Week 4 Sherpath Flashcards by Monica Galvan-Valencia

Which actions are involved in the planning step of the nursing process?

Select all that apply.

Assessing the patient

Prioritizing nursing diagnoses

Developing patient-centered goals

Creating a personalized plan of care

Evaluating the patient’s response to interventions

Prioritizing nursing diagnoses

Developing patient-centered goals

Creating a personalized plan of care

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At which point would the nurse begin the planning stage of the nursing process?

At patient discharge

When the patient requires care

When the patient and nurse first interact

Upon patient admission to the hospital

When the patient and nurse first interact

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Which type of planning would the office nurse perform when contacting a patient with information about what to expect before, during, and after a scheduled surgery?

Discharge planning

Home care planning

Preadmission planning

Inpatient care planning

Preadmission planning

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Which goal is an example of a long-term goal for the patient?

The patient will achieve wound healing in 3 weeks.

The patient will have a pain level of less than 3 for 48 hours.

The patient will demonstrate an increase in activity tolerance in 1 week.

The patient’s wound will decrease in dimension in 2 days.

The patient will achieve wound healing in 3 weeks.

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Which duration reflects an appropriate time frame for achievement of a short-term goal?

1 week

2 weeks

1 month

6 months

1 week

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Which rationale explains the importance of outcome identification to the achievement of patient goals?

Determines goal validity

Indicates goal attainment

Standardizes patient goals

Tells the nurse which goals to measure

Indicates goal attainment

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If the nurse collaborates with the patient when setting goals, which behaviors is the patient more likely to demonstrate?

Select all that apply.

Be aware of priority needs.

Accept realistic goals.

Allow the nurse to control care.

Be more successful in achieving goals.

Comply with interventions and behavior changes.

Be aware of priority needs.

Accept realistic goals.

Be more successful in achieving goals.

Comply with interventions and behavior changes.

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Which statement about nursing interventions is accurate?

Interventions are another term for health care provider orders.

The nurse selects standardized interventions to promote safety.

Interventions are activities that assist the patient in achieving goals.

The nurse and the health care provider select the appropriate interventions for the patient.

Interventions are activities that assist the patient in achieving goals.

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Which components would the nurse include in a comprehensive plan of care?

Select all that apply.

Evaluation

Interventions

Measurable goals

Medical diagnosis

Nursing diagnosis

Evaluation

Interventions

Measurable goals

Nursing diagnosis

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Which part of the plan of care contains the statement, “Patient will display complete healing of surgical area within 3 weeks”?

Evaluation

Interventions

Measurable goal

Nursing diagnosis

Measurable goal

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Which statement describes the plan of care?

Development of the plan of care is the first component in the planning step of the nursing process.

The Joint Commission requires the plan of care to be part of the electronic health record.

The plan of care summarizes the patient’s condition, goals, and planned interventions.

The plan of care is most effective when standardized to incorporate evidence-based practice.

The plan of care summarizes the patient’s condition, goals, and planned interventions.

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Which information would the nurse expect to find on a conceptual care map (CCM)?

Select all that apply.

Medications

Pathophysiology

Medical history

Health care provider orders

Nursing plan of care

Medications

Medical history

Health care provider orders

Nursing plan of care

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For a patient scheduled for knee surgery, which statement identifies when the planning step of the nursing process begins?

After the surgery is complete

When the patient is admitted to the hospital

Just before being discharged from the hospital

When the nurse contacts the patient to schedule surgery

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Match the nursing diagnosis to its prioritization.

Life-threatening

Clinically urgent

Routine

Answered choices

Impaired Airway Clearance

Impaired Sleep

Impaired Tissue Integrity

Life-threatening
Impaired Airway Clearance

Clinically urgent
Impaired Tissue Integrity

Routine
Impaired Sleep

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Which nursing diagnosis would be ranked as the highest priority?

Constipation

Pressure Ulcer

Impaired Gas Exchange

Impaired Tissue Integrity

Impaired Gas Exchange

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Which statement is an example of a long-term patient goal?

Dress independently within 6 months.

Demonstrate deep-breathing techniques by end of shift.

Report an increase in appetite within 1 week.

Identify interventions to reduce risk for infection in 2 days.

Dress independently within 6 months.

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When a patient who needs to lose 60 lb (27 kg) wants to change the nurse’s recommended goal from exercising for 30 minutes a day, four times per week to exercising for 15 minutes per day, two times a week, which action would the nurse take?

Ask why the patient does not want to lose weight.

Allow the patient to set any goal the patient wants.

Tell the patient the goal will not work.

Discuss personal factors influencing the patient’s perspective.

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Which action would the nurse implement to promote patient success through goal attainment?

Ask what the patient would like to achieve.

Identify the goal, and tell the patient what it is.

Tell the patient the goal was ordered by the health care provider.

Identify one goal reflecting the nurse’s priority and another that reflects the patient’s priority.

