife become very concerned, and the patient’s call light is activated. What referent initiated communication between the patient and the nurse?a.Interaction between the patient and his wife
c. pain experienced by the pt
Pain is the referent that initiated the communication process. The interaction between the patient and his wife was the result of the patient’s pain as was the concern of the patient’s spouse. The call light could be considered a channel through which the patient’s interaction with the nurse began.
Which factor influences whether a message is effectively communicated? (SATA)a.Timing of the conversation
a, b, c, d
Timing of a conversation dramatically influences the receptivity of the receiver. The educational level of those seeking to communicate has an impact on the type of language and technical terminology that can be used in conversation. Using more than one mode of communication can enhance the effectiveness of a message. Making sure the environment is devoid of excess noise and distraction can facilitate a greater understanding of shared information.
If a patient is grimacing, what assessment statement or question would be most beneficial to identifying the underlying cause of the nonverbal communication?a.“Did you lose something?”
b. "you appear to be having pain"
Grimacing is a common nonverbal sign of pain. Sharing an observation encourages the patient to elaborate on nonverbal communication. Asking the patient whether something is lost indicates that the nurse has not attended to the nonverbal cues of the patient. It is important to do an assessment of the patient before initiating any interventions.
What action by the nurse would most ensure accurate interpretation of patient communication?a.Providing feedback regarding the conveyed message
a. providing feedback regarding conveyed message
Feedback is the most effective way to avoid misinterpretation of a message. It helps ensure that the message sent is perceived by the receiver in a way that is consistent with the intention of the sender. Writing down conversational highlights can be misinterpreted unless feedback is sought. Avoid assuming things abt cultural differences. Verifying a patient’s emotional state does not ensure accurate interpretation of a conversation.
If a patient’s verbal and nonverbal communications are inconsistent, which form of communication is most likely to convey the true feelings of the patient?a.Written notes
b. facial expressions
Nonverbal communication is the more accurate mode of conveying feelings. When a patient’s verbal and nonverbal cues are incongruent, it is important to explore observations made by the nurse to discern the true feelings of the patient. Written notes, implied inferences, and spoken words do not provide the opportunity for observing nonverbal cues.
What strategy would be most effective in communicating with a highly anxious adult immediately before surgery?a.Providing specific, concise instructions
a. providing specific, concise instructions
Only essential information supplied in short, succinct sentences can be comprehended by adults who are extremely anxious. The source of this pt’s anxiety is already stated to be the surgery, so the nurse need not elaborate on it. Postoperative teaching is best completed well in advance of surgery and reinforced after completion of the procedure. Multimedia DVDs are not effective teaching tools immediately before surgery.
What action should the nurse take if an alert and oriented pt asks the nurse for personal contact information?a.Ask the pt why the personal information is needed.
c. state that it would not be appropriate
It is important for the nurse to immediately communicate that sharing personal contact information with patients is inappropriate and violates professional role boundaries. Asking “why” questions and changing the subject are nontherapeutic. Neither action will discourage the pt from further infringing on the nurse’s personal right to privacy. Reporting the interaction to a supervisor may be helpful but shouldn't be the 1st step.
What would be the best therapeutic response to a patient who expresses indecision about recommended chemotherapy treatments?a.“Can you tell me why you are undecided?”
d. "what are you thinking about @ this pt?"
Asking open-ended questions allows patients to share freely on a subject. “Why” questions, using closed-ended questions, and giving advice are all nontherapeutic communication techniques that limit patient reflection and sharing on topics of concern.
Which statement is most accurate?a.Skills confidence can be shared most effectively by nurses through wearing distinctive clothing.
d. Nondramatic make-up use and minimal accessories by nurses demonstrates professionalism
Nurses demonstrate professionalism by adhering to institutional dress codes that require minimal accessorizing and cosmetic use. Wearing distinctive clothing is not linked to skills confidence. Clothing choices often reflect the economic resources of an individual, and make-up use by a hospitalized patient is a personal preference that should be honored.
