Manic Monday
What is the primary purpose of the patient record?
-Research
-Advocacy
-Education
-Communication
Communication
What cognitive processes must the nurse use to measure patient achievement of outcomes during evaluation?
-Intuitive thinking
-Traditional thinking
-Critical thinking
-Rote memory
Critical thinking
A nurse is evaluating the outcomes of a plan of care to teach an obese patient about the calorie content of foods. What type of outcome is this?
-Affective
-Cognitive
-Physiologic
-Psychomotor
Cognitive
The nurse should utilize ISBARR communication (Introduction, Situation, Background, Assessment, Recommendation, Read Back) during which clinical situation?
-When preparing to discharge the patient home
-When reporting to a patient's family member or significant other
-When transferring a patient from the ER to the acute care unit
-When documenting the care that was provided to a patient whose condition recently deteriorated
When transferring a patient from the ER to the acute care unit
Of the following data, what objective type would be collected during a physical assessment?
-Type, amount, and duration of pain
-Color, moisture, and temperature of the skin
-Foods eaten that cause nausea
-Specific allergies resulting in itching
Color, moisture, and temperature of the skin
What is the nurse accountable for, according to state nurse practice acts?
-prescribing PRN (as needed) meds
-making nursing diagnoses
-managing the care team effectively
-mentoring other nurses
making nursing diagnoses
Which nursing diagnosis is validated by the presence of major defining characteristics?
-Risk nursing diagnosis
-Actual nursing diagnosis
-Possible nursing diagnosis
-Wellness diagnosis
Actual nursing diagnosis
The nurse is performing an assessment of a patient who has a small wound on the knee, collecting cues about the patient's health status. Which symptom would the nurse identify as a subjective cue?
-Temp 102F
-Pulse 90 bpm
-Sharp pain in the knee
-Small bloody drainage on the dressing
Sharp pain in the knee
The nurse is writing a nursing diagnosis after assessment of the patient. What part of the nursing diagnosis statement will suggest the nursing interventions to be included in the plan of care?
-Etiology of the problem
-Outcomes criteria
-Defining characteristics
-Problem statement
Etiology of the problem
The nurse is developing a care plan for a newly admitted pt. What guideline will the nurse use when writing the nursing diagnosis?
-The nurse recognizes person biases as a strength in formulating nursing diagnoses
-The nurse keeps an open mind and ensures data is accurate and complete when formulating nursing diagnoses
-The nurse respects clinical intuitions but does not allow her intuition to determine a nursing diagnoses
-The nurse trusts her clinical judgment and experience over asking for help from other nurses
The nurse keeps an open mind and ensures data is accurate and complete when formulating nursing diagnoses
The patient is experiencing shortness of breath, lethargy, and cyanosis. These three cues provide organization, or:
-grouping
-clustering
-diagnosing
-categorizing
clustering
Which outcome is correctly written?
-On discharge, the patient will be free of infection.
-During home care, nurse will not observe symptoms of infection.
-On discharge, the patient will be able to list five symptoms of infection.
-Abdominal incision will show no signs of infection.
On discharge, the patient will be able to list five symptoms of infection.
The nurse completes a health history and physical assessment on a patient who has been admitted to the hospital for surgery. What is the purpose of this initial assessment?
-to compare and contrast current health status to baseline data
-to identify life-threatening problems that require immediate attention
-to establish a database to identify problems and strengths
-to gather data about a specific and current health problems
to establish a database to identify problems and strengths
Which guideline is a correct one to follow when composing a nursing diagnosis statement?
-Incorporate subjective and judgmental terminology
-Phrase the nursing diagnosis as a client need
-Place defining characteristics after the etiology and link them by the phase "as evidenced by"
-Place the etiology prior to the client problem and linked by the phrase "related to"
Place defining characteristics after the etiology and link them by the phase "as evidenced by"
A male 30 year old patient is post op day 2 following a nephrectomy (kidney removal) but has not yet mobilized or dangled at the bedside. Which of the following is the nurse's BEST intervention in this patient's care?
