What category does this fall under?
primary source/ subjective data
When performing hand hygiene, the nurse notices the LPN. Which actions made suggest further teaching is needed? Removal of jewelry, wetting hands then applying soap, allow hands to air dry, using circular motion for 20 seconds
allow hands to air dry
A nurse is writing the nursing diagnosis for a patient in the psych clinic. Which nursing diagnoses are writing correctly as two part diagnosis?
ineffective coping related to the inability to maintain marriage as evidence recent divorce
risk for defensive coping related to recent job loss
altered mental status related to bipolar disorder as evidence by hallucinations and grandiose thoughts
risk for defensive coping related to recent job loss
the nurse is caring for a patient with Sundown syndrome who is slightly confused during the day. Which of the following actions by the nurse suggests clinical reasoning? complete bed bath every early morning, only consulting with family related to plan of care, have a time limit for patients when performing tasks, allowing the patient to tackle one task at time with time for questions
allowing the patient to tackle one task at a time with time for questions
You are helping a patient from bed to chair. Which of the following actions can be taken to ensure safety?
Get someone else to do it
Call the male CNA for assistance
Sit patient on the side of bed, count to three, lift from the waist
Using power lift assistance
using power lift assistance
A potassium level of 5.6 is considered this form of collection data?
secondary source/ objective data
A group of students have decided to help a mentally confused patient with bathing. Which techniques can be an assistance to bathing the client? bathing the patient quickly to avoid agitation, family required to assist with bathing, use of music help calm the client while being bathed, early morning baths before 0600
use of music to help calm the client while being bathed
A nurse is prioritizing the following diagnoses related to Maslow's Hierarchy of needs. Label answer choices from highest priority to lowest
1. disturbed body image
2. ineffective airway clearance
3. risk for infection
4. decreased cardiac output
2,4,3,1
You are gathering objective data on a newly admit client. Which documentation suggest further teaching is necessary?
urinary output of 250ml
HR 98
pain rating 10/10
xray confirming tuberculosis
pain rating of 10/10
Client who is at the greatest risk for falls ask for ways to prevent injury at home. STA
Keep lighting dim
remove area rugs
keep barefoot to have the best grip to the floor
keep necessity items close to bedside
have exposed cords at the foot of the bed
remove area rugs keep necessity items close to bedside
decrease venous return
While performing a complete bed bath on a compromised male patient, which of the following statements by the student nurse requires further teaching? wash in circular motions, replace foreskin, place patient in low fowler's position, place patient in lithotomy with support pillows
place patient in lithotomy with support pillows
The nurse is caring for patient admitted for recurrent diarrhea. Which of the following is the first step in the nursing process?
evaluate
compare data with physiologic norms
preparing nursing diagnosis
analyze data including subjective/ objective data
analyze data including subjective/objective data
(assessment)
Which statement made by the patient or family suggest further teaching is necessary? STA
I will keep my elbows in a flexed position
I should keep the crutches at maximum 6ft away from me
I will bear the weight on my hands and not in my axillae
I will use my brother's spare crutches he kept in the basement
I should keep the crutches at maximum 6ft away from me; I will use my brother's spare crutches he kept in the basement
A newly admitted client with elevated blood pressure, states that they have blurred vision, seeing spots, and has a medical history of tonic clonic seizures. What would be the nurse's next course of action? Name three
pad the side rails, have suction equipment available, have oxygen available for use, bed in lowest position, declutter the area for safety, notify provider
Following admission, which actions would be considered under the diagnosis phase of the nursing process?
analyze data
creating client goals
evaluating the effectiveness of client's new prescriptions
identify and prioritize problem
identify and prioritize problem
You have the following assigned clients. Which client should the nurse see first?
A confused client who is resting with support person in room
a patient requesting pain medication actively eating breakfast
a patient crying requesting to speak to family prior to their surgery
a client with a new diagnosis of cerebrovascular accident (stroke) and needing assistance to bathroom
a client with a new diagnosis and needing assistance to bathroom
The nurse is reviewing the care plan of her student nurse for the day. Which of the following diagnosis requires follow-up by the nurse of the student?
deficient fluid volume r/t nausea and vomiting
activity intolerance r/t recurrent disease process
cardiomegaly r/t to poor lifestyle choices
risk for impaired skin integrity
cardiomegaly r/t poor life style choices
Patient has right sided weakness from recent illness. You note the patient has a correct understanding of canes when stating,
"I will keep the cane on the right side and use it to walk with my left"
"I will hold the cane in my left hand and swing with the left side"
"I will use my strong side to step up first and then use the cane to aid the weak side"
" I will use the cane in the left hand to walk and move at the same time as my left leg"
I will use my strong side to step up first then use the can to aid the weak side
The rn is developing ways to prevent injuries for nurses moving patients on the unit. What statement below indicates a correct understanding of prevention?
Wear only a back brace while lifting heavier patients
Bending at the knees keeping feet close to together
assistive devices are not necessary only for complete non-bearing patients
Mechanical lifts can aid in transport from bed to chair
mechanical lifts can aid in transport from bed to chair
In this step of the nursing process, the nurse reviews the data and diagnostics to formulate goals and specific interventions
planning
Which of the following statements would imply the patient is at the highest risk for falls?
visual acuity decreased, accompanied by confusion, left sided weakness
hearing aids, agitation, and multiple medication use
wearing flip flops and leaving side rails up x2
Age, poor diet control, and non-skid footwear
visual acuity decreased, accompanied by confusion and left sided weakness
In this stage of the nursing process, the nurse intervenes, supervises care, and encourage active participation
implementation
Oral hygiene is essential especially for patient with sedation and intubation. Which of the following nursing actions is inappropriate when providing oral care?
Keeping suction equipment at bedside
turning the patient's head to right lateral to house secretions for suctioning
cleaning mouth tongue and teeth with a specialized foam brush
laying the patient supine and suctioning as needed
lying the patient supine and suctioning as needed
Client admitted post MVA with a spinal cord injury, requesting help with changing their briefs. Their blood pressure 132/84, HR 68, denies pain, oxygen saturation of 98%. The family is also at bedside and stated they are available to help. Identify the proper method of moving the patient while bathing?
Knee to chest, have the client reach over and help turn themselves
have the patient to lift from the waist to remove the under brief
Assist the patient the chair and change the entire linens that are soiled
logroll the patient to keep alignment
logroll the patient to keep alignment