Which defense mechanism is being exhibited when a 27-year-old patient insists on having a parent present during routine care?a.Denial
Young adults who require their parents’ presence for routine care are exhibiting regression, which is behavior consistent with earlier stages of development. Patients in denial refuse to see the reality of their situation. Repression is storing painful feelings in the unconscious, causing them to be temporarily forgotten. Displacement transfers emotional energy away from the actual source of stress to an unrelated object or person.
What is the purpose of the nursing process?a.Providing patient-centered care
c. organizing the ways nurses think about the pt care
The nursing process is the methodology used to “think like a nurse.” Providing patient-centered care and enhancing communication among health team members is facilitated through the use of care plans. Collaborating with rather than identifying members of the health care team is part of many plans of care.
A patient comes to the emergency department complaining of nausea and vomiting. What should the nurse ask the patient about first?a.Family history of diabetes
d. severity and duration of the n/v
In an emergent situation, the nurse initially focuses on the patient’s chief complaint to determine its cause. Before initiating care, the nurse gathers information on the other topics.
An alert, oriented patient is admitted to the hospital with chest pain. Who is the best source of primary data on this patient?
The nurse collects primary data directly from patients who are alert and oriented. Family members and other members of the health care team may provide secondary data on patients.
What is the primary purpose of the nursing diagnosis?
a.Resolving patient confusion
b.Communicating patient needs
c.Meeting accreditation requirements
d.Articulating the nursing scope of practice
b. communicating pt needs
Each nursing diagnosis label identifies either a patient problem or need, which is its purpose. Resolving patient confusion, meeting accreditation requirements, and articulating the nurse’s scope of practice are not related to the purpose of the nursing diagnostic process.
On what premise is a nursing diagnosis identified for a patient?
c. clustered data
Nursing diagnoses emerge from groupings of clustered data collected during the assessment phase of the nursing process. The nurse documents the pt's medical diagnosis as 1 piece of data, which may be clustered with others to support a nursing diagnosis. Data collected from a nurse’s intuition and 1st impressions may also be listed in the pt's assessment findings as long as they are objectively recorded without prejudice and are not judgmental in nature.
Which statement is an appropriately written short-term goal?
a.Patient will walk to the bathroom independently without falling within 2 days after surgery.
b.Nurse will watch patient demonstrate proper insulin injection technique each morning.
c.Patient’s spouse will express satisfaction with patient’s progress before discharge.
d.Patient’s incision will be well approximated each time it is assessed by the nurse.
a. Pt will walk to the bathroom independently without falling within 2 day after surgery
Goals are to be patient-focused, realistic, and measurable. Only the first goal meets these three criteria.
What should be the primary focus for nursing interventions?
d.Patient’s family requests
a. Pt needs
Patient needs are always the primary focus of nursing interventions. Nursing concerns, physician priorities, and family requests can provide additional guidance in the development of a patient-centered plan of care.
Which nursing action is critical before delegating interventions to another member of the health care team?
a.Locate all members of the health care team.
b.Notify the physician of potential complications.
c.Know the scope of practice for the other team member.
d.Call a meeting of the health care team to determine the needs of the patient.
c. know the scope of practice for the other team member
Knowing the scope of practice of the other team member is critical to understanding what is appropriate and safe to delegate to that person. It is unnecessary to locate or meet with all members of the health care team prior to delegation. Physicians are already aware of potential complications related to patient care.
A patient reports feeling tired and complains of not sleeping at night. What action should the nurse perform first?
a.Identify reasons the patient is unable to sleep.
b.Request medication to help the patient sleep.
c.Tell the patient that sleep will come with relaxation.
d.Notify the physician that the patient is restless and anxious.
a. ID reasons the pt is unable to sleep
When a patient shares a concern, the first action by the nurse is to assess potential reasons for the patient’s problem. Depending on the underlying reason for the patient’s inability to sleep, the nurse may then want to administer prescribed sleep medication, teach the patient some relaxation techniques, or discuss patient behaviors with the primary care provider.
