Nursing Process
Client states he is not sure when he should check his blood sugars, so he has not been monitoring. Therefore, he states he is not sure when he should take his oral hypoglycemic medicine. Utilizing the subjective information presented, which is the most appropriate nursing diagnosis for this client?
a. Skin Integrity, risk for
b. Diabetes mellitus, risk for
c. Knowledge, deficit
c. Knowledge, deficit
This pulse is taken for 1 minute at the apex of the heart, left mid-clavicular by the 5th intercostal space.
What is Apical?
After assessing a client's radial pulse, the nurse notes an irregular beat. She asks the UAP to assess pulse for a full minute. Should the nurse delegate this task.
What is no. Why?
Use only _____abbreviations when documenting.
What is standardized or approved?
True or False
Dorothea Orem's nursing theory is based on the fact that the client is able to prioritize his or her own care.
What is False.
Which of the following is a properly written OUTCOME?
a. Abdominal incision will be ok.
b. Client knows how to give insulin.
c. Client will list 3 signs/symptoms of hypoglycemia upon discharge.
c. Client will list 3 signs/symptoms of hypoglycemia upon discharge.
This pulse is palpated on the dorsal side of the patient's foot.
What is DORSALIS PEDIS?
The nurse delegates oral care for an unconscious client to an unlicensed assistive personnel (UAP). You note that the UAP places the client in Supine position. Should the nurse intervene? Why or why not?
Client should be positioned in left
Two identifiers that can be used to accurately identify a patient.
What is name, date of birth, or other unique patient identifier?
After placing a client on a bedpan, what position should the client be placed afterwards.
What is fowler's position?
True or False
The information collected from the client during the health assessment will be the basis for the nursing process.
True
The bottom number of a blood pressure reading that reflects the heart at rest is called _______.
What is DIASTOLIC?
A client complains of pain to an UAP, stating ,"I'm still in pain after the nurse gave me pain medication." The UAP reports to the nurse. The nurse's next step is to ___.
What is assess patient's pain level?
These standards protects the nurse, the patient and the institution. Every state and US territory have set laws to govern the practice of nursing.
What is the Nursing Practice Act?
While performing a bed bath, the nurse observes the UAP wiping the eyes from the inner canthus to the outer canthus. Should the nurse intervene? Why?
What is no? This is a proper technique.
Which of the following is a collaborative nursing intervention?
a. monitoring abdominal dressing
b. educating signs and symptoms of infection
c. administering an analgesic for pain 6/10
c. administering an analgesic for pain 6/10
The term used when a patient's temperature is elevated.
What is FEBRILE?
True or False
After emptying a foley catheter bag, the UAP is delegated the task of documenting the urine output. Can this task be delegated?
What is yes? Why?
The personal protective equipment the nurse must wear upon entering the client's room.
What is gown and gloves (clean)?
What does the "R" in the acronym RACE stand for?
What is rescue?
True or False
Interventions for a plan of care to prevent falls include placing call light within reach, raising all four side rails, and applying non-skid socks.
False.
The nurse receives a patient from the OR after a total knee replacement (TKR). What is the nurse's PRIORITY assessment?
a. surgical site dressing
b. gag reflex
c. respirations
What is c. respirations.
A nurse and a UAP are getting ready to pull a client up in bed. Name safety interventions to complete the task.
What are:
locking bed, placing client in supine position, raising bed to working height?
Some components of making an occupied bed are:
What are: explaining the procedure to the client, raising bed to working height, locking the bed, keeping patient covered, keep side rail up on the opposite side?