Fundamental 1
Nurse designing a form for Lesbian, Gay, Bisexual, & Transgender (LGBT) patients. Which wording should the nurse use?
Use partnered rather than married
The nurse would ask a surgical patient in pain which questions?
what pain-relief methods, pharmacological and non-pharmacological have worked in the past
Patient c/o incision pain 9/10 after pain med. Pt is not due for another dose for another 2 hours. What should the nurse do first?
explore other options for pain relief
Nurse providing ROM to shoulder and must perform external rotation. Which action will the nurse take?
moves patient's arm until thumb is upward and lateral to head with elbow flexed
Pt presents with heatstroke Nurse uses cool packs, cooling blanket, and fan which technique is the nurse using when the fan produces heat loss?
convection
Nurse providing discharge teaching for tube feeding. Spouse states "I will not be able to perform feeding due to arthritis" Which action should the nurse take?
obtain extra feeding supplies
Which action indicates a nurse is being responsible for making clinical decisions
takes immediate action when a patient's condition worsens
Pt just had hip surgery and nurse needs to insert indwelling catheter, which action should the nurse take?
adapt the positioning techniq to the situation
Nurse reviews immobilized patient's lab results and discovers hypercalcemia. Which condition will the nurse monitor closely with the patient?
renal calculi
Patient admitted for possible sepsis. Which action should the nurse perform first?
obtain specified cultures
Nurse assessing threats concerning the family. Which areas will the nurse include in the assessment?
homelessness, domestic violence, presence of illness and changing economic status
Nurse is using the critical thinking skill of evaluation. Which action will the nurse take
review the effectiveness of nursing actions
Pt having trouble reaching water fountain with crutches. The nurse suggests that the pt place crutches against wall and stabilize self with 2 hands on water fountain. Which critical thinking attitude did the nurse use?
creativity
Nurse preparing to lift a patient which action will the nurse take first?
assess weight and determine assistance needs
Student nurse asks why brushing pt's teeth with a toothbrush in ICU is important for infection control. What response by the Nurse is best?
It mechanically removes biofilm on teeth
Nurse assessing the realms of family life. Which preocesses will the nurse assess?
developmental, interactive, integrity and coping
Which action by a nurse indicates application of the critical thinking model to make the best clinical decisions
using the nursing process
Nurse caring for pt with pressure ulcer applies recommended drissing according the hospital policy which standard is the nurse following?
institutional practice guidelines
The nurse assessing body alignment for a pt who is immobilized which pt position will the nurse use
lateral position
An older patient's serum calcium level is 8.7 what possible etiologies does the nurse consider for this result
normal age-related decrease in serum calcium, possible occurrence of osteoporosis or osteomalacia
Which action should the nurse take when using critical thinking to make clinical decisions?
consider what is important in a given situation
Patient appears to be in no distress but vital signs taken by PCA reveal and low pulse. Nurse then auscultates apical pulse and asks pt if he has a history of heart problems. Nurse is utilizing which critical thinking skill?
interpretation
Nurse using problem-oriented approach to data collection. Which action will the nurse take first?
focu on the patient's presenting situation
Nurse assessing the skin of an immobilized pt. what will the nurse do?
use a standardized tool such as the Braden scale
Nurse knows that hematopoiesis occurs in what part of the muscoloskeletal system
red marrow