What should the nurse do if the pt appears to have met the short-term goal of urinating w/in 1 hr post-op?
a.Consult the surgeon to see if the clinical pathway is being followed.
b.Discontinue the plan of care, because the pt has met the established goal.
c.Monitor patient urine output to evaluate the need for the current plan of care.
d.Notify the patient that the goal has been attained and no further intervention is needed.
c. Monitor pt urine output to evaluate the need for the current plan of care
The nurse should evaluate the need to continue or discontinue a plan of care if a patient has met a short-term goal. It is unnecessary to consult the surgeon unless there is a concern. Discontinuing the care plan may be premature, and the decision needs to be evaluated before taking action. The patient’s intake and output will continue to be monitored throughout hospitalization, not just for 1 hour after surgery.
Which action by a patient marks the beginning of the physical assessment process?
a.Redressing after a physical examination
b.Breathing normally during auscultation
c.Greeting the nurse in the examination room
d.Sharing work environment information
c. greeting the nurse in the examination room
Assessment begins at the moment the patient first interacts with the nurse. Redressing takes place at the end of the physical examination. Breathing during auscultation is part of the respiratory assessment, and sharing health history and demographic information takes place during the patient interview.
Which factors should be taken into consideration by the nurse before and during a pt interview? (SATA)
a.Distance between the chairs in which the nurse and patient are sitting
b.Traditional treatments typically used by the patient to treat disease
c.Gender preference for primary care providers
d.Physical condition of the patient
e.Music preference of the patient
a, b, c, d
The distance that is comfortable for personal interaction and gender preferences for care providers are affected by cultural and age norms. Its imp to ask pts abt the treatments that they traditionally use in response to illness. Preferred treatments sometimes can be incorporated. The physical condition of pts affects their ability to answer questions during an interview. There should not be music playing during the interview b/c it would be a distraction.
Which action by the nurse is most appropriate during the orientation phase of the patient interview?
a.Always position patients in a comfortable reclined position to ensure their comfort during questioning.
b. Ask which name a patient prefers to be called during care to show respect and build trust.
c.Quickly conduct a review of systems to determine the need for a complete or focused assessment.
d.Begin with questions about intimacy and sexuality to address sensitive issues first.
b. ask which name a pt prefers
The nurse should provide a personal intro & est the name by which the pt wants to be called at the very beginning of interview as part of orientation phase. In most cases, the patient and the nurse should be seated at eye level during the interview portion of the assessment. Qs about intimacy and sexuality should be reserved for later in the interview. A review of systems takes place during the working phase of the interview.
Which activity by the nurse best demonstrates part of the working phase of a patient interview?
a.Summarizing previously discussed key topics
b.Including selected family members in care planning
c.Transferring care responsibilities to the home health nurse
d.Verifying the name by which a patient prefers to be addressed
b. Including selected family members in care plan
Care planning takes place during the working phase of the nurse-patient interview. When a patient needs care assistance, it is important for family members who will be helping with the patient’s care to be involved in the process. Verifying the name that a patient prefers to be called takes place during the orientation or introductory phase. Summarizing key topics covered in the interview and transferring care responsibilities take place in the termination phase.
Which entry in a patient’s electronic health record best indicates the need for a nurse to gather secondary rather than primary subjective data?
a.Complaining of chest pain
b.Apical pulse 110
Primary data are obtained from the patient directly. A patient who is comatose is unable to speak and therefore unable to share subjective, primary data. A patient complaining of chest pain has already shared primary, subjective data. A patient with an apical pulse of 110 who is alert or one who has difficulty swallowing may still be able to contribute subjective information to the data collection.
Which line of questioning best represents an appropriate approach to the review of systems?
a.“What do you do for a living? Can you describe your work environment?”
b.“Is there a family history of heart disease, cancer, high blood pressure, or stroke?”
c.“When was your last annual physical? What immunizations did you receive at that time?”
d.“Do you have any chest tightness, shortness of breath, or difficulty breathing while exercising?”
d. "Do you have any chest tightness, SOB, or diff breathing while exercising?"
During a review of systems, the patient is asked questions about each body system to determine the level of functioning. Asking about work-related information, family history, and immunizations is accomplished during the collection of health history data before initiating the review of systems.