Ask what the patient would like to achieve.

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Which role would the nurse associate with selection of interventions during the planning step of the nursing process?

Validation of nursing diagnoses

Evaluation of the patient’s goal attainment

Facilitation of clear communication of patient needs

Assistance for the patient in achieving goals and improving health

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Which strategies would the nurse use to promote individualization of the identified nursing interventions?

Select all that apply.

Consider patient assessment findings.

Ensure interventions align with patient acceptance.

Consult other professionals involved in the patient’s care.

Consider the underlying etiology and related factors.

Select interventions based on experience with other patients.

Consider patient assessment findings.

Ensure interventions align with patient acceptance.

Consult other professionals involved in the patient’s care.

Consider the underlying etiology and related factors.

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Place the components of the planning step of the nursing process in the correct order.

Create a plan of care.

Prioritize nursing diagnoses.

Select interventions.

Establish goals and outcomes.

Prioritize nursing diagnoses.

Establish goals and outcomes.

Select interventions.

Create a plan of care

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Match the component of the plan of care with the related information.

Heart rate (HR) 34 beats/min

Impaired Cardiac Function, supported by bradycardia

HR will return to 60 to 90 beats/min in 48 hours; monitor cardiac rhythm continuously

HR 70 to 79 beats/min × 48 hours; goal met; discontinue goal

Answer choices

Nursing diagnosis

Key assessment data

Measurable goal and intervention

Evaluation

Heart rate (HR) 34 beats/min
Key assessment data

Impaired Cardiac Function, supported by bradycardia
Nursing diagnosis

HR will return to 60 to 90 beats/min in 48 hours; monitor cardiac rhythm continuously
Measurable goal and intervention

HR 70 to 79 beats/min × 48 hours; goal met; discontinue goal
Evaluation

Which rationale supports the use of a conceptual care map (CCM) to develop a plan of care?

Provides criteria for the selection of interventions

Assists with the development of a standardized plan of care

Lists all of the patient’s medical history in a concise format

Provides a quick, yet comprehensive, overview of the patient’s status and plan

The nurse performs patient care interventions and documents interventions during which step of the nursing process?

Analysis

Planning

Evaluation

Implementation

Which statement summarizes how the scope of nursing practice influences interventions? It promotes evidence-based practice. It focuses on a specific clinical situation. It describes what actions a nurse can take. It outlines recommended interventions for a patient problem.

It describes what actions a nurse can take.

Which statement accurately describes nursing documentation? Missing documentation does not harm patients. The nurse charts only direct-care interventions. Nurses document interventions primarily in the plan of care. Documentation conveys interventions and outcomes to other health care providers.

Documentation conveys interventions and outcomes to other health care providers.

The nurse would categorize interventions according to which formal descriptors? Select all that apply. Priority Purpose Time frame Type of patient contact Who initiates the intervention

Purpose Type of patient contact Who initiates the intervention

Match the intervention category to its description. Manages and treats existing issues Avoids patient problems Involves personal contact with the patient Benefits the patient without face-to-face contact Answer choices Prevention-oriented Indirect-care Problem-based Direct-care

Manages and treats existing issues Problem-based Avoids patient problems Prevention-oriented Involves personal contact with the patient Direct-care Benefits the patient without face-to-face contact Indirect-care

Match the type of intervention to its process. Initiated and implemented by the nurse Initiated by a health care provider prescription and conducted by the nurse Initiated by the nurse and executed by other health care team members Answer choices Dependent nursing Collaborative nursing Independent nursing

Initiated and implemented by the nurse Independent nursing Initiated by a health care provider prescription and conducted by the nurse Dependent nursing Initiated by the nurse and executed by other health care team members Collaborative nursing

Which activity reflects an indirect-care type of intervention? Delegation Physical care Reassessment Patient education

Delegation

Which activity occurs during the fourth step of the nursing process? Analyzing patient data Planning the patient’s care Implementing interventions Evaluating the patient’s response

Implementing interventions

According to the American Nurses Association (ANA) scope of nursing practice, which statements describe an intervention the nurse should be qualified and competent to perform? Select all that apply. The facilitation of healing The prevention of illness and injury The advocacy of patients and families The optimization of patient health and abilities The transfer of evidence-based practice to the clinical setting

The facilitation of healing The prevention of illness and injury The advocacy of patients and families The optimization of patient health and abilities

Which statement describes how nurses use clinical practice guidelines (CPGs) in determining patient care interventions? CPGs provide individualized patient care interventions. The American Nurses Association (ANA) developed CPGs to describe nursing actions. Nurses select interventions that they are qualified and competent to perform by applying CPGs. Nurses apply CPGs to implement standardized interventions for a specific clinical situation.

Nurses apply CPGs to implement standardized interventions for a specific clinical situation.

