Planning, Outcome, and Implementing Nursing Care
A nurse is prioritizing nursing diagnoses for a patient with multiple issues. Which diagnosis should the nurse address first?
A. Disturbed Sleep Pattern.
B. Impaired Gas Exchange.
C. Knowledge Deficit.
D. Risk for Infection.
B: Prioritization should follow the ABCs (Airway, Breathing, Circulation); Impaired Gas Exchange is a high-priority physiological need.
The nurse sits down to talk with a patient and leans forward. Which aspect of communication is the nurse demonstrating?
A. Verbal communication.
B. Nonverbal communication.
C. Metacommunication.
D. Intrapersonal communication.
B: Posture, gait, and eye contact are all key aspects of nonverbal communication.
4. The nurse receives a telephone order from a provider. Which action is required?
A. Write the order down and sign the provider's name.
B. Ask a student nurse to take the call.
C. Read the order back to the provider for verification.
D. Wait for the provider to come to the unit to sign it before acting.
C: Documentation of telephone orders requires a "read-back" process to ensure accuracy.
What are the five steps of the nursing process?
Assessment, Diagnosis, Planning, Implementation, Evaluation
What is a post void residual? Why do you obtain this?
amount of urine left in the bladder
after the patient has voided
Which type of nursing intervention is a "Dependent Nursing Intervention"?
A. Elevating an edematous extremity.
B. Administering a prescribed antibiotic.
C. Providing patient education on a low-sodium diet.
D. Performing a physical assessment.
B: Dependent interventions require an order from a health care provider.
What is the most effective way to evaluate if a patient has understood the education provided?
A. Ask the patient, "Do you have any questions?"
B. Have the patient perform a "teach-back" or return demonstration.
C. Give the patient a written test.
D. Assume the patient understands if they nod their head.
B: Teach-back is a specific evaluation method to confirm understanding and patient outcomes.
A patient is crying after receiving a terminal diagnosis. The nurse says, "I can see that you are very upset." Which therapeutic technique is the nurse using?
A. Sharing observations.
B. False reassurance.
C. Giving personal opinions.
D. Changing the subject.
A: Sharing observations involves stating what the nurse perceives about the patient's behavior or emotional state.
What does iSBARR stand for?
introduction, Situation, Background, Assessment, Recommendation, repeat
Serous: Clear, watery plasma; indicates normal healing and minimal inflammation.
Sanguineous: Bright red blood; indicates active bleeding or trauma to the wound bed.
Before implementing a nursing intervention, what is the first step the nurse should take?
A. Document the care in the medical record.
B. Reassess the patient to ensure the intervention is still appropriate.
C. Gather all necessary equipment.
D. Delegate the task to an AP.
B: The implementation process begins with reassessing the patient to avoid adverse events and ensure care is current.
A nurse is teaching a group of older adults about heart health. Which strategy should the nurse use?
A. Speak very loudly and quickly.
B. Use complex medical jargon.
C. Provide information in small, manageable amounts.
D. Present all information in a single 2-hour lecture.
C: Teaching for older adults should be adapted to their specific needs, often requiring slower pacing and repetition.
Which communication technique is considered "Nontherapeutic"?
A. Active listening.
B. Asking for explanations (e.g., "Why did you do that?").
C. Providing information.
D. Using silence.
B: Asking for explanations can make the patient feel defensive.
What are the "7 Rights" of medication administration?
Right patient, right drug, right dose, route, time, documentation/indication
Discuss the signs, causes, and immediate nursing actions for:
Signs: Partial or total separation of wound layers; increased serosanguineous drainage; patient may report feeling “something gave way.”
Causes: Poor nutrition, obesity, sudden strain (coughing, vomiting), infection, smoking, steroid use.
Immediate Nursing Actions:
Notify the provider.
Cover the wound with sterile saline-moistened gauze.
Instruct patient to splint the wound and avoid coughing/straining.
Keep patient on bedrest with knees bent to reduce tension.
The nurse identifies that a patient is not adhering to the prescribed exercise plan. What is the nurse's best response?
A. Scold the patient for not following instructions.
B. Document that the patient is "non-compliant."
C. Introduce interventions that the patient is willing and able to follow.
D. Tell the patient they will not be discharged until they exercise.
C: To achieve outcomes, nurses should promote adherence by adapting interventions to the patient's needs and capabilities.
Which of the following is a legal guideline for nursing documentation?
A. Use "white-out" to correct errors.
B. Document for a colleague who was too busy.
C. Record all facts accurately and objectively.
D. Leave blank spaces in the progress notes.
C: Guidelines for quality documentation state that entries must be factual and accurate.
The nurse identifies that a patient is not adhering to the prescribed exercise plan. What is the nurse's best response?
A. Scold the patient for not following instructions.
B. Document that the patient is "non-compliant."
C. Introduce interventions that the patient is willing and able to follow.
D. Tell the patient they will not be discharged until they exercise.
C: To achieve outcomes, nurses should promote adherence by adapting interventions to the patient's needs and capabilities.
List some complications of immobility?
skin breakdown, pneumonia, DVT/VTE, orthostatic hypotension, contractures, foot drop, urinary stasis,
- Stage 1: Non-blanchable redness of intact skin; skin may be painful, firm, warm, or cooler compared to surrounding tissue.
A nurse uses a preprinted document that contains medical orders for specific patients with identified clinical problems. What is this called?
A. A Nursing Care Plan.
B. A Standing Order.
C. A Clinical Practice Guideline.
D. A Nursing Diagnosis Classification.
B: Standing orders are preprinted medical orders used for specific clinical situations.
What is the most important rule regarding the confidentiality of a patient's health record?
A. It is okay to share information with a friend who is also a nurse.
B. Students may take pictures of the chart for study purposes.
C. Access to the record is limited to those involved in the patient's care.
D. Passwords should be shared with the preceptor to save time.
C: HIPAA and institutional policies require maintaining the privacy and security of the health care record.
What is the primary purpose of a patient-centered outcome?
A. To organize the nurse's daily tasks.
B. To reflect the patient's highest possible level of wellness and independence.
C. To justify the cost of the hospital stay.
D. To provide a list of medical diagnoses.
B: Patient-centered outcomes are focused on the patient's health status and functional goals.
Which electrolyte imbalances are associated with Trousseau’s and Chvostek’s signs?
Hypocalcemia and hypomagnesemia
Adequate nutrition provides the building blocks for tissue repair and helps maintain intact skin.
Protein: Essential for collagen synthesis, immune function, and tissue regeneration