Which cue by a patient can be validated by laboratory and diagnostic test results?
a.Deeply sighing with fatigue
b.Bilateral crackles in the lungs
c.Oxygen saturation of 98% on room air
d.2+ pitting edema of the ankles and feet
a. deeply sighing with fatigue
A cue is a behavioral hint of a potential disease process or concern. In this case, the only cue is a deep sigh indicating fatigue. The level of fatigue can be verified by evaluating the patient’s hemoglobin and hematocrit levels for anemia. Crackles, oxygen saturation, and pitting edema are all physical assessment findings, not cues.
A patient discusses his job stress and family relationships with the nurse during his health history interview. In which organizational framework is this type of data likely to be recorded most extensively?
a.Body systems model
b.Physical assessment model
c.Head-to-toe assessment model
d.Functional health patterns model
d. functional health patterns model
Job stress and family relationships data will only be recorded extensively when using the Functional health patterns model. The functional health patterns model is holistic in its approach. The body systems model and head-to-toe assessment model focus on physical rather than psychological or emotional concerns. All three models listed are ways to organize physical assessment findings.
When initiating a physical examination, which action should the nurse take first?
a.Review of the patient’s prior medical records
b.Gather admission health history forms
c.Assess the patient’s vital signs
d.Perform light and deep palpation for fluid
c. assess the pt's vitals
Assessment of the patient’s vital signs begins the physical examination aspect of the assessment process. This provides the nurse with baseline information about cardiac and respiratory function, pain level, and temperature. The nurse should review the patient’s prior medical records before or after. Admission health history forms need to be gathered before initiating the interview, and abdominal palpation takes place about halfway through the head-to-toe physical examination.
If the nurse discovers that a patient’s right elbow is swollen and painful during a physical examination, which action should the nurse take next?
a.Apply ice to decrease swelling and reduce pain
b.Percuss the area to determine the presence of fluid
c.Perform passive range of motion to promote flexibility
d.Inspect the patient’s left elbow to compare its appearance
d. inspect the pt's left elbow to compare its appearance
A major aspect of assessment is checking for symmetry. If an abnormality is observed on one side of a patient’s body, the next step in the assessment is to compare that area with the other side. Applying ice is premature until the assessment is complete and an underlying cause of the swelling and pain is understood. Percussion is not needed. Performing passive range of motion is not appropriate.
d. pt safety
Safety is the most important reason for using standardized language to communicate patient’s needs and information. Using the same definitions of terms helps nurses and other health care professionals interpret the information. Helping with insurance documentation, supporting professional autonomy, and clarifying the nursing role in patient care are uses for NANDA-I taxonomy, but they are not the most important.
b, c, d
Readiness for Enhanced Relationship is a heath-promotion nursing diagnosis and is written with two sections: the label and the defining characteristics. Noncompliance is a nursing diagnosis that requires a related factor and defining characteristics. Risk for Bleeding requires at least one risk factor, which it has as it is written. Use of related factors in a risk nursing diagnosis is not the accepted NANDA-I format. The nursing diagnosis of Chronic Pain is incorrectly written because it includes a medical diagnosis and a related factor that is supportive of acute rather than chronic pain.
c. ineffective adaptation to recent loss
Related factors are broad statements that indicate the cause for the defining characteristics, which are signs or symptoms identified from collecting the patient’s data. Redness and swelling, unsteady gait, and complaint of restlessness are specific defining characteristics that would be clustered with other data to support the existence of an actual or health-promotion nursing diagnosis.
a, b, d
Before determining the types of nursing diagnoses that are appropriate for a patient, the nurse must review and analyze all of the pt's data, including the medical history. Considering potential complications permits the nurse to ID the need for risk nursing diagnoses. Outlining an individualized p.o.c. takes place during the planning stage of the nursing process post-diagnoses. Evaluation of a pt's response to treatment is part of the evaluation stage.
a. defining characteristics aren't part of risk dx
Risk diagnoses do not have defining characteristics; actual and health-promotion nursing diagnosis statements have defining characteristics. Risk diagnoses do not establish a cause and effect, because they identify potential rather than existing problems. Risk diagnoses contain related or risk factors rather than defining characteristics, subjective or otherwise. Risk diagnoses, like actual diagnoses, have nursing interventions to address a patient’s current or potential problem.
