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Flashcards in Ch. 1 MJ Deck (15):
1

The nurse has admitted a patient with a new diagnosis of pneumonia and explained to the patient that together they will plan the patient’s care and set goals for discharge. The patient says, “How is that different from what the doctor does?” Which response by the nurse is most appropriate?

a. “The role of the nurse is to administer medications and other treatments prescribed by your doctor.”

b. “The nurse’s job is to help the doctor by collecting data and communicating when there are problems.”

c. “Nurses perform many of the procedures done by physicians, but nurses are here in the hospital for a longer time than doctors.”

d. “In addition to caring for you while you are sick, the nurses will assist you to develop an individualized plan to maintain your health.”

d. “In addition to caring for you while you are sick, the nurses will assist you to develop an individualized plan to maintain your health.”

2

When providing patient care using evidence-based practice, the nurse uses

a. clinical judgment based on experience.

b. evidence from a clinical research study.

c. evidence-based guidelines in addition to clinical expertise.

d. evaluation of data showing that the patient outcomes are met.

c. evidence-based guidelines in addition to clinical expertise.

3

The nurse primarily uses the nursing process in the care of patients

a. to explain nursing interventions to other health care professionals

b. as a problem-solving tool to identify and treat patients’ health care needs

c. as a scientific-based process of diagnosing the patient’s health care problems

d. to establish nursing theory that incorporates the biopsychosocial nature of humans

b. as a problem-solving tool to identify and treat patients’ health care needs

4

The nurse plans an every 2-hour turning schedule to prevent skin breakdown for a critically ill patient in the intensive care unit. In this case, the nursing action is considered to be

a. dependent.

b. cooperative.

c. independent.

d. collaborative.

d. collaborative.

5

A patient who has been admitted to the hospital for surgery tells the nurse, “I do not feel right about leaving my children with my neighbor.” Which action should the nurse take next?

a. Reassure the patient that these feelings are common for parents.

b. Have the patient call the children to ensure that they are doing well.

c. Call the neighbor to determine whether adequate childcare is being provided.

d. Gather more data about the patient’s feelings about the childcare arrangements.

d. Gather more data about the patient’s feelings about the childcare arrangements.

6

A patient with a stroke is paralyzed on the left side of the body and has developed a pressure ulcer on the left hip. The best nursing diagnosis for this patient is

a. impaired physical mobility related to left-sided paralysis.

b. risk for impaired tissue integrity related to left-sided weakness.

c. impaired skin integrity related to altered circulation and pressure.

d. ineffective tissue perfusion related to inability to move independently.

c. impaired skin integrity related to altered circulation and pressure.

7

A patient with an infection has a nursing diagnosis of deficient fluid volume related to excessive diaphoresis. An appropriate patient outcome identified by the nurse is that the

a. patient has a balanced intake and output.

b. patient’s bedding is changed when it becomes damp.

c. patient understands the need for increased fluid intake.

d. patient’s skin remains cool and dry throughout hospitalization.

a. patient has a balanced intake and output.

8

A nursing activity that is carried out during the evaluation phase of the nursing process is

a. determining if interventions have been effective in meeting patient outcomes.

b. documenting the nursing care plan in the progress notes in the medical record.

c. deciding whether the patient’s health problems have been completely resolved.

d. asking the patient to evaluate whether the nursing care provided was satisfactory.

a. determining if interventions have been effective in meeting patient outcomes.

9

During the assessment phase of the nursing process, the nurse

a. obtains data with which to diagnose patient problems.

b. uses patient data to develop priority nursing diagnoses.

c. teaches interventions to relieve patient health problems.

d. helps the patient identify realistic outcomes to health problems.

a. obtains data with which to diagnose patient problems.

10

An example of a correctly written nursing diagnosis statement is

a. altered tissue perfusion related to heart failure.

b. risk for impaired tissue integrity related to sacral redness.

c. ineffective coping related to response to biopsy test results.

d. altered urinary elimination related to urinary tract infection.

c. ineffective coping related to response to biopsy test results.

11

The nurse writes a complete nursing diagnosis statement by including

a. a problem and the suggested patient goals or outcomes.

b. a problem, its cause, and objective data that support the problem.

c. a problem with all its possible causes and the planned interventions.

d. a problem with its etiology and the signs and symptoms of the problem.

d. a problem with its etiology and the signs and symptoms of the problem.

12

Using the Situation-Background-Assessment-Recommendation (SBAR) format, in which order should the nurse make these statements to communicate a change in patient status to a health care provider?

a. Mr. A was admitted 2 days ago with heart failure and has been receiving furosemide (Lasix) for diuresis, but his urine output has been low.

b. I think that he needs to be evaluated immediately and may need intubation and mechanical ventilation.

c. This is the nurse on the surgical unit. I am calling about Mr. A in room 3. After assessing him, I am very concerned about his shortness of breath.

d. Today, he has crackles audible throughout the posterior chest and his O2 saturation is 89%. His condition is very unstable.

c. This is the nurse on the surgical unit. I am calling about Mr. A in room 3. After assessing him, I am very concerned about his shortness of breath.

13

Which of these nursing actions for the patient with heart failure is appropriate for the nurse to delegate to experienced nursing assistive personnel (NAP)?

a. Assess for shortness of breath or fatigue after ambulation.

b. Instruct the patient about the need to alternate activity and rest.

c. Obtain the patient’s blood pressure and pulse rate after ambulation.

d. Determine whether the patient is ready to increase the activity level.

c. Obtain the patient’s blood pressure and pulse rate after ambulation.

14

Which action by a newly graduated RN working on the postsurgical unit indicates that more education about delegation and assignment is needed?

a. The nurse delegates measurement of patient oral intake and urine output to NAP.

b. The nurse delegates assessment of a patient’s bowel sounds to experienced NAP.

c. The nurse assigns an LPN/LVN to administer oral medications to several patients.

d. The nurse assigns a “float” RN from pediatrics to care for a patient with diabetes.

b. The nurse delegates assessment of a patient’s bowel sounds to experienced NAP.

15

Which of these tasks is appropriate for the registered nurse to delegate to a licensed practical/vocational nurse?

a. Perform a sterile dressing change for an infected wound.

b. Complete the initial admission assessment and plan of care.

c. Teach a patient about the effects of prescribed medications.

d. Document patient teaching about a routine surgical procedure.

a. Perform a sterile dressing change for an infected wound.