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fundamentals elsevier Terms in this set (164)Which feature is true about standing orders? 3 Which action would the nurse perform when revising a nursing care plan? Select all that apply. One, some, or all responses may be correct. 1,2,4 Which action is an example of an independent nursing intervention? Select all that apply. One, some, or all responses may be correct. 1,4,5 Which problem
would the nurse add to the care plan after evaluating a diabetic patient who had a problem with glucose control but is now restless and asking many questions about an upcoming procedure on the big toe? 1 Setting a time frame for outcomes of care determines which purpose? 4 Which action would the nurse take for a patient who agrees with the nurse that expected outcomes were met? 3 Which response would the nurse make for a patient who expresses confusion about how to manage a leg wound after discharge? 3 The nurse would evaluate which goal based upon the following reassessment: upon removal of the intravenous (IV) line from the right arm, the site was clean and dry with no signs of redness or tenderness? 3 Which priority action would the nurse take before administering a new drug? 2 Which expected outcome would be appropriate for a patient who is vomiting? 1 Which
intervention performed by the nurse is an interdependent intervention? Select all that apply. One, some, or all responses may be correct. 3,4,5 Which action would the nurse take when the patient who is nothing by mouth (NPO) (no food or fluids allowed) develops an adverse reaction to a new intravenous (IV) drug? Select all that apply. One, some, or all responses may be correct. 1,2,3 Which outcome is correctly written and would the nurse add to the plan of care about the patient's apical pulse? 4 Which intervention performed by the nurse would require an order from a health care provider? Select all that apply. One, some, or all responses may be correct. 1,2,3 Which action indicates that the nurse is using physical care techniques? 3 Which word does the letter "T" represent in the SMART acronym as it relates to setting goals for the patient? 1 Which action would the nurse take when a nursing goal is not met in the care of a patient? Select all that apply. One, some, or all responses may be correct. 1,2,3 Which feature is typical of an intermediate priority nursing diagnosis? 3 Which expected outcome for the goal "Patient will achieve a gain of 10 pounds (4.5 kg) in body weight in a month" is written correctly? 1 Arrange the steps of the nursing process in their appropriate order. 1,2,3,4,5 Which element is the final step of the nursing process? 3 Place the following events in order of priority, starting with the most important event. 2,1,4,3 Which initial action would
the nurse take when the goals are not being met as a result of the patient's response to illness? 1 In which order would the nurse modify the patient's plan of
care? 4,1,5,3,2 Which outcome would be appropriate for the depressed patient who lost weight but has a goal to return to baseline weight in 3 months? Select all that apply. One, some, or all
responses may be correct. 2,3 Which information correctly describes the evaluation process? Select
all that apply. One, some, or all responses may be correct. 1,3,4 Which characteristic of nursing goals and expected outcomes would the nurse keep in mind when developing a care plan? Select all
that apply. One, some, or all responses may be correct. 1,2,3 Which component would be included in a comprehensive nursing care plan? Select all that apply. One, some, or all responses may be correct. 1,2,5 Which statement describes the unique difference between a hospital's nursing care plan and the home care plan? 2 Which evaluative measure would be appropriate for determining if an obese patient who is maintaining a sleep diary achieves restful sleep? Select all that apply. One, some, or all responses may be correct. 2,3,4 When assessing a patient with a terminal illness, the nurse notes the patient's monosyllabic replies and limited eye contact. Which direct care intervention does the nurse perform? 2 Which action would the nurse take for a patient who reports frequent periods of nausea that interfere with eating after chemotherapy treatments? 2 Which direct care measure would the nurse be using when consulting with the dietitian and health care provider to determine the initial rate that will be prescribed for the tube feeding to lessen the chance of diarrhea? 2 Arrange the steps to be taken by the nurse in the appropriate order to evaluate the effectiveness of the care plan in meeting the expected outcome for the patient. 2,3,4,5,1 which intervention would the nurse perform for a patient who has developed a hypersensitivity reaction to penicillin and has developed hives? Select all that apply. One, some, or all responses may be