-Respect the pts wishes to remain in his bed and ask him when he would like to begin mobilizing
-Show the pt the expected outcomes on his clinical pathway that relate to mobilization
-Educate the pt about the benefits of early mobilization and offer to assist him
-Document the pts noncompliance and reiterate the consequences of delaying mobilization
Educate the pt about the benefits of early mobilization and offer to assist him
The nurse is creating care plans for newly admitted patients. Which nursing intervention demonstrates a clearly, well written activity?
-The patient will understand the importance of drinking adequate amounts of fluid
-The nurse will offer the patient 100mL of water every 2 hours while awake
-The nurse will offer the patient water when the patient reports thirst
-The patient will continue to increase oral intake when awake
The nurse will offer the patient 100mL of water every 2 hours while awake
The nurse has drafted a nursing diagnosis of Imbalanced Nutrition: More than body requirements in the care of a moderately obese patient. How should the nurse proceed after writing this diagnosis?
-Identify potential complications
-Validate the nursing diagnosis
-Cross-reference the nursing diagnosis with medical diagnosis
-Modify interventions based on the diagnosis
Validate the nursing diagnosis
A nurse delegates a specific intervention to an unlicensed assistive personnel (UAP). What implications does this have for the nurse?
-The nurse transfers responsibility bur is accountable for the outcome
-The UAP can function in an independent role for all interventions
-Nurses do not have authority to delegate interventions
-The UAP is responsible and accountable for her own actions
The nurse transfers responsibility bur is accountable for the outcome
The nurse formulates the following patient outcome: "Patient will correctly draw up morning dose of insulin and identify four signs and symptoms of hypoglycemia by Dec. 12". Which error has the nurse made?
-The nurse wrote vague outcomes that will confuse other nurses
-The nurse used verbs that are not observable and measurable
-The nurse included more that one patient behavior in the outcome
-The nurse expressed the patient outcomes as an intervention
The nurse included more that one patient behavior in the outcome
A nurse is preparing to insert an IV line and begin administering IV fluids. The pt has visitors in the room. What should the nurse do?
-Ask the pt if visitors should remain in the room
-Ask the visitors to leave the room
-Tell the pt to ask the visitors to leave the room
-Wait unit the visitors leave to begin the procedure
Ask the pt if visitors should remain in the room
The nurse overhears two nursing students talking about nursing interventions. Which statement by one of the students indicates further education is required?
-"Nursing interventions must be compatible with other therapies planned for the patient."
-"Nursing interventions must be approved by other members of the healthcare team."
-"Nursing interventions must be consistent with standards of care and research findings."
-"Nursing interventions must be culturally sensitive and individualized for the patient."
"Nursing interventions must be approved by other members of the healthcare team."
After assessing a patient, the nurse formulates several nursing diagoses. Which would the nurse identify as an actual nursing diagnosis?
-Possible impaired adjustment
-Risk for infection
-Impaired urinary elimination
-Readiness for enhanced sleep
Impaired urinary elimination
The patient had a total knee replacement. The nurse developed a care plan for this patient. Which actions are physician-initiated interventions. (select all)
-Encourage fluids to 2000 to 3000 mL per day
-Discontinue foley catheter on first day post op
-Remove wound drainage device
-Teach the patient to deep breathe & cough every hour while awake
-Increase flexion on continuous passive motion machine every day to achieve 70 degrees
Discontinue foley catheter on first day post op
Remove wound drainage device
Increase flexion on continuous passive motion machine every day to achieve 70 degrees
Which activities would the nurse perform during the evaluation stage? (pick all that apply)
-Validate with the patient the reported problem of constipation
-Collect data to determine the number of catheter-associated infections on the nursing unit
-Increase the frequency of repositioning from every 2 to every 1 hour
-Set a goal of ambulating from bed to room door and back to bed
-Identify smoking and sedentary lifestyle and risk factors for hypertension
Collect data to determine the number of catheter-associated infections on the nursing unit
Increase the frequency of repositioning from every 2 to every 1 hour
A nurse is changing a sterile pressure ulcer dressing based on established protocol. What does this mean?
-The nurse is using critical thinking to implement the dressing change.
-The physician verbally requested specific steps of the dressing change
-Written plans are developed that specify nursing activities for this skill
-The pt has specified how the dressing should be changed
Written plans are developed that specify nursing activities for this skill