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Nursing process 2
Which feature is true about standing orders? 1 Meet instrumental activities of daily living. 2 Ensure familiarity with evidence-based guidelines for nursing care. 3 Allow a quick response to a rapidly changing clinical situation. 4 Minimize documentation issues for nurses. - 3 Which action would the nurse perform when revising a nursing care plan? Select all that apply. One, some, or all responses may be correct. 1 Revise the nursing diagnoses. 2 Add new data with appropriate dates. 3 Maintain irrelevant nursing diagnoses. 4 Choose the method of evaluation for monitoring patient outcomes. - 1,2, Which action is an example of an independent nursing intervention? Select all that apply. One, some, or all responses may be correct. 1 Provide health education 2 Start intravenous (IV) fluids 3 Administer a hypertension agent 4 Assist with daily activities 5 Reposition a patient - 1,4, Which problem would the nurse add to the care plan after evaluating a diabetic patient who had a problem with glucose control but is now restless and asking many questions about an upcoming procedure on the big toe? 1 Anxiety 2 Glucose control 3 Diabetes
Risk of toe infection - 1 Setting a time frame for outcomes of care determines which purpose? 1 The priority level 2 Time it takes to complete an intervention 3 How long the nurse is scheduled to care for a patient 4 When the patient is expected to respond in the desired manner - 4 Which action would the nurse take for a patient who agrees with the nurse that expected outcomes were met? 1 Modify the care plan. 2 Revise the plan of care. 3 Discontinue the care plan. 4 Continue with the plan of care. - 3 Which response would the nurse make for a patient who expresses confusion about how to manage a leg wound after discharge? 1 Provide a written document that contains the necessary instructions. 2 Tell the patient that a relative will be taught how to take care of the wound. 3 Explain and demonstrate the necessary action to the patient. 4 Inform the patient that it will be explained later during discharge. - 3 The nurse would evaluate which goal based upon the following reassessment: upon removal of the intravenous (IV) line from the right arm, the site was clean and dry with no signs of redness or tenderness? 1 Patient expresses acceptance of health status by day of discharge. 2 Patient's surgical wound will be free of drainage. 3 Patient's IV site will remain free of infection. 4 Patient understands when to call the health care provider to report complications. -
Stop the medication and administer it again after the reaction subsides. - 1,2, Which outcome is correctly written and would the nurse add to the plan of care about the patient's apical pulse? 1 The patient will have a normal apical pulse. 2 The patient's apical pulse values will be stable. 3 The patient will have acceptable apical pulse values. 4 The patient's apical pulse will be at least 70 beats per minute. - 4 Which intervention performed by the nurse would require an order from a health care provider? Select all that apply. One, some, or all responses may be correct. Correct Getting an x-ray of the chest to rule out pulmonary complications Correct Administering an antibiotic to prevent infection Correct Starting an intravenous (IV) infusion of normal saline 4 Instructing the patient to splint the incision when coughing 5 Teaching the patient about the side effects of the medication - 1,2, Which action indicates that the nurse is using physical care techniques? 1 Meeting the patient's expressed needs 2 Performing indirect care measure 3 Using safe patient-handling procedures 4 Providing a hand-off report - 3 Which word does the letter "T" represent in the SMART acronym as it relates to setting goals for the patient? 1 Timed 2 Treatment 3 Therapeutic 4
Thermoregulation - 1 Which action would the nurse take when a nursing goal is not met in the care of a patient? Select all that apply. One, some, or all responses may be correct. 1 Reassess the patient. 2 Repeat the entire nursing process. 3 Revise the care plan. 4 Notify the health care provider immediately. 5 Discontinue the care plan for the patient. - 1,2, Which feature is typical of an intermediate priority nursing diagnosis? 1 Life threatening 2 Long term 3 Nonemergent 4 Low priority - 3 Which expected outcome for the goal "Patient will achieve a gain of 10 pounds (4.5 kg) in body weight in a month" is written correctly? 1 Patient will eat at least three-fourths of each meal by the end of 1 week. 2 Patient will verbalize relief of nausea and have no episodes of vomiting in 1 week. 3 Administer patient liquid supplements 3 times a day. 4 Provide patient high-calorie meals 3 times a day. - 1 Arrange the steps of the nursing process in their appropriate order.