Which action occurs after the nurse performs interventions? Determining goals Assessing the patient Resolving the interventions Documenting the interventions

Documenting the interventions

Which type of intervention benefits the patient but does not involve face-to-face contact with the patient? Direct Indirect Independent Prevention-based

Indirect

Which intervention category is likely to have the highest priority? Direct-care Independent Problem-oriented Prevention-based

Problem-oriented

Match the intervention category to the intervention. Monitoring a patient’s temperature and skin color for fever Administering antibiotics for infection as prescribed by the health care provider Delegating bathing and dressing to a nursing assistant Answer choices Collaborative Dependent Independent

Monitoring a patient’s temperature and skin color for fever Independent Administering antibiotics for infection as prescribed by the health care provider Dependent Delegating bathing and dressing to a nursing assistant Collaborative

Which activities are direct-care interventions? Select all that apply. Advocacy Research Reassessment Informal counseling Activities of daily living (ADLs)

Reassessment Informal counseling Activities of daily living (ADLs)

Which action is an indirect-care intervention? Informal counseling Patient assessment Activities of daily living (ADLs) Communications with health care providers

Communications with health care providers

Which activities are independent nursing interventions? Select all that apply. Hand hygiene Patient ambulation Intravenous (IV) fluid management Administration of medications Teaching use of incentive spirometer

Hand hygiene Patient ambulation Teaching use of incentive spirometer

Which statement describes the evaluation step of the nursing process? Evaluation is not a collaborative process. Evaluation is the fourth step of the nursing process. This step facilitates the selection of nursing diagnoses. The nurse determines whether the goals were achieved.

The nurse determines whether the goals were achieved.

Which action would the nurse take when the patient’s goal states, “Skin will remain intact while in the hospital” and the nurse notices a new stage 2 pressure injury? Document the goal as being met. Delete the goal and write a new one. Reflect on factors that prevented goal achievement. Document the goal as being met once the skin has healed.

Reflect on factors that prevented goal achievement.

Which information would the nurse include in an evaluation statement? Select all that apply. Level of goal attainment Revisions needed in the plan of care Date when the goal will be reevaluated The name of the person evaluating the goal Factors contributing to goal achievement

Level of goal attainment Revisions needed in the plan of care Factors contributing to goal achievement

Which process occurs when the nurse uses data and specific methods to systematically increase the quality of patient care? Planning Evaluation Nursing process Quality improvement

Quality improvement

Sequentially arrange the steps taken by nurses to implement the quality improvement process in nursing. Determine factors contributing to positive patient results. Review data about nursing care. Make changes in nursing practice.

Review data about nursing care. Determine factors contributing to positive patient results. Make changes in nursing practice.

According to The Joint Commission requirements, which time frame describes when the nurse would evaluate the plan of care? Daily Every shift Continuously Only if the patient’s condition changes

Continuously

During which step of the nursing process would the nurse review the patient’s plan of care and determine whether a goal was met? Planning Evaluation Assessment Implementation

Evaluation

Once a patient meets a goal, which action would the nurse take? Discontinue the goal. Discontinue the plan of care. Revise the entire plan of care. Decide whether to continue or discontinue the goal.

Decide whether to continue or discontinue the goal.

Consider the goal: Patient will ambulate 50 ft twice daily with assistance. Match the level of goal attainment with the evaluation statement. Patient is consistently ambulating 50 ft twice daily. Patient is ambulating between 20 and 50 ft twice daily. Patient is on bed rest due to the development of a pulmonary embolus. Answer choices Goal is unmet. Goal is met. Goal is partially met.

Patient is consistently ambulating 50 ft twice daily. Goal is met. Patient is ambulating between 20 and 50 ft twice daily. Goal is partially met. Patient is on bed rest due to the development of a pulmonary embolus. Goal is unmet.

A patient sets a goal to quit smoking within the next 30 days. After 30 days, the patient has not quit but reports that their smoking is reduced by 50%. The goal for the next 30 days is revised. Which outcome would the nurse document regarding goal attainment? Goal met Goal unmet Goal partially met Goal unattainable

Goal partially met

Which process occurs when the nursing staff of a small emergency department implements a process to reduce wait times? Evaluation Patient satisfaction Quality improvement Evidence-based practice

Quality improvement

Match the step of the Plan-Do-Study-Act (PDSA) improvement model to the nursing action that takes place during each step. Consider what the data show, and revise the plan of care if needed State the objective and develop a plan Review results Implement interventions Answer choices Study Act Do Plan

Consider what the data show, and revise the plan of care if needed Act State the objective and develop a plan Plan Review results Study Implement interventions Do

Which statement explains the importance of making modifications to the plan of care when a patient’s status changes? Plan modification enhances communication among health care providers. The Joint Commission requires modification to the plan of care. Revision is a necessary component of providing safe patient care. The hospital can be reimbursed for interventions provided when revision occurs.

Revision is a necessary component of providing safe patient care.