correct. 2,3,4,5 As the nurse makes decisions about how to implement skin care for a patient, which action would the nurse implement? Select all that apply. One, some, or all responses may be correct. 1,2,4,5 Which patient evaluative measure would be most appropriate for determining if the obese patient
achieves the goal of a 15-pound weight loss? 2 Place the steps of consultation in the correct sequence. 2,1,4,5,3 Which information about standing orders is accurate? Select all that apply. One, some, or all responses may be correct. 2,3,4
Which intervention would the nurse add to the nursing care plan to reduce anxiety in a patient? Select all that apply. One, some, or all responses may be correct. 1,2,4 Which factor would the nurse consider before setting a goal that the patient will self-administer insulin injections? Select all that apply. One, some, or all responses may be correct. 1,3,4 Which action would the nurse perform for unmet and partially met goals? Select all that apply. One, some, or all responses may be correct. 1,2 Which action does the nurse take right before implementing interventions? 3 Which initial action would the nurse take when a
patient's symptoms have changed from those that were recorded earlier? 2 Which tip would be helpful when a nurse is making a phone
consultation? Select all that apply. One, some, or all responses may be correct. 2,3,4,5 Which guideline would the nurse use to counsel a patient and family members about coping? Select all that apply. One, some, or all responses may be correct. 1,2,4,5 Which action would the nurse take next when the expected outcome was stating three side effects of chemotherapy, but after a teaching session the patient related over five side effects of the medication? 2 After evaluation of the patient, which action would the nurse take when the intervention is unsuitable? Select all that apply.
One, some, or all responses may be correct. 3,4, Which purpose describes the importance of a nurse documenting patient outcomes? Select all that apply. One, some, or all responses may be correct. 1,2,3,4 The family of a patient states, "We found out that our loved one has end-stage hepatitis. We don't know what that means." How does the nurse respond? 4 The reduction of which incidence is a nursing-sensitive quality outcome? Select all that apply. One, some, or all responses may be correct. 1,2,3,4 Arrange the steps in proper sequence for measures the nurse would take when a patient does not meet the goal stated in the care plan. 1,3,2,4 Prioritize the nursing diagnoses for an older-adult patient with pneumonia who is fatigued and lives alone. 1,2,4,3 The nurse
provides education for a group of nursing students about cultural preferences related to activities of daily living (ADLs). The nurse reminds the students of the need to respect patients' wishes and determine patient preferences. Which example does the nurse include? 4 Which evaluative criterion would the nurse use to measure nursing care for a patient who is short of breath? Select all that apply. One, some, or all responses may be correct. 1,2,3 Which expected outcome is correctly written? Select all that apply. One, some, or all responses may be correct. 1,3 Which problem is considered a high priority for a patient? Select all that apply. One, some, or all responses may be correct. 1,3 Which activity would the nurse perform when preparing for the implementation phase of the nursing process? Select all that apply. One, some, or all responses may be correct. 1,3,5 Place the steps in proper order for modifying the plan of care when a patient develops nausea after chemotherapy. 2,4,1,3 The nurse reviews potential interventions for a patient who is experiencing pain. When considering the administration of an analgesic, the nurse identifies that the medication may cause an adverse reaction, including
increasing the patient's fall risk. The nurse is demonstrating which principle of critical judgment and decision-making? 2 Which
action would the nurse perform when revising interventions for a patient? Select all that apply. One, some, or all responses may be correct. 2,3,5 Which action would the
nurse take before implementing health care provider-initiated interventions? Select all that apply. One, some, or all responses may be correct. 1,4,5
Which sequence would the nurse follow for making decisions about implementing interventions? 4,3,2,1 Which component is an element of the
