Nursing Process
This is required when using an "Actual" nursing diagnosis on your Care Plan, but is not when using an "At Risk" diagnosis
What is "Evidenced by" or "Related to" followed by explanatory information?
Not applicable for risk diagnosis. A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred and nursing interventions are directed at prevention. This type of diagnosis can be accompanied by risk factors.
The LIP just ordered a Salem Sump to be inserted into your patient. What type of suction do you anticipate to be ordered?
What is low continuous suction?
This term refers to the period when the patient is in the process of having surgery.
What is the intra-operative period?
When administering medication by this route, you place the medication underneath the patient's tongue.
What is the sub-lingual route?
This skin discoloration that is associated with a later sign of hypoxia is called this.
What is cyanosis?
This is a bluish hue to the skin that occurs with continued hypoxia.
This statement is an example of which part of the Nursing Process?
Client will maintain weight/demonstrate progressive weight gain toward the goal with normalization of laboratory values and be free of signs of malnutrition.
What is the Desired Outcome or Goal
This is the best way to confirm the placement of a nasogastric tube.
What is a chest x-ray?
This term refers to the period inclusive of the pre, intra and post-operative period.
What is the peri-operative period?
This term refers to a situation when increased dosages of medication is needed for a patient to achieve a continued therapeutic effect.
What is drug tolerance?
When performing a comprehensive assessment of the respiratory system. The nurse should would perform this as the final step.
What is auscultation of the chest?
Assist patient with ambulation twice a day is an example of which part of the Nursing Process?
What is a Nursing Intervention.
In order to determine how much of a nasogastric tube to insert, the nurse should measure the distance from the tip of the patient's nose to this body part, then from this body part to which end point?
What is the ear lobe and the xiphoid process?
This is the apparatus that helps to prevent atelectasis and pneumonia by encouraging the patient to increase their tidal volume after surgery.
What is an Incentive Spirometer?
Clindamycin 600 mg IVPB every 8 hours has been ordered for your patient. The pharmacy sends up a piggyback bag of NS with 600 mg of clindamycin / 100 mL of NS.The order says to hang over 20 minutes. You will program the IV pump at this rate.
What is 300 mL/ hr?
100 mL / 20 min = 5 mL / min x 60 min = 300 mL
When assessing a patient who is experiencing narrowing airways, the nurse expects to hear this sound when auscultating the lungs
What is wheezing?
Which of the following statements best illustrates the Evaluation step of a Nursing Process.
Pt will not sustain a fall while in the hospital.Pt has not sustained a fall while in the hospital.
What is
Pt has not sustained a all while in the hospital.
The other statement is an example of a Goal.
You are assessing a patient who has just returned from the post anesthesia care unit after undergoing resection of a rectal tumor. From the knowledge you have regarding caring for patients with colostomy, you do the following when you notice the stoma to be very red.
What is document the findings, this is normal?
This is an important rationale behind using alternate methods of pain control. These methods include treatments such as aroma, music and pet therapy, along with NSAIDS, nerve blocks, anti-epileptic medications and pain pumps.
What is to decrease opioid use in an effort to reduce or eliminate serious adverse effects such as respiratory depression?
Other adverse effects include constipation and decreased peristalsis.
You enter your 82 y/o patient's room to administer 8am cefazolin IVPB. Upon programming the IV pump, you notice the primary IV is infusing at 175 mL/h. You know the order says to run at 75 mL/h and the night nurse hung a new 1000 mL bag at 3 am. Based on what you know, after correcting the IV pump, you immediately perform this assessment.
What is a respiratory assessment of breath sounds?
This patient received 500 extra mL IV fluid which could cause overload, especially an elderly patient. Assessing for basilar crackles would be representative of pulmonary congestion caused by heart failure.
The nurse understands that when attempting to apply the highest concentration of oxygen to a patient, you should use this type of mask.
What is a non-rebreather mask?
A non-rebreather mask can deliver as much as 80% oxygen
The first step of the Nursing Process is always done in this format.
What is Head to Toe?
During SBAR from the night shift on a patient 1 day post bowel resection, you are told he received hydromorphone 1mg every 4hrs during the night, last dose approximately 1 hr ago due to increasing pain. Upon initial assessment, you find him lethargic, with a pulse of 119, a BP of 78/49 and a large, firmly distended abdomen. There is no bleeding noted on the dressing. When you palpate the abdomen he moans with pain. Anticipating this complication. you call a Rapid Response.
What is post operative bleeding?
This patient shows signs of hypovolemic shock. Although there is no bleeding at the incision site, it is within the peritoneal cavity
Early ambulation, anticoagulants and sequential compression devices are all ways to help prevent this post-operative complication.
What is deep vein thrombosis?
This can lead to a more severe complication which is pulmonary embolus
You are preparing to administer insulin novolog to your patient. You will not administer prior to the patient's meal arriving because you are aware that insulin novolg is this type of insulin.
What is a rapid acting insulin?
Novolog has a rapid onset of action. It can start working in 5-10 minutes after injection and will peak within 1 -2 hrs
You observe the surgeon palpating around the site of a closed-chest water-seal system drainage thoracic tube on a 1 day post-op patient who underwent thoroscopy. You understand that the surgeon is assessing for this condition.
What is subcutaneous emphysema?
Crackles are felt under the fingers upon palpation. Air can leak into the subcutaneous tissue after lung injury, in this case thoroscopy.