Assessing
The nurse practitioner is performing a short assessment of a newborn who is displaying signs of jaundice. The nurse observes the infant’s skin color and orders a test for bilirubin levels to report to the primary care provider. What type of assessment has this nurse performed?
4. Quick priority
A nurse is caring for a patient who presents with labored respirations, productive cough, and fever. What would be appropriate nursing diagnoses for this patient? Select all that apply.
2: Impaired gas exchange, 3: Ineffective airway clearance, 6: Risk for septic shock
A nurse is planning care for a patient who was admitted to the hospital for treatment of a drug overdose. Which nursing actions are related to the outcome identification and planning step of the nursing process? Select all that apply.
2. The nurse identifies expected patient outcomes.
3. The nurse selects evidence-based nursing interventions.
4. The nurse explains the nursing care plan to the patient.
A school nurse notices that a student is losing weight and decides to perform a focused nutritional assessment to rule out an eating disorder. What is the nurse’s best action?
A. Perform the focused assessment as this is an independent nurse-initiated intervention.
B. Request an order from Jill’s physician since this is a physician-initiated intervention.
C. Request an order from Jill’s physician since this is a collaborative intervention.
D. Request an order from the nutritionist since this is a collaborative intervention.
A. Perform the focused assessment as this is an independent nurse-initiated intervention.
After one nursing unit with an excellent safety record meets to review the findings of the audit, the nurse manager states, “We’re doing well, but we can do better! Who’s got an idea to foster increased patient well-being and satisfaction?” This is an example of leadership that values:
A. Quality assurance
B. Quality improvement
C. Process evaluation
D. Outcome evaluation
D. Outcome evaluation
The nurse is admitting a 35-year-old pregnant woman to the hospital for treatment of preeclampsia. The patient asks the nurse: “Why are you doing a history and physical exam when the doctor just did one?” Which statements best explain the primary reasons a nursing assessment is performed? Select all that apply.
1, 5, and 6
A nurse makes a clinical judgment that an African American man in a stressful job is more vulnerable to developing hypertension than a White man in the same or a similar situation. The nurse has formulated what type of nursing diagnosis?
2. Risk
The nurse is helping a patient turn in bed and notices the patient’s heels are red. The nurse places the patient on precautions for skin breakdown. This is an example of what type of planning?
3. Ongoing planning
An RN working on a busy hospital unit delegates patient care to UAPs. Which patient care could the nurse most likely delegate to a UAP safely? Select all that apply.
A. Performing the initial patient assessments
B. Making patient beds
C. Giving patients bed baths
D. Administering patient medications
E. Ambulating patients
F. Assisting patients with meals
B. Making patient beds
C. Giving patients bed baths
E. Ambulating patients
F. Assisting patients with meals
A quality-assurance program reveals a higher incidence of falls and other safety violations on a particular unit. A nurse manager states, “We’d better find the people responsible for these errors and see if we can replace them.” This is an example of:
A. Quality by inspection
B. Quality by punishment
C. Quality by surveillance
D. Quality by opportunity
A. Quality by inspection
A nurse notes that a shift report states that a patient has no special skin care needs. The nurse is surprised to observe reddened areas over bony prominence during the patient bath. What nursing action is appropriate?
4. Perform and document a focused assessment of skin integrity.
When the initial nursing assessment revealed that a patient had not had a bowel movement for 2 days, the student nurse wrote the diagnostic label “constipation.” What would be the instructor’s BEST response to this student’s diagnosis?
1. “Was this diagnosis derived from a cluster of significant data or a single clue?”
A nurse is using a concept map care plan to devise interventions for a patient with sickle cell anemia. What is the BEST description of the “concepts” that are being diagrammed in this plan?
3. The nurse’s ideas about the patient problem and treatment
A nurse is about to perform pin site care for a patient who has a halo traction device installed. What is the FIRST nursing action that should be taken prior to performing this care?
A. Administer pain medication.
B. Reassess the patient.
C. Prepare the equipment.
D. Explain the procedure to the patient.
B. Reassess the patient.
A nurse is writing an evaluative statement for a patient who is trying to lower cholesterol through diet and exercise. Which evaluative statement is written correctly?