American Nurses Association (ANA) standards of practice and scope of nursing practice? Select all that apply. One, some, or all responses may be correct. 1,4,5 After the nurse raises the head of the bed and suctions a patient's lungs, which finding would be classified as an evaluative measure toward the goal that the patient's lungs will be free of secretions? Select all that apply. One, some, or all responses may be correct. 2,4 Place the steps in the correct order the nurse would take to evaluate outcomes of care for a patient with a skin condition. 2,1,5,4,3 The nurse provides postoperative care for a patient and notes a slightly elevated temperature. Which intervention demonstrates the nurse's
understanding of evidence-based practice? 1 Which intervention would the nurse perform when communicating the patient's progress with the patient and the family members? Select all that apply. One, some, or all responses may be
correct. 1,2,4 The nurse reviews potential interventions for a
patient who is experiencing pain. When considering the administration of an analgesic, the nurse identifies that the medication may cause an adverse reaction, including increasing the patient's fall risk. The nurse is demonstrating which principle of critical judgment and decision-making? 2 Which capability of the nurse would help in choosing suitable nursing interventions? Select all that apply. One, some, or all responses may be correct. 1,3,5 Which action would the nurse perform when revising interventions for a patient? Select all that apply. One, some, or all responses may be correct. 2,3,5 Which information would the nurse include in a teaching session about the levels of prevention? Select all that apply. One, some, or all responses may be correct. 1,2,3,4 Which step of the nursing process is the nurse performing when he or she
asks the patient to rate pain 45 minutes after administering an analgesic? 4 Which intervention indicates the nurse is delivering ethical care? 2 Which nursing-sensitive patient outcome is written correctly? Select all that apply. One, some, or all responses may be correct. 2,4,5 The health care provider prescribes interventions to the nurse to treat the medical diagnosis of the patient. To which category does such an intervention belong? 3 Which
information accurately describes a physical care technique? Select all that apply. One, some, or all responses may be correct. 1,2,4 Which
prevention level would describe a clinic nurse screening a patient for diabetes? 2 Which action would the nurse perform to redefine the diagnosis after evaluation of a patient goal? 3 Which factor would be considered when choosing a nursing intervention to address a patient problem? Select all that apply. One, some, or all responses may be correct. 2,3,4,5 Which action would the nurse perform first when he or she enters the room and finds the patient's drainage tube disconnected, 100 mL of fluid in the intravenous (IV) line, and the patient asking to be turned? 1 Which activity would be a component of the evaluation phase of the nursing process? Select all that apply. One, some, or all responses may be correct. 4,5 Which characteristic is a component of well-written goals and expected outcomes? Select all that apply. One, some, or all responses may be correct. 2,4,5 Which interpretation would the nurse make regarding a patient with pneumonia whose cough decreased and respiratory rate
decreased from 33 to 25 breaths/min after nebulization treatments? 3 Which evaluative measure would the nurse use to determine care for a patient with a myocardial infarction
(heart attack)? 1 A home-health nurse provides palliative care for a patient in a community setting. The patient states, "The pain pills that I have been taking are not as
effective as they used to be." After reviewing the patient's standing orders, which action does the nurse take? 2 Which question would the nurse ask to evaluate a patient's expectations of care? 3 Which major component would be included in a nursing care plan? Select all that apply. One, some, or all responses may be correct. 1,4,5 Which modification would the nurse make to the care plan for a patient with diabetes who can no longer prepare or administer insulin because of tremors and has a caregiver who lives in the home? 4 Which activity would the nurse perform when implementing indirect care measures? 2 Which standard would the nurse use to evaluate a middle-aged patient's response to chemotherapy? Select all that apply. One, some, or all responses may be correct. 1,2 Which information would the nurse share with the patient when starting an intravenous (IV) medication? Select all that apply.
