Upgrade to remove ads
Unit 1 Part 3 Chapters 18-20
Terms in this set (67)
The nurse completes a thorough assessment of a patient and analyzes the data to identify nursing diagnoses. Which step will the nurse take next in the nursing process?
A patient's plan of care includes the goal of increasing mobility this shift. As the patient is ambulating to the bathroom at the beginning of the shift, the patient suffers a fall. Which initial action will the nurse take next to revise the plan of care?
Assess the patient.
Which information indicates a nurse has a good understanding of a goal?
It is a broad statement describing a desired change in a patient's behavior.
A nurse is developing a care plan for a patient with a pelvic fracture on bed rest. Which goal statement is realistic for the nurse to assign to this patient?
Patient will increase activity level this shift.
The following statements are on a patient's nursing care plan. Which statement will the nurse use as an outcome for a goal of care?
The patient will verbalize a decreased pain level less than 3 on a 0 to 10 scale by the end of this shift.
A charge nurse is reviewing outcome statements using the SMART approach. Which patient outcome statement will the charge nurse praise to the new nurse?
The patient will feed self at all mealtimes today without reports of shortness of breath.
A nursing assessment for a patient with a spinal cord injury leads to several pertinent nursing diagnoses. Which nursing diagnosis is the highest priority for this patient?
Reflex urinary incontinence
The new nurse is caring for six patients in this shift. After completing their assessments, the nurse asks where to begin in developing care plans for these patients. Which statement is an appropriate suggestion by another nurse?
"Begin with the highest priority diagnoses, then select appropriate interventions."
A patient's son decides to stay at the bedside while his father is confused. When developing the plan of care for this patient, what should the nurse do?
Involve the son in the plan of care as much as possible.
A nurse is caring for a patient with a nursing diagnosis of Constipation related to slowed gastrointestinal motility secondary to pain medications. Which outcome is most appropriate for the nurse to include in the plan of care?
Patient will have one soft, formed bowel movement by end of shift.
The nurse performs an intervention for a collaborative problem. Which type of intervention did the nurse perform?
A registered nurse administers pain medication to a patient suffering from fractured ribs. Which type of nursing intervention is this nurse implementing?
Which action indicates the nurse is using a PICOT question to improve care for a patient?
Implements interventions based on scientific research
A nurse is developing a care plan. Which intervention is most appropriate for the nursing diagnostic statement Risk for loneliness related to impaired verbal communication?
Provide the patient with a writing board each shift.
A nurse is completing a care plan. Which intervention is most appropriate for the nursing diagnostic statement Impaired skin integrity related to shearing forces?
Turn the patient every 2 hours, even hours.
A patient has reduced muscle strength following a left-sided stroke and is at risk for falling. Which intervention is most appropriate for the nursing diagnostic statement Risk for falls?
Assist patient into and out of bed every 4 hours or as tolerated.
Which action will the nurse take after the plan of care for a patient is developed?
Communicate the plan to all health care professionals involved in the patient's care.
A nurse is preparing to make a consult. In which order, beginning with the first step, will the nurse take?
1. Identify the problem.
2. Discuss the findings and recommendations.
3. Provide the consultant with relevant information about the problem.
4. Contact the right professional, with the appropriate knowledge and expertise.
5. Avoid bias by not providing a lot of information based on opinion to the consultant.
1, 4, 3, 5, 2
A hospital's wound nurse consultant made a recommendation for nurses on the unit about how to care for the patient's dressing changes. Which action should the nurses take next?
Include dressing change instructions and frequency in the care plan.
A nurse is planning care for a patient with a nursing diagnosis of Impaired skin integrity. The patient needs many nursing interventions, including a dressing change, several intravenous antibiotics, and a walk. Which factors does the nurse consider when prioritizing interventions? (Select all that apply.)
a. Rank all the patient's nursing diagnoses in order of priority.
b. Do not change priorities once they've been established.
c. Set priorities based solely on physiological factors.
d. Consider time as an influencing factor.
e. Utilize critical thinking.
A nurse is teaching the staff about the benefits of Nursing Outcomes Classification. Which information should the nurse include in the teaching session? (Select all that apply.)
a. Includes seven domains for level 1
b. Uses an easy 3-point Likert scale
c. Adds objectivity to judging a patient's progress
d. Allows choice in which interventions to choose
e. Measures nursing care on a national and international level
c & e
A nurse is providing nursing care to patients after completing a care plan from nursing diagnoses. In which step of the nursing process is the nurse?
The nurse is teaching a new nurse about protocols. Which information from the new nurse indicates a correct understanding of the teaching?
Protocols assist the clinician in making decisions and choosing interventions for specific health care problems or conditions.
The standing orders for a patient include acetaminophen 650 mg every 4 hours prn for headache. After assessing the patient, the nurse identifies the need for headache relief and determines that the patient has not had acetaminophen in the past 4 hours. Which action will the nurse take next?
