Foundations Chapter 18 Planning Nursing Care – Flashcards

A nurse enters the room of a 32-year-old patient newly diagnosed with cancer at the beginning of the 0700 evening/night shift. The nurse noted in the patient's nursing history that this is her first hospitalization. She is scheduled for surgery in the morning to remove a tumor and has questions about what to expect after surgery. She is observed talking with her mother and is crying. The patient says, "This is so unfair." An order has been written for an enema to be given this evening in preparation for the surgery. The nurse establishes priorities for which of the following situations first? A. Giving the enema on time B. Talking with the patient about her past experiences with illness C. Talking with the patient about her concerns and acknowledging her sense of unfairness D. Beginning instruction on postoperative procedures

A nurse assesses a 78-year-old patient who weighs 108.9 kg (240 lbs) and is partially immobilized because of a stroke. The nurse turns the patient and finds that the skin over the sacrum is very red and the patient does not feel sensation in the area. The patient has had fecal incontinence on and off for the last 2 days. The nurse identifies the nursing diagnosis of Risk for Impaired Skin Integrity. Which of the following outcomes is appropriate for the patient? A. Patient will be turned every 2 hours within 24 hours. B. Patient will have normal bowel function within 72 hours. C. Patient's skin integrity will remain intact through discharge. D. Erythema of skin will be mild to none within 48 hours.

A home health nurse visits a 42-year-old woman with diabetes who has a recurrent foot ulcer. The ulcer has prevented the woman from working for over 2 weeks. The patient has had diabetes for 10 years. The ulcer has not been healing; it has drainage with a foul-smelling odor. As the nurse examines the patient, she learns that the patient is not following the ordered diabetic diet. Which of the following is considered a low-priority goal for this patient? A. Achieving wound healing of the foot ulcer B. Enhancing patient knowledge about the effects of diabetes C. Providing a dietitian consultation for diet retraining D. Improving patient adherence to diabetic diet

The nurse writes an expected outcome statement in measurable terms. An example is: A. Patient will have normal stool evacuation. B. Patient will have fewer bowel movements. C. Patient will take stool softener every 4 hours. D. Patient will report stool soft and formed with each defecation.

A nursing student is reporting during hand-off to the RN assuming her patient's care. She explains, "I ambulated him twice during the shift; he tolerated well walking to end of hall and back with no shortness of breath. Mr. Roarke said he slept better last night after I closed his door and gave him a chance to be uninterrupted. I changed the dressing over his intravenous (IV) site and started a new bag of D5 ½ NS. Which intervention is a dependent intervention? A. Reporting hand-off at change of shift B. Ambulating patient down hallway C. Sleep hygiene D. IV fluid administration

A nursing student knows that all patients should be ambulated regularly. The patient to which she is assigned has had reduced activity tolerance. She followed orders to ambulate the patient twice during the shift of care. In what way can the nursing student make the goal of improving the patient's activity tolerance a patient-centered effort? A. Engage the patient in setting mutual outcomes for distance he is able to walk B. Confirm with the patient's health care provider about ambulation goals C. Have physical therapy assist with ambulation D. Refer to medical record regarding nature of patient's physical problem

A patient signals the nurse by turning on the call light. The nurse enters the room and finds the patient's drainage tube disconnected, 100 mL of fluid remaining in the intravenous (IV) line, and the patient asking questions about whether his doctor is coming. Which of the following does the nurse perform first? A. Reconnect the drainage tubing B. Inspect the condition of the IV dressing C. Obtain the next IV fluid bag from the medication room D. Explain when the health care provider is likely to visit

A 62-year-old patient had a portion of the large colon removed and a colostomy created for drainage of stool. The nurse has had repeated problems with the patient's colostomy bag not adhering to the skin and thus leaking. The nurse wants to consult with the wound care nurse specialist. Which of the following should the nurse do? (Select all that apply.) A. Assess condition of skin before making the call B. Rely on the nurse specialist to know the type of surgery the patient likely had C. Explain the patient's response emotionally to the repeated leaking of stool D. Describe the type of bag being used and how long it lasts before leaking E. Order extra colostomy bags currently being used

It is time for a nurse hand-off between the night nurse and nurse starting the day shift. The night nurse checks the most recent laboratory results for the patient and then begins to discuss the patient's plan of care to the day nurse using the standard checklist for reporting essential information. The patient has been seriously ill, and his wife is at the bedside. The nurse asks the wife to leave the room for just a few minutes. The night nurse completes the summary of care before the day nurse is able to ask a question. Which of the following activities are strategies for an effective hand-off? (Select all that apply.) A. Using a standardized checklist for essential information B. Asking the wife to briefly leave the room C. Completing the hand-off without inviting questions D. Doing prework such as checking laboratory results before giving a report E. Including the wife in the hand-off discussion

Which of the following factors does a nurse consider in setting priorities for a patient's nursing diagnoses? (Select all that apply.) A. Numbered order of diagnosis on the basis of severity B. Notion of urgency for nursing action C. Symptom pattern recognition suggesting a problem D. Mutually agreed on priorities set with patient E. Time when a specific diagnosis was identified

A patient has the nursing diagnosis of Nausea. The nurse develops a care plan with the following interventions. Which are examples of collaborative interventions? (Select all that apply.) A. Providing mouth care every 4 hours B. Maintaining intravenous (IV) infusion at 100 mL/hr C. Administering prochlorperazine (Compazine) via rectal suppository D. Consulting with dietitian on initial foods to offer patient E. Controlling aversive odors or unpleasant visual stimulation that triggers nausea

Which of the following factors does a nurse consider for a patient with the nursing diagnosis of Disturbed Sleep Pattern related to noisy home environment in choosing an intervention for enhancing the patient's sleep? (Select all that apply.) A. The intervention should be directed at reducing noise. B. The intervention should be one shown to be effective in promoting sleep on the basis of research. C. The intervention should be one commonly used by the patient's sleep partner. D. The intervention should be one acceptable to the patient. E. The intervention should be one you used with other patients in the past.

A nurse begins the night shift being assigned to five patients. She learns that the floor will be a registered nurse (RN) short as a result of a call in. A patient care technician from another area is coming to the nursing unit to assist. The nurse is required to do hourly rounds on all patients, so she begins rounds on the patient who has recently asked for a pain medication. As the nurse begins to approach the patient's room, a nurse stops her in the hallway to ask about another patient. Which factors in this nurse's unit environment will affect her ability to set priorities? (Select all that apply.) A. Policy for conducting hourly rounds B. Staffing level C. Interruption by staff nurse colleague D. RN's years of experience E. Competency of patient care technician

A nursing student is reporting during hand-off to the registered nurse (RN) assuming her patient's care. The student states, "Mr. Roarke had a good day, his intravenous (IV) fluid is infusing at 124 mL/hr with D5 ½ NS infusing in right forearm. The IV site is intact, and no complaints of tenderness. I ambulated him twice during the shift; he tolerated well walking to end of hall and back with no shortness of breath. He still uses his cane without difficulty. Mr. Roarke said he slept better last night after I closed his door and gave him a chance to be uninterrupted. If the nurse's goal for Mr. Roarke was to improve activity tolerance, which expected outcomes were shared in the hand-off? (Select all that apply.) A. IV site not tender B. Uses cane to walk C. Walked to end of hall D. No shortness of breath E. Slept better during night

The nurse prepares for collaborative interventions and those initiated by the healthcare provider. What should the nurse do before implementing the interventions? Select all that apply. 1 Clarify orders. 2 Implement procedures as ordered by the healthcare provider. 3 Administer medications as ordered by the healthcare provider. 4 Determine if the