Assessment
Diagnosis
Planning
Implementation
Which outcome would be appropriate for the depressed patient who lost weight but has a goal to return to baseline weight in 3 months? Select all that apply. One, some, or all responses may be correct. 1 Patient discusses the source of depression by next clinic visit. 2 Patient achieves an intake of 2400 calories daily in 2 weeks. 3 Patient reports improvement in appetite in 1 week. 4 Patient identifies food protein sources. 5 Patient does not display signs of depression in 2 weeks. - 2, Which information correctly describes the evaluation process? Select all that apply. One, some, or all responses may be correct. 1 Is a complex process 2 Usually reveals obvious changes in patients 3 Involves making clinical decisions 4 Requires the use of assessment skills 5 Is performed once for each intervention - 1,3, Which characteristic of nursing goals and expected outcomes would the nurse keep in mind when developing a care plan? Select all that apply. One, some, or all responses may be correct. 1 Realistic 2 Attainable 3 Specific to patient 4 Health care provider-centered 5 No time limit - 1,2, Which component would be included in a comprehensive nursing care plan? Select all that apply. One, some, or all responses may be correct. 1 Nursing diagnoses 2 Expected outcomes
Generalized nursing interventions 4 Orders for diagnostic tests 5 Evaluation findings - 1,2, Which statement describes the unique difference between a hospital's nursing care plan and the home care plan? 1 The goals of care will always be more long term. 2 The patient and family need to be able to provide most of the health care. 3 The patient's goals need to be mutually set with family members who will care for the patient. 4 The expected outcomes need to address what can be influenced by interventions. - 2 Which evaluative measure would be appropriate for determining if an obese patient who is maintaining a sleep diary achieves restful sleep? Select all that apply. One, some, or all responses may be correct. 1 Reassess the patient for any skin lesions. 2 Ask the patient if he or she feels rested after sleeping. 3 Review the sleep diary of the patient. 4 Interview the patient to reassess sleep habits. 5 Reassess the skin color of the patient. - 2,3, When assessing a patient with a terminal illness, the nurse notes the patient's monosyllabic replies and limited eye contact. Which direct care intervention does the nurse perform? 1 Ensuring privacy 2 Providing counseling 3 Requesting an analgesic 4 Consulting a palliative care team - 2 Which action would the nurse take for a patient who reports frequent periods of nausea that interfere with eating after chemotherapy treatments? 1
Reassure the patient. - 2,3,4, As the nurse makes decisions about how to implement skin care for a patient, which action would the nurse implement? Select all that apply. One, some, or all responses may be correct. 1 Review the set of all possible nursing interventions for the patient's problem. 2 Examine all possible consequences associated with each possible nursing action. 3 Act before thinking. 4 Determine the probability of all possible consequences. 5 Consider supplies/resources available for skin care. - 1,2,4, Which patient evaluative measure would be most appropriate for determining if the obese patient achieves the goal of a 15-pound weight loss? 1 Eats 1500 calories a day 2 Is weighed during each clinic visit 3 Discusses factors for starting an exercise program 4 Reviews the food diary that tracks intake of daily meals - 2 Place the steps of consultation in the correct sequence.
Direct the consultation to the right professional.
Identify the problems associated with the patient.
Incorporate the consultant's recommendations into the care plan.
Provide the consultant with relevant information about the problem area.