One, some, or all responses may be correct. 1,3,4,5 Which level of prevention describes a nurse administering a
vaccine to an infant? 1 Which action is an example of a dependent nursing intervention? Select all that apply. One, some, or all responses may be correct. 2,3,4 Which category is a type of nursing intervention? Select all that apply. One, some, or all responses may be correct. 3,4,5 Which resource would the nurse use to develop a plan
of care? Select all that apply. One, some, or all responses may be correct. 1,2,3,5 Which action would the nurse take for a patient who has an outcome of walking the entire hallway by 10/17 and the patient walks halfway down the hallway on 10/16? 2 Which action would the nurse take for a patient who continues to have congested lungs after coughing and deep-breathing exercises? 4 Which action would the home-health nurse take first when during a follow-up visit, the nurse finds the goal not met? 2 Which option is an example of a nurse managing indirect care activities? 1 Which option explains the primary purpose for the nurse performing evaluative measures? 4 Which action is classified as an indirect care measure? Select all that apply. One, some, or all responses may be correct. 1,3 Which action would the nurse take for a patient who is not meeting the expected outcomes? Select all that apply. One, some, or all responses may be correct. 1,2,5 Which statement or action by the nurse is characteristic of an effective hand-off report? 1 Which type of problem is a high priority? 2 Which expected outcome is correctly written and would be appropriate for a patient who must have surgery for a knee injury? Select all that apply. One, some, or all
responses may be correct. 3,4,5 Which action by the nurse reflects critical thinking while implementing interventions with patients? 2 Which feature is typical of "missed care"? 4 Which patient finding would be the most suitable nursing-sensitive outcome for a patient who is immobile, does not ambulate, and has a nursing
diagnosis of backache? 3 Which category is a level of the Nursing Interventions Classification (NIC) model? Select all that apply. One, some, or all responses may be
correct. 1,2,5 For which patient would a short-term goal be most appropriate? 4 How many classes are included in the second level of the Nursing Interventions Classification (NIC) model? Record your answer using a whole number. ________ 30 Which intervention would be appropriate for a postoperative patient who is on bed rest and at risk of skin injuries after surgery? Select all that apply. One,
some, or all responses may be correct. 1,2,4 Which activity is the third step in the five-step nursing
process? 1 Which action would the nurse take while documenting and reporting the evaluation of care for a patient? 3 Which information is characteristic of evaluation? 1 Which action would be an example of a collaborative intervention? 4 Which type
of implementation skill is described when the nurse correctly administers an enema solution to a patient? 4 Which patient care goal is a long-term goal for a newly diagnosed medically unstable patient with diabetes? 3 Which level of prevention describes the nurse working in collaboration with a physiotherapist to help aid the ambulatory functions of a patient who suffered a motor vehicle
accident? 3 Which conclusion would the nurse infer when during a follow-up visit, the patient's wound infection is resolved and the patient followed proper instructions? 2 Which process is involved in the planning phase of the nursing process? Select all that apply. One, some, or all responses may be correct. 1,4,5 Which implementation skill describes a nurse explaining to the patient about inserting a feeding tube? 3 Which action would be implemented when the nurse is unsure about implementing fall prevention guidelines for an older-adult patient? 1 Which type of nursing intervention is an interdependent intervention? 2 Which action
performed for the patient is a nurse-initiated intervention? Select all that apply. One, some, or all responses may be correct. 1,2,4 Which principle of care coordination would the nurse use to achieve a desired
outcome for patients? Select all that apply. One, some, or all responses may be correct. 1,2,3 Which patient indicator would be used to measure a reduction in pain level for a patient? Select all that apply. One, some, or
all responses may be correct. 3,4,5 Which statement is true about the standards of care? 4 Which option correctly describes a nurse's actions? Select all that apply. One, some, or all responses may be correct. 2,3,4 Which outcome would be directly related to the goal of pain relief for a confused
patient? 1 Which activity is classified as an instrumental activity of daily living (IADL)? Select all that apply. One, some, or all responses may be
correct. 1,4,5 Which statement is true regarding actions after surgery? 1 Which type of nursing theory answers the question, "What is nursing?" 1 Which source is a vehicle for infection transmission?