A. “Outcome not met.”
B. “1/21/20—Patient reports no change in diet.”
C. “Outcome not met. Patient reports no change in diet or activity level.”
D. “1/21/20—Outcome not met. Patient reports no change in diet or activity level.”
D. “1/21/20—Outcome not met. Patient reports no change in diet or activity level.”
A student nurse attempts to perform a nursing history for the first time. The student nurse asks the instructor how anyone ever learns all the questions the nurse must ask to get good baseline data. What would be the instructor’s best reply?
2. “You make the basic questions a part of you and then learn to modify them for each unique situation, asking yourself how much you need to know to plan good care.”
The nurse records a patient’s blood pressure as 148/100. What is the priority action of the nurse when determining the significance of this reading?
1. Compare this reading to standards
A nurse is identifying outcomes for a patient who has a leg ulcer related to diabetes. What is an example of an affective outcome for this patient?
4. By 6/12/20, the patient will verbalize valuing health sufficiently to practice new health behaviors to prevent recurrence of leg ulcer.
A nurse is using the implementation step of the nursing process to provide care for patients in a busy hospital setting. Which nursing actions best represent this step? Select all that apply.
A. The nurse carefully removes the bandages from a burn victim’s arm.
B. The nurse assesses a patient to check nutritional status.
C. The nurse formulates a nursing diagnosis for a patient with epilepsy.
D. The nurse turns a patient in bed every 2 hours to prevent pressure injuries.
E. The nurse checks a patient’s insurance coverage at the initial interview.
F. The nurse checks for community resources for a patient with dementia.
A. The nurse carefully removes the bandages from a burn victim’s arm.
D. The nurse turns a patient in bed every 2 hours to prevent pressure injuries.
F. The nurse checks for community resources for a patient with dementia.
A nurse writes the following outcome for a patient who is trying to lose weight: “The patient can explain the relationship between weight loss, increased exercise, and decreased calorie intake.” This is an example of what type of outcome?
A. Cognitive
B. Psychomotor
C. Affective
D. Physical changes
A. Cognitive
The nurse is surprised to detect an elevated temperature (102°F) in a patient scheduled for surgery. The patient has been afebrile and shows no other signs of being febrile. What is the priority nursing action?
3. Validate the finding
After assessing a patient who is recovering from a stroke in a rehabilitation facility, a nurse interprets and analyzes the patient data. Which of the four basic conclusions has the nurse reached when identifying the need to collect more data to confirm a diagnosis of situational low self-esteem?
2. Possible problem
A nurse is prioritizing the following patient diagnoses according to Maslow’s hierarchy of human needs:
(1) Disturbed Body Image
(2) Ineffective Airway Clearance
(3) Spiritual Distress
(4) Impaired Social Interaction
Which answer choice below lists the problems in order of highest priority to lowest priority based on Maslow’s model?
A. 2, 4, 1, 3
B. 3, 1, 4, 2
C. 2, 4, 3, 1
D. 3, 2, 4, 1
A. 2, 4, 1, 3
Ineffective Airway Clearance
Impaired Social Interaction
Disturbed Body Image
Spiritual Distress
A nurse develops a detailed care plan for a 16-year-old patient who is a new single mother of a premature infant. The plan includes collaborative care measures and home health care visits. When presented with the plan, the patient states, “We will be fine on our own. I don’t need any more care.” What would be the nurse’s best response?
A. “You know your personal situation better than I do, so I will respect your wishes.”
B. “If you don’t accept these services, your baby’s health will suffer.”
C. “Let’s take a look at the plan again and see if we can adjust it to fit your needs.”
D. “I’m going to assign your case to a social worker who can explain the services better.”
C. “Let’s take a look at the plan again and see if we can adjust it to fit your needs.”
A new nurse who is being oriented to the subacute care unit is expected to follow existing standards when providing patient care. Which nursing actions are examples of these standards? Select all that apply.
A. Monitoring patient status every hour
B. Using intuition to troubleshoot patient problems
C. Turning a patient on bed rest every 2 hours
D. Becoming a nurse mentor to a student nurse
E. Administering pain medication ordered by the physician
F. Becoming involved in community nursing events
A. Monitoring patient status every hour
C. Turning a patient on bed rest every 2 hours
E. Administering pain medication ordered by the physician