Be available to discuss the consultant's findings and recommendations. - 2,1,4,5, Which information about standing orders is accurate? Select all that apply. One, some, or all responses may be correct. 1 They provide instructions from the unit manager about care in emergencies. 2 They are preprinted documents that contain orders for various clinical problems. 3
They provide legal protection to the nurse when caring for the patient. 4 They are signed by the licensed prescribing health care provider in charge at the time of implementation. 5 They are signed by the patient or the patient's relative before the treatment is started. - 2,3, Which intervention would the nurse add to the nursing care plan to reduce anxiety in a patient? Select all that apply. One, some, or all responses may be correct. 1 Use a reassuring approach in discussions. 2 Teach the patient relaxation exercises using deep breathing. 3 Prevent close family members from entering the discussions. 4 Work with the health care provider to provide factual medical information. 5 Discourage the patient from sharing any feelings or expressing apprehension. - 1,2, Which factor would the nurse consider before setting a goal that the patient will self- administer insulin injections? Select all that apply. One, some, or all responses may be correct. 1 Patient's ability to meet the goal 2 Nurse's competency in teaching about insulin 3 Patient's cognitive function 4 Availability of the patient's support network to assist 5 Patient's social network - 1,3, Which action would the nurse perform for unmet and partially met goals? Select all that apply. One, some, or all responses may be correct. 1 Redefine priorities. 2 Continue some or all interventions. 3 Discontinue the care plan. 4 Maintain nursing care plan as written. 5 Compare the patient's response with that of another patient. - 1,
Understand that a patient requiring nursing counseling has normal adjustment difficulties and may be upset or frustrated. - 1,2,4, Which action would the nurse take next when the expected outcome was stating three side effects of chemotherapy, but after a teaching session the patient related over five side effects of the medication? 1 Ask the patient to motivate other patients about learning chemotherapy side effects. 2 Discontinue the health education related to side effects of chemotherapy. 3 Modify the expected outcome to include five side effects of chemotherapy. 4 Continue to teach the patient about chemotherapy side effects. - 2 After evaluation of the patient, which action would the nurse take when the intervention is unsuitable? Select all that apply. One, some, or all responses may be correct. 1 Reprioritize the nursing diagnosis. 2 Discontinue the care plan. 3 Discontinue the unsuitable intervention. 4 Add new interventions. 5 Change the frequency of the intervention. - 3,4, Which purpose describes the importance of a nurse documenting patient outcomes? Select all that apply. One, some, or all responses may be correct. 1 To inform other health care team members 2 To share information about the patient's progress 3 To make ongoing clinical decisions 4 To acknowledge revision of the care plan 5 To replicate the care in another patient - 1,2,3, The family of a patient states, "We found out that our loved one has end-stage hepatitis. We don't know what that means." How does the nurse respond? 1 Offering to contact their pastor for spiritual support
Giving the family written information about the disease 3 Contacting the health care provider to provide more information 4 Asking about the family's understanding of the patient's illness - 4 The reduction of which incidence is a nursing-sensitive quality outcome? Select all that apply. One, some, or all responses may be correct. 1 Severe pressure injuries 2 Vascular catheter-associated infections 3 Catheter-associated infections 4 Falls 5 Hospital readmissions - 1,2,3, Arrange the steps in proper sequence for measures the nurse would take when a patient does not meet the goal stated in the care plan.
Reassess the patient.
Establish new goals and expected outcomes.
Determine the accuracy of the nursing diagnosis.
Select a new intervention. - 1,3,2, Prioritize the nursing diagnoses for an older-adult patient with pneumonia who is fatigued and lives alone.
Reduced oxygenation
Threat of immobility
Possible isolation from the community
Poor health management - 1,2,4, The nurse provides education for a group of nursing students about cultural preferences related to activities of daily living (ADLs). The nurse reminds the students of the need to respect patients' wishes and determine patient preferences. Which example does the nurse include?
Skin lesions - 1, Which activity would the nurse perform when preparing for the implementation phase of the nursing process? Select all that apply. One, some, or all responses may be correct. 1 Reassessing the patient 2 Focusing on preventive measures 3 Organizing resources and care delivery 4 Counseling and motivating the patient 5 Reviewing and revising the existing nursing care plan - 1,3, Place the steps in proper order for modifying the plan of care when a patient develops nausea after chemotherapy.
Select approaches for controlling environmental factors that worsen nausea.
Enter data in the assessment column showing new information about the patient's nausea.
Decide to use the patient's self-report of appetite and fluid intake as evaluation measures.