d. provide evidence-based research to support care
Supporting a suggestion for a new nursing diagnostic label with research is required for consideration by NANDA-I. Sharing concerns, providing alternative care, and advocating for patients are all a part of the nursing role, but are not the most important part of having a diagnosis considered for inclusion in the NANDA-I taxonomy.
a. lack of direction for formulating pt plans of care
Accurate nursing diagnostic statements provide direction for the development of individualized plans of care. Orders are part of the patient’s assessment data. Combining unrelated patient problems is a function of diagnostic development, not a result of an improperly written statement. Poorly written nursing diagnostic statements may or may not result in increased team collaboration.
d. medical diagnoses may be interrelated
Nursing dx consider the underlying etiology, needs, potential concerns, & pt response to a pt's medical dx, so the 2 types of diagnoses are interrelated. Nurses consider the medical diagnosis as one aspect of concern when identifying an actual or potential health problem & the pt's response, so medical diagnoses are relevant, but not the focus of nursing dxs.
b. perform the steps of the nursing process related to the pt's current condition
The patient’s condition requires immediate performance of the lifesaving steps of the nursing process. All other answers are secondary actions. The nurse later resumes all interventions for previously identified nursing diagnoses and evaluates the success of the acute care plan for management of the cardiac arrest. Nurses do not seek the input of the physician for creation of nursing diagnoses.
b, c, e
An elevated pulse rate, continuous toe tapping, and verbalizing nervousness are consistent with extreme anxiety and should be clustered together. Ease of falling asleep and being able to focus on a challenging task, such as giving an injection, are not indicative of a patient experiencing a high level of anxiety.
Which action would the nurse undertake first when beginning to formulate a patient’s plan of care?
a.List possible treatment options
b.Identify realistic outcome indicators
c.Consult with health care team members
d.Rank patient concerns from assessment data
d. rank pt concerns from assessment data
Prioritizing or ranking patient needs precedes the identification of outcome indicators, consulting with team members, or consulting with interdisciplinary team members.
Which resource is most helpful when prioritizing identified nursing diagnoses?
a.Nursing Interventions Classification (NIC)
b.Gordon’s functional health patterns
c.Maslow’s hierarchy of needs
d.Nursing Outcomes Classification (NOC)
c. Maslow's hierarchy of needs
Maslow’s hierarchy of needs and the airway, breathing, circulation (ABCs) of life support are the most helpful tools in identifying priorities of care. Functional health patterns is one method of organizing assessment data. NOC and NIC are resources for identifying outcomes and interventions to include in a patient’s care plan after priorities have been established.
If a patient is exhibiting signs and symptoms of each of the following nursing diagnoses, which should the nurse address first while planning care?
d.Body Image Disturbance
b. Acute Pain
Acute Pain is the most urgent nursing diagnosis to address. Fatigue may be a result of the pain and may be alleviated if the patient’s pain level is reduced. Body Image Disturbance and Knowledge Deficit can be treated only after the patient’s pain level is at an acceptable level. Both diagnoses require teaching, during which the patient needs to concentrate. A person’s ability to concentrate is affected by the pain level.
Which statement illustrates a characteristic of goals within the care planning process?
a.Goals are vague objectives communicating expectations for improvement.
b.Short-term goals need not be measurable, unlike long-term goals.
c.Goal attainment can be measured by identifying nursing interventions.
d.Long-term goals are helpful in judging a patient’s progress.
d. Long-term goals are helpful in judging a pt's progress
Long-term goals are very useful in determining patient progress. Both short-term and long-term goals need to be measurable. Goal attainment is based on patient actions, not nursing actions.
Which nursing goal is written correctly for a patient with the nursing diagnosis of Risk for Infection after abdominal surgery?
a.Nurse will encourage use of sterile technique during each dressing change.
b.Patient’s white blood count will remain within normal range throughout hospitalization.
c.Patient’s visitors will be instructed in proper hand washing before direct interaction with patient.
d.Patient will understand the importance of cleaning around the incision with a clean cloth during bathing.
b. pt's WBC will remain w/in normal range
A patient’s white blood cell count is a laboratory test that is a measureable indicator of infection. The correct answer is also patient-focused and realistic. Encouraging the use of sterile technique by the nurse during each dressing change and instructing the patient’s visitors in the proper handwashing technique before direct interaction with the patient are not patient-focused. The patient understanding the importance of cleaning around the incision with a clean cloth during bathing uses a nonmeasurable verb, which should be avoided when formulating patient goals.