Select all that apply. One, some, or all responses may be correct. 3,4,5 Which statement is true regarding the roles of a scrub nurse during surgery? Select all that apply. One, some, or all responses may be correct. 1,5 Which statement is true regarding the infant immune system? 1 Which statement accurately describes the unit-dose system? Select all that apply. One, some, or all responses may be correct. 1,2 Which quantity of vitamin C is recommended for wound healing? Record your answer using a whole number. ______ mg/day 1000
Which patient may require a pulsatile high-pressure lavage for wound irrigation? 2 Which classification of drug promotes gluconeogenesis of
protein? 4 How do reminiscence strategies evaluate the memory of an older adult? 3 Which action describes an independent nursing intervention? Select all that apply. One, some, or all responses may be correct. 2,3,4,5 Which patient outcome about a wound would allow the nurse to measure a patient's response to care more precisely? 3 Which action would be classified as a health
care provider-initiated intervention? Select all that apply. One, some, or all responses may be correct. 1,2,5 Which action would the nurse take during consultations? 4 Which goal is appropriate for the patient who is at high risk of skin injuries? 2 Which evaluative measure for ability to tolerate ambulation would the nurse use for a patient with limited mobility in lower extremities who ambulates with a walker? 4 Which statement is true about discharge planning? Select all that apply. One, some, or all responses may be correct. 1,2 Which type of action would describe a nurse performing cardiopulmonary resuscitation (CPR) for a patient in cardiac arrest? Select all that apply. One, some, or all responses may be correct. 1,4 Which activity would the nurse include in a nursing plan for indirect care of a patient? 1 Which nurse-initiated intervention would the nurse perform to
help an anxious male patient express acceptance of his health status? Select all that apply. One, some, or all responses may be correct. 1,3,5 Which nursing intervention is
an example of direct care for a patient? Select all that apply. One, some, or all responses may be correct. 1,2,4 Which action would allow the nurse to interpret and judge a
patient's condition and whether predicted changes occurred during the evaluation phase of the nursing process? 4 Which action
would the nurse take when administering a new, unfamiliar medication to a patient who cannot have food or fluids for 24 hours? Select all that apply. One, some, or all responses may be correct. 1,2,4 Which level of prevention describes a nurse conducting health awareness training programs at a community center? 1 When does implementation begin? 3 Which factor helps ensure quality data collection of nursing practices and enables evaluation across health care organizations? 1 Which step of the
nursing process describes the nurse observing that the patient's redness on the heels has decreased over the past 2 days after using measures to relieve pressure points? 3 Which action would a student nurse take when asked to perform a procedure that the student nurse has been trained in but has not performed in the hospital? Select all
that apply. One, some, or all responses may be correct. 1,3,4
Which priority level would be assigned to the patient diagnosed with decreased gas exchange? 1 Which expected outcome is written in measurable terms? 4 Which criterion is used to evaluate efficacy of interventions? 4 Which option would be an appropriate goal statement for a patient at risk of an infection? 2 Sets found in the same folderCh 18-20127 terms mfamilia Sherpath - Ch. 18: Planning34 terms gescobar519 Sherpath - Preparation for Patient Interview and P…25 terms CheyMcQ Ch29- EAQ38 terms erin_floyd_coley Other sets by this creatorInfection83 terms genesissanchezgr Hygiene242 terms genesissanchezgr Nursing Process Part 212 terms genesissanchezgr Other Quizlet sets475: Mod 1 quiz20 terms carab101 apes chapter 1 test44 terms marissabonham test one53 terms shelby_m_hill ATI106 terms KSidhu12PLUS Related questionsQUESTION During an examination, you notice a patterned injury on a patient's back. Which is the most likely? 15 answers QUESTION While assessing the vital signs of a 4-year-old patient, the nurse finds that the child is expressing fear. Which action is appropriate in this situation? 2 answers QUESTION rheumatic fever; need for more teaching: 15 answers QUESTION The nurse questions a physicians order to administer a placebo to the patient. The nurses action is based on which ethical principle? 4 answers Which initial action would the nurse take when the goals are not being met as a result of the patient's response to illness?Which initial action would the nurse take when the goals are not being met as a result of the patient's response to illness? Reassess the patient.
What must a nurse do when patient goals are not met?If the patient did not achieve the goals of the care plan, then the nurse would be required to reassess the patient and revise interventions. When goals are not met, you identify the factors that interfere with their achievement.
What are the initial steps of most nursing interventions?A nursing care plan is a formal process that includes six components: assessment, diagnosis, expected outcomes, interventions, rationale, and evaluation. Documenting these steps ensures effective communication between doctors, nurses, and other healthcare professionals over multiple shifts.
What is the first action when the nurse performs a procedure?The first phase of the nursing process is the assessment phase.
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