Add the current patient condition of nausea as a nursing diagnosis. - 2,4,1, The nurse reviews potential interventions for a patient who is experiencing pain. When considering the administration of an analgesic, the nurse identifies that the medication may cause an adverse reaction, including increasing the patient's fall risk. The nurse is demonstrating which principle of critical judgment and decision-making? 1 Review the set of all possible nursing interventions for the patient's problem. 2 Review all possible consequences associated with each possible nursing action. 3 Judge the value of the consequences to the patient. 4 Determine the probability of all possible consequences. - 2 Which action would the nurse perform when revising interventions for a patient? Select all that apply. One, some, or all responses may be correct. 1 Continue with all existing interventions. 2 Modify the frequency of interventions. 3
Maintain high-quality standards of care. 4 Avoid changes in the frequency of interventions. 5 Change the level of nursing care. - 2,3, Which action would the nurse take before implementing health care provider-initiated interventions? Select all that apply. One, some, or all responses may be correct. 1 Clarify questionable prescriptions. 2 Implement procedures automatically. 3 Administer medications without question. 4 Decide if the intervention is appropriate for the patient. 5 Determine if collaboration with other care disciplines is required. - 1,4, Which sequence would the nurse follow for making decisions about implementing interventions?
Judge the value of the consequences to the patient.
Determine the probability of possible consequences.
Review all possible consequences associated with each intervention.
Review all possible interventions for the patient. - 4,3,2, Which component is an element of the American Nurses Association (ANA) standards of practice and scope of nursing practice? Select all that apply. One, some, or all responses may be correct. 1 Describes what a nurse is licensed to perform 2 Is a definition of skills competencies for nurses 3 Sets standards for diagnosing diseases and disorders 4 Identifies the nature and intent of the ways nurses intervene for patients 5 Is an authoritative statement regarding the duties all nurses are expected to perform - 1,4,
Avoid discussing clinical results with the patient. 4 Follow agency guidelines about sharing medical information. 5 Provide appropriate nursing care without any documentation. - 1,2, The nurse reviews potential interventions for a patient who is experiencing pain. When considering the administration of an analgesic, the nurse identifies that the medication may cause an adverse reaction, including increasing the patient's fall risk. The nurse is demonstrating which principle of critical judgment and decision-making? 1 Review the set of all possible nursing interventions for the patient's problem. 2 Review all possible consequences associated with each possible nursing action. 3 Judge the value of the consequences to the patient. 4 Determine the probability of all possible consequences. - 2 Which capability of the nurse would help in choosing suitable nursing interventions? Select all that apply. One, some, or all responses may be correct. 1 Functioning within a particular setting of the health care unit 2 Directing the consultation to the right professional 3 Knowing the scientific rationale for the intervention 4 Aligning a consultation to identify the problems of the patient 5 Possessing the necessary psychomotor and interpersonal skills - 1,3, Which action would the nurse perform when revising interventions for a patient? Select all that apply. One, some, or all responses may be correct. 1 Continue with all existing interventions. 2 Modify the frequency of interventions. 3 Maintain high-quality standards of care. 4 Avoid changes in the frequency of interventions. 5 Change the level of nursing care. - 2,3,
Which information would the nurse include in a teaching session about the levels of prevention? Select all that apply. One, some, or all responses may be correct. 1 Primary prevention involves immunizations, health education programs, nutrition, and physical activities. 2 Secondary prevention involves early diagnosis and prompt treatment. 3 Tertiary prevention involves minimizing the effects of long-term illness or disability, including rehabilitation. 4 Secondary prevention focuses on people who are experiencing health problems or illnesses. - 1,2,3, Which step of the nursing process is the nurse performing when he or she asks the patient to rate pain 45 minutes after administering an analgesic? 1 Assessment 2 Diagnosis 3 Implementation 4 Evaluation - 4 Which intervention indicates the nurse is delivering ethical care? 1 Administering morphine for pain relief 2 Understanding the patient's expectations 3 Assessing the patient for any signs of organ failure 4 Referring the patient for appropriate diagnostic interventions - 2 Which nursing-sensitive patient outcome is written correctly? Select all that apply. One, some, or all responses may be correct. 1 The patient will administer a self-injection of insulin and control diet. 2 The patient will administer a self-injection by discharge. 3 The patient will appear less anxious. 4 The body temperature will remain at or below 37° C (98.6° F). 5 The heart rate will remain between 70 to 90 beats per minute. - 2,4,