If the nurse chooses the Nursing Outcome Classification (NOC), Appetite (1014) for a chemotherapy patient, which outcome indicators would be acceptable for evaluation of goal attainment? (SATA)
a.Expressed desire to eat
b.Report that food smells good
c.Use of relaxation techniques before meals
d.Preparation of home-cooked meals for self and family
e.Uses nutritional information on labels to guide selections
a, b, d
Sharing a desire to eat, reporting that food smells good, and preparing meals are indications of an increased appetite. Although relaxation techniques may decrease anxiety associated with eating, they do not indicate an increase in appetite. Reading nutrition labels is unlikely to increase a person’s appetite.
Which action by the nurse would be most important in developing a patient-centered plan of care for an alert, oriented adult?
a.Providing a written copy of care options to the patient and family
b.Collaborating with the patient’s social worker to determine resources
c.Listening to the patient’s concerns and beliefs about proposed treatment
d.Engaging the patient’s family, friends, or care providers in conversation
c. listening to the pt's concerns and beliefs abt proposed treatment
It is most important to involve the patient in developing realistic, attainable, patient-centered plans of care. Involving others in care planning is secondary to involving the patient, unless the patient is cognitively impaired.
Which intervention can the nurse initiate independently while providing patient care? (SATA)
a.Ordering a blood transfusion
b.Auscultating lung sounds
c.Monitoring skin integrity
d.Applying heel protectors
e.Adjusting antibiotic dosages
b, c, d
Auscultating lung sounds and monitoring skin integrity are both important aspects of basic patient assessment that are required independent nursing actions. Ordering and applying heel protectors is done independently by nurses to prevent skin breakdown on patient’s confined to the bed. Ordering blood transfusions and adjusting antibiotic dosages are the responsibility of the patient’s primary health care provider.
The nurse notices that a patient is becoming short of breath and anxious. Which of the following interventions is a dependent nursing action, requiring the order of a primary care provider?
a.Elevating the head of the patient’s bed
b.Administering oxygen by nasal cannula
c.Assessing the patient’s oxygen saturation
d.Evaluating the patient’s peripheral circulation
b. administering oxygen by nasal cannula
Before a nurse can legally administer oxygen to a patient, the method of delivery and amount must be ordered by the primary care provider. Elevating the head of the bed and assessing a patient’s oxygen saturation and peripheral circulation are all independent nursing interventions.
Which situation indicates the greatest need for collaborative interventions provided by several health care team members?
c.Activities of daily living
d.Health history interview
a. Hospice referral
Hospice referral requires collaboration with many health care team members. Physical assessment and completion of a health history interview are independent nursing actions that can be performed by a nurse alone. Activities of daily living can be completed by patients independently or with the help of a nurse or unlicensed assistive personnel (UAP), requiring little collaboration among health care team members.
a.Potential communication barriers
b.Diverse cultural practices
c.Scope of nursing practice
d.Functional status of the patient
e. Time of most recent shift change
a, b, c, d
Cultural practices, functional status, communication barriers, and scope of practice influence whether an intervention should or may be implemented. Shift change time is not necessary to consider before implementation of most interventions.
a.Instruct the patient to shower and shave simultaneously
b.Discourage the patient from bathing while hospitalized
c.Encourage the patient to rest between bathing activities
d.Ask the patient’s spouse to assist with all bathing
c. encourage the pt to rest between bathing activities
When patients are unable to complete their personal care without fatigue, it is best to encourage them to rest between activities. All patients should be encouraged to wash during hospitalization and to complete as much of their personal care as independently as possible. Patients who tire easily should not be encouraged to shower and shave simultaneously but should space out personal care while seated.