Administer the acetaminophen.
Which action indicates a nurse is using critical thinking for the implementation of nursing care to patients?
Determines whether an intervention is correct and appropriate for the given situation
A nurse is reviewing a patient's care plan. Which information will the nurse identify as a nursing intervention?
Provide assistance while the patient walks in the hallway twice this shift with crutches.
A patient recovering from a leg fracture after a fall reports having dull pain in the affected leg and rates it as a 7 on a 0 to 10 scale. The patient is not able to walk around in the room with crutches because of leg discomfort. Which nursing intervention is a priority?
Administer pain medication.
The nurse is caring for a patient who requires a complex dressing change. While in the patient's room, the nurse decides to change the dressing. Which action will the nurse take just before changing the dressing?
Assesses the patient's readiness for the procedure
A patient visiting with family members in the waiting area tells the nurse "I don't feel good, especially in the stomach." What should the nurse do?
Ask the patient to return to the room, so the nurse can inspect the abdomen.
A newly admitted patient who is morbidly obese asks the nurse for assistance to the bathroom for the first time. Which action should the nurse take initially?
Review the patient's activity orders.
A new nurse is working in a unit that uses interdisciplinary collaboration. Which action will the nurse take?
Develop good communication skills.
Which action should the nurse take first during the initial phase of implementation?
Reassess the patient.
Vital signs for a patient reveal a high blood pressure of 187/100. Orders state to notify the health care provider for diastolic blood pressure greater than 90. What is the nurse's first action?
Assess the patient for other symptoms or problems, and then notify the health care provider.
Which initial intervention is most appropriate for a patient who has a new onset of chest pain?
Reassess the patient.
A nurse is making initial rounds on patients. Which intervention for a patient with poor wound healing should the nurse perform first?
Observe wound appearance and edges.
The nurse establishes trust and talks with a school-aged patient before administering an injection. Which type of implementation skill is the nurse using?
The nurse inserts an intravenous (IV) catheter using the correct technique and following the recommended steps according to standards of care and hospital policy. Which type of implementation skill is the nurse using?
A staff development nurse is providing an in-service for other nurses to educate them about the Nursing Interventions Classification (NIC) system. During the in-service, which statement made by one of the nurses in the room requires the staff development nurse to clarify the information provided?
"This system can help medical students determine the cost of the care they provide to patients."
The nurse is intervening for a family member with role strain. Which direct care nursing intervention is most appropriate?
Counseling about respite care options
The nurse is intervening for a patient that has a risk for a urinary infection. Which direct care nursing intervention is most appropriate?
Teaches proper handwashing technique
The nurse is revising the care plan. In which order will the nurse perform the tasks, beginning with the first step?
1. Revise specific interventions.
2. Revise the assessment column.
3. Choose the evaluation method.
4. Delete irrelevant nursing diagnoses.
2, 4, 1, 3
Modification of an existing written care plan includes four steps
1. Revise data in the assessment column to reflect the patient's current status. Date any new data to inform other members of the health care team of the time that the change occurred.
2. Revise the nursing diagnoses. Delete nursing diagnoses that are no longer relevant and add and date any new diagnoses. Revise related factors and the patient's goals, outcomes, and priorities. Date any revisions.
3. Revise specific interventions that correspond to the new nursing diagnoses and goals. Be sure that revisions reflect the patient's present status.
4. Choose the method of evaluation for determining whether you achieved patient outcomes.
A nurse is implementing interventions for a group of patients. Which actions are nursing interventions? (Select all that apply.)
a. Order chest x-ray for suspected arm fracture.
b. Prescribe antibiotics for a wound infection.
c. Reposition a patient who is on bed rest.
d. Teach a patient preoperative exercises.
e. Transfer a patient to another hospital unit.
A nurse is providing nursing care to a group of patients. Which actions are direct care interventions? (Select all that apply.)
a. Ambulating a patient
b. Inserting a feeding tube
c. Performing resuscitation
d. Documenting wound care
e. Teaching about medications
A, B, C, E
A nurse is preparing to carry out interventions. Which resources will the nurse make sure are available? (Select all that apply.)
b. Safe environment
d. Assistive personnel
A, B, D
Which interventions are appropriate for a patient with diabetes and poor wound healing? (Select all that apply.)
a. Perform dressing changes twice a day as ordered.
b. Teach the patient about the signs and symptoms of infection.
c. Instruct the family about how to perform dressing changes.
d. Gently refocus the patient from discussing body image changes.
e. Administer medications to control the patient's blood sugar as ordered.
A, B, C, E
A nurse determines that the patient's condition has improved and has met expected outcomes. Which step of the nursing process is the nurse exhibiting?
A nurse completes a thorough database and carries out nursing interventions based on priority diagnoses. Which action will the nurse take next?
A new nurse asks the preceptor to describe the primary purpose of the evaluation. Which statement made by the nursing preceptor is most accurate?
