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Flashcards in Ch.1 MD Deck (18):
1

1. The nurse completes an admission database and explains that the plan of care and discharge goals will be developed with the patient’s input. The patient states, “How is this different from what the doctor does?” Which response would be most appropriate for the nurse to make?

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 information and communicating
any problems that occur.”
c. “Nurses perform many of the same procedures as the doctor, but nurses are with the patients for a longer time than the doctor.”
`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

The nurse describes to a student nurse how to use evidence­based practice guidelines when caring for patients. Which statement, if made by the nurse, would be the most accurate?

a. “Inferences from clinical research studies are used as a guide.”
b. “Patient care is based on clinical judgment, experience, and traditions.”
c. “Data are evaluated to show that the patient outcomes are consistently met.”
d. “Recommendations are based on research, clinical expertise, and patient
preferences.”

d. “Recommendations are based on research, clinical expertise, and patient
preferences.”

3

The nurse teaches a student nurse about how to apply the nursing process when
providing patient care. Which statement, if made by the student nurse, indicates that
teaching was successful?

a. “The nursing process is a scientific­based method of diagnosing the patient’s health
care problems.”
b. “The nursing process is a problem­solving tool used to identify and treat patients’
health care needs.”
c. “The nursing process is based on nursing theory that incorporates the
biopsychosocial nature of humans.”
d. “The nursing process is used primarily to explain nursing interventions to other
health care professionals.”

b. “The nursing process is a problem­solving tool used to identify and treat patients’
health care needs.”

4

A patient has been admitted to the hospital for surgery and tells the nurse, “I do
not feel comfortable leaving my children with my parents.” 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. Gather more data about the patient’s feelings about the child­care arrangements.
d. Call the patient’s parents to determine whether adequate child care is being
provided.

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

5

A patient who is paralyzed on the left side of the body after a stroke develops a
pressure ulcer on the left hip. Which nursing diagnosis is most appropriate?

a. Impaired physical mobility related to left­sided paralysis
b. Risk for impaired tissue integrity related to left­sided 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

6

A patient with a bacterial infection has a nursing diagnosis of deficient fluid
volume related to excessive diaphoresis. Which outcome would the nurse recognize as most appropriate for this patient?

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.

7

A nurse asks the patient if pain was relieved after receiving medication. What is
the purpose of the evaluation phase of the nursing process?

a. To determine if interventions have been effective in meeting patient outcomes
b. To document the nursing care plan in the progress notes of the medical record
c. To decide whether the patient’s health problems have been completely resolved
d. To establish if the patient agrees that the nursing care provided was satisfactory

a. To determine if interventions have been effective in meeting patient outcomes

8

The nurse interviews a patient while completing the health history and physical
examination. What is the purpose of the assessment phase of the nursing process?

a. To teach interventions that relieve health problems
b. To use patient data to evaluate patient care outcomes
c. To obtain data with which to diagnose patient problems
d. To help the patient identify realistic outcomes for health problems

c. To obtain data with which to diagnose patient problems

9

Which nursing diagnosis statement is written correctly?

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

10

The nurse admits a patient to the hospital and develops a plan of care. What
components should the nurse include in the nursing diagnosis statement?

a. The problem and the suggested patient goals or outcomes
b. The problem with possible causes and the planned interventions
c. The problem, its cause, and objective data that support the problem
d. The problem with an etiology and the signs and symptoms of the problem

d. The problem with an etiology and the signs and symptoms of the problem

11

A nurse is caring for a patient with heart failure. Which task is appropriate for
the nurse to delegate to experienced unlicensed assistive personnel (UAP)?

a. Monitor 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.

12

A nurse is caring for a group of patients on the medical­surgical unit with the
help of one float registered nurse (RN), one unlicensed assistive personnel (UAP), and one licensed practical/vocational nurse (LPN/LVN). Which assignment, if delegated by the nurse, would be inappropriate?

a. Measurement of a patient’s urine output by UAP
b. Administration of oral medications by LPN/LVN
c. Check for the presence of bowel sounds and flatulence by UAP
d. Care of a patient with diabetes by RN who usually works on the pediatric unit


c. Check for the presence of bowel sounds and flatulence by UAP

13

Which task is appropriate for the nurse to delegate to a licensed practical/vocational nurse (LPN/LVN)?

a. Complete the initial admission assessment and plan of care.
b. Document teaching completed before a diagnostic procedure.
c. Instruct a patient about low­fat, reduced sodium dietary restrictions.
d. Obtain bedside blood glucose on a patient before insulin administration.

d. Obtain bedside blood glucose on a patient before insulin administration.

14

A nurse is assigned as a case manager for a hospitalized patient with a spinal cord injury. The patient can expect the nurse functioning in this role to perform which
activity?

a. Care for the patient during hospitalization for the injuries.
b. Assist the patient with home care activities during recovery.
c. Determine what medical care the patient needs for optimal rehabilitation.
d. Coordinate the services that the patient receives in the hospital and at home.

d. Coordinate the services that the patient receives in the hospital and at home.

15

The nurse is caring for an older adult patient who had surgery to repair a fractured hip. The patient needs continued nursing care and physical therapy to improve
mobility before returning home. The nurse will help to arrange for transfer of this patient to which facility?

a. A skilled care facility
b. A residential care facility
c. A transitional care facility
d. An intermediate care facility

c. A transitional care facility

16

A home care nurse is planning care for a patient who has just been diagnosed
with type 2 diabetes mellitus. Which task is appropriate for the nurse to delegate to the
home health aide?

a. Assist the patient to choose appropriate foods.
b. Help the patient with a daily bath and oral care.
c. Check the patient’s feet for signs of breakdown.
d. Teach the patient how to monitor blood glucose.

b. Help the patient with a daily bath and oral care.

17

The nurse is providing education to nursing staff on quality care initiatives.
Which statement would be the most accurate description of the impact of health care financing on quality care?

a. “Hospitals are reimbursed for all costs incurred if care is documented
electronically.”
b. “Payment for patient care is primarily based on clinical outcomes and patient
satisfaction.”
c. “If a patient develops a catheter­related infection, the hospital receives additional
funding.”
d. “Because hospitals are accountable for overall care, it is not nursing’s responsibility
to monitor care delivered by others.”

b. “Payment for patient care is primarily based on clinical outcomes and patient
satisfaction.”

18

The nurse documenting the patient’s progress in the care plan in the electronic
health record before an interdisciplinary discharge conference is demonstrating competency in which QSEN category?

a. Patient­centered care
b. Quality improvement
c. Evidence­based practice
d. Informatics and technology

d. Informatics and technology