Which nursing intervention is most important to complete before giving medication to a patient?
a.Provide water to aid in the patient’s ability to swallow the medication.
b.Double-check the patient’s allergies before giving the drug.
c.Ask the patient to verify having taken the medication before.
d.Place the patient in a side-lying position to prevent aspiration
b. double-check pt's allergies before giving the drug
Verifying patient allergies before administering medication is the most important intervention listed to ensure patient safety. Providing water may or may not be necessary, depending on the type of medication being administered. Although it is okay to ask a patient about having taken a medication previously, it is not routinely done or most important. It is preferable to have patients sit up while taking medication unless contraindicated
Which direct-care intervention would be most effective in helping a patient cope emotionally with a new diagnosis of cancer?
a.Reassessing for changes in the patient’s physical condition
b.Teaching the patient various methods of stress reduction
c.Referring the patient for music and massage therapy
d.Encouraging the patient to explore options for care
d. encouraging the pt to explore options for care
Encouraging the patient to explore options for care empowers the patient to have some control over the situation and to be actively involved in care planning. It is a form of informal counseling. Reassessment and teaching are not immediately indicated at this time. Although referring a patient with a new cancer diagnosis may be helpful, it is an indirect care intervention.
What should be taken into consideration by the nurse when deciding on interventions to include in a patient’s plan of care? (SATA)
a.Patient’s treatment preferences
b.Cultural and ethnic influences
c.Professional level of expertise
d.Current evidence-based research
e. Convenience to the nursing staff
a, b, c, d
Patient treatment preferences, cultural and ethnic influences, the level of a nurse’s professional expertise, and current evidence-based research should all be taken into consideration when planning care. The convenience to nursing staff should not be of concern.
Which task may the registered nurse safely delegate to unlicensed assistive personnel without prior intervention?
a.Ambulating a patient with ataxia and new right sided paresthesia
b.Feeding a patient with cerebral palsy who recently aspirated
c.Transporting a patient to the hospital entrance for discharge
d.Administering prescribed programmed medications
c. transporting a pt to the hospital entrance for discharge
Transporting the stable patient for discharge can be delegated immediately to UAP. A patient with new neurologic symptoms needs to be assessed before being ambulated. Patients who have recently choked need to be evaluated for their ability to swallow before being fed. Administering medication is not within the UAP’s scope of practice and can never be delegated to UAP.
Which action is a part of the evaluation step in the nursing process? (SATA)
a.Recognizing the need for modifications to the care plan
b.Documenting performed nursing interventions
c.Determining if nursing interventions were completed
d.Reviewing whether a patient met their short-term goal
e.Identifying realistic outcomes with patient input
Determining whether a goal or outcome is met is part of the evaluation. Making sure interventions are completed and documenting them are part of implementation. Identifying outcome criteria is done during the planning stage of the nursing process.
Which action by the day-shift nurse provides objective data that enables the night- shift nurse to complete an evaluation of a patient’s short-term goals?
a.Encouraging the pt to share observtns from the day
b.Leaving a message with the charge nurse before shift change
c.Documenting pt assessment findings in pt's chart
d.Checking with the pharmacist regarding possible drug interactions
c. documenting pt assessment findings in the pt's chart
Documentation of assessment findings is the only objective form of data listed as an option that can support the night nurse in evaluating whether the patient achieved short-term goals. Patient observations are subjective in nature. Leaving a message with the charge nurse produces secondary subjective data, and checking for drug interactions is unrelated to the evaluation process.
Which notation is most appropriate for the nurse to include in a patient’s chart regarding evaluation of the goal, “Patient will ambulate three times daily in the hallway before discharge without shortness of breath (SOB)”?
a.Goal not met; patient states he is tired.
b.Goal not met; patient ambulated three times in room.
c.Goal met; pt ambulated three times in the hallway.
d.Goal met; patient ambulated three times in the hallway without SOB
d. gaol met; pt ambulated 3 times in the hallway w/out SOB
Option d is the only notation that indicates whether the goal was met and how all of the outcome criteria were attained.
What is the primary purpose of quality improvement?
a.Recognizing the need to discipline employees violating policies
b.Preventing patient injury that may contributor to the death of others
c.Increasing institutional profits to support further scientific research
d.Enhancing current practices to improve patient outcomes and care
d. enhancing current practices to improve pt outcomes and care
Quality improvement focuses on improving processes. This has many benefits and is not primarily directed at preventing the death of patients, providing discipline, or making money.
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