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NurseLogic 2.0 Nursing Concepts Beginning Test

Terms in this set (20)

Autonomy

Autonomy is respecting the client's right to make personal health care decisions, whether or not the nurse believes those decisions are in the best interest of the client. This is the ethical principle the nurse is illustration by making the referral as requested

The content of this question emphasizes the concept of professionalism by using ethical principles to guide nursing practice. Professionalism incorporates legal and ethical principles, as well as compliance with the standards of nursing practice in the provision of safe, quality nursing care that exhibits both accountable and responsible behaviors.

- Justice is the use of fairness, which is not the ethical principle the nurse is illustrating by making the referral as requested. Examples of justice in nursing practice includes advocating for fair distribution of resources or providing all clients with the same level of care regardless of his or her level of health benefits.

- Veracity is the act of truth-telling. This is not the ethical principle the nurse is illustrating by making the referral as requested. An example of veracity in nursing practice includes telling a client of his terminal diagnosis when he asks, even if it goes against the wishes of the family.

- Fidelity is the act of keeping promises. This is not the ethical principle the nurse is illustrating by making the referral as requested. An example of fidelity includes following through on a promise to return with pain medication in a specified period of time
Including in a client notes that an incident report was completed after a medication error

When an incident report should be completed for a medication error, this report is not referred to, nor does it become part of, the client's permanent record
The content of this question emphasizes the concept of professionalism through the recognition of documentation requirements. Professionalism incorporates legal and ethical principles, as well as compliance with the standards of nursing practice in the provision of safe, quality nursing care that exhibits both accountable and responsible behavior. This is not an appropriate action and requires intervention from the nurse preceptor. Incident reports are completed for incidents that are considered to be a deviation from expected outcomes of routine care and are often used in quality improvement programs for the facility. While an incident report should be completed for a medication error, this report is not referred to, nor does it become part of, the client's permanent record.

- The nurse should draw a horizontal line through blank spaces in the nurses' notes to prevent incorrect information being added by another individual.

- The nurse should not chart vital signs taken by another nurse. The vital signs might not be accurate and the nurse is accountable for the information she documents

- The nurse should document when a provider is contacted to clarify a questionable prescription because the nurse is legally responsible, and liable, for carrying out the prescription.
Potassium 2.5 mEq/L

A potassium level of 2.5 mEq/L is below the expected reference range. Hypokalemia can lead to arrhythmia's or cardiac arrest. Because this level is life threatening, it is the priority at this time.

The content of this question emphasizes the concept of priority setting by requiring the determination of which laboratory value requires immediate intervention. Priority setting is the use of nursing judgment when making decisions about the rank order in which to take nursing actions. Various priority setting frameworks, such as Maslow's Hierarchy of Needs, nursing process, ABC, and safety and risk reduction, can be useful in determining the priority of needed actions. This finding requires immediate intervention.
~Other answers (not most correct answer):
- Blood Glucose 150 mg/dL: This finding does not require immediate intervention. While this blood glucose level is above the expected reference range, it will not cause life-threatening complications. This finding should be monitored to determine the need for intervention; however, another finding is a higher priority at this time.

- Total Protein 5.2 g/dL: This finding does not require immediate intervention. While this total protein level is below the expected reference range, it will not cause life-threatening complications. This finding should be monitored to determine the need for intervention; however, another finding is a higher priority at this time.

- Urine Specific Gravity 1.040: While this urine specific gravity is above the expected reference range, it will not cause life-threatening complications. A natural mechanism of the body is to conserve urine when fluids are being lost in other places. This finding should be monitored to determine the need for intervention; however, another finding is a higher priority at this time.
Difficulty breathing

This finding can lead to hypoxia; therefore, immediate intervention is warranted. The difficulty in breathing can be caused by edema in the larynx or trachea and is a serious complication

The content of this question emphasizes the concept of priority setting by requiring the determination of which finding requires immediate intervention. Priority setting is the use of nursing judgment when making decisions about the rank order in which to take nursing actions. Various priority setting frameworks, such as Maslow's Hierarchy of Needs, nursing process, ABC, and safety and risk reduction, can be useful in determining the priority of needed actions.

~ other answer (wrong/not most right) rationales:

- This finding may require intervention if it doesn't resolve within a specified time frame; however, it does not require immediate intervention. Blood-tinged mucous and sputum is an expected finding following the procedure because of trauma of the tissue of the larynx, trachea, or bronchi when the bronchoscope is inserted

- This finding may require intervention to relieve discomfort; however, it does not require immediate intervention. A hoarse voice is an expected finding following a bronchoscopy. The client may complain of hoarseness after the bronchoscopy because of the trauma to tissue of the larynx and the trachea.

- This finding may require intervention to relieve discomfort; however, it does not require immediate intervention. Painful swallowing is an expected finding following a bronchoscopy. The swallowing reflex is usually blocked for about 6 hr after the procedure. When the reflex returns, the client may experience some discomfort and difficulty when swallowing.
States that pain is an 8 on a scale of 0 to 10

Physical symptoms, such as pain, fatigue, or anxiety, can prevent the client from learning because of a reduced ability to focus on and participate in education

The content of this question emphasizes the concept of client education by recognizing physical symptoms that can impair the client's readiness and ability to learn. Client education is the provision of health-related education to clients to facilitate the acquisition of new knowledge and skills, adoption of new behaviors, and modification of attitudes. It is important for nurses to develop skills in identifying client learning needs, as well as client- and educator-related barriers to learning. This response by the client indicates the nurse should postpone teaching. Deep breathing and coughing exercises help prevent postoperative respiratory complications. A key principle of teaching and learning is to first determine the client's readiness and ability to learn.

~ other answer (wrong/not most right) rationales:

- states that partner should be given the information:

- This response by the client does not indicate the nurse should postpone teaching. Deep breathing and coughing exercises help prevent postoperative respiratory complications. The fact that the client believes that learning how to deep breathe and cough is the responsibility of her partner should indicate to the nurse that additional teaching is needed. The client does not exhibit any physical symptoms, such as pain, fatigue, or anxiety, that necessitate postponing the teaching.

- This response by the client does not indicate the nurse should postpone teaching. Deep breathing and coughing exercises help prevent postoperative respiratory complications and can be uncomfortable. The fact that the client is expressing concern about the exercises causing pain when performed after surgery should indicate to the nurse the need for additional explanation, such as mechanisms that will be used to control the pain. The client does not exhibit any physical symptoms, such as pain, fatigue, or anxiety, that necessitate postponing the teaching.

- This response by the client does not indicate the nurse should postpone teaching. Deep breathing and coughing exercises help prevent postoperative respiratory complications. The fact that the client is expressing uncertainty about the benefits of the exercises should indicate to the nurse that reinforcing the importance of the exercises, and a description of possible negative outcomes, should be discussed. The client does not exhibit any physical symptoms, such as pain, fatigue, or anxiety, that necessitate postponing the teaching