"Nurses use evaluation to determine the effectiveness of nursing care."
After assessing the patient and identifying the need for headache relief, the nurse administers acetaminophen for the patient's headache. Which action by the nurse is a priority for this patient?
Reassess the patient's pain level in 30 minutes.
A nurse is getting ready to discharge a patient who has a problem with physical mobility. What does the nurse need to do before discontinuing the patient's plan of care?
Evaluate whether patient goals and outcomes have been met.
The nurse is evaluating whether patient goals and outcomes have been met for a patient with physical mobility problems due to a fractured leg. Which finding indicates the patient has met an expected outcome?
The patient is able to ambulate in the hallway with crutches.
The nurse is evaluating whether a patient's turning schedule was effective in preventing the formation of pressure ulcers. Which finding indicates the success of the turning schedule?
Absence of skin breakdown
A nurse has instituted a turning schedule for a patient to prevent skin breakdown. Upon evaluation, the nurse finds that the patient has a stage II pressure ulcer on the buttocks. Which action will the nurse take next?
Reassess the patient and situation.
A new nurse is confused about using evaluative measures when caring for patients and asks the charge nurse for an explanation. Which response by the charge nurse is most accurate?
"Evaluative measures include assessment data used to determine whether patients have met their expected outcomes and goals."
The nurse is caring for a patient who has an open wound and is evaluating the progress of wound healing. Which priority action will the nurse take?
Measure the wound and observe for redness, swelling, or drainage.
The nurse is caring for a patient who has an order to change a dressing twice a day, at 0600 and 1800. At 1400, the nurse notices that the dressing is saturated and leaking. What is the nurse's next action?
Revise the plan of care and change the dressing now.
A goal for a patient with diabetes is to demonstrate effective coping skills. Which patient behavior will indicate to the nurse achievement of this outcome?
States feels better after talking with family and friends
A nurse is providing education to a patient about self-administering subcutaneous injections. The patient demonstrates self-injection. Which type of indicator did the nurse evaluate?
A nurse is evaluating the goal of acceptance of body image in a young teenage girl. Which statement made by the patient is the best indicator of progress toward the goal?
"I'll wear the blue dress. It matches my eyes."
A nurse is evaluating goals and expected outcomes for a confused patient. Which finding indicates positive progress toward resolving the confusion?
Patient correctly states names of family members in the room.
A nurse identifies a fall risk when assessing a patient upon admission. The nurse and the patient agree that the goal is for the patient to remain free from falls. However, the patient fell just before shift change. Which action is the nurse's priority when evaluating the patient?
Identify factors interfering with goal achievement.
A patient was recently diagnosed with pneumonia. The nurse and the patient have established a goal that the patient will not experience shortness of breath with activity in 3 days with an expected outcome of having no secretions present in the lungs in 48 hours. Which evaluative measure will the nurse use to demonstrate progress toward this goal?
Lungs clear to auscultation following use of inhaler
A nurse is evaluating an expected outcome for a patient that states the heart rate will be less than 80 beats/min by 12/3. Which finding will alert the nurse that the goal has been met?
Heart rate 78 beats/min on 12/3
A nurse is modifying a patient's care plan after evaluation of patient care. In which order, starting with the first step, will the nurse perform the tasks?
1. Revise the nursing diagnosis.
2. Reassess blood pressure reading.
3. Retake blood pressure after medication.
4. Administer new blood pressure medication.
5. Change goal to blood pressure less than 140/90.
2, 1, 5, 4, 3
A nurse is caring for a group of patients. Which evaluative measures will the nurse use to determine a patient's responses to nursing care? (Select all that apply.)
a. Observations of wound healing
b. Daily blood pressure measurements
c. Findings of respiratory rate and depth
d. Completion of nursing interventions
e. Patient's subjective report of feelings about a new diagnosis of cancer
A, B, C, E
Which nursing actions will the nurse perform in the evaluation phase of the nursing process? (Select all that apply.)
a. Set priorities for patient care.
b. Determine whether outcomes or standards are met.
c. Ambulate patient 25 feet in the hallway.
d. Document results of goal achievement.
e. Use self-reflection and correct errors.
B, D, E
THIS SET IS OFTEN IN FOLDERS WITH...
Unit 1 exam (chapters 1/4/5 Potter)
Unit 1 Part 2 chap 15-17
Unit 1 Part 4 chapters 27/49/26
Unit 1/Chapter 28 &40
YOU MIGHT ALSO LIKE...
Foundations Exam #2
Chapter 18: Planning Nursing Care
OTHER SETS BY THIS CREATOR
ATI FUNDAMENTALS PROCTORED EXAM
HEALTH PROMOTION AND AGING
Fundamentals Chapter 1
RNSG-FINAL- 2021- Fields
OTHER QUIZLET SETS
Psychology Review #5
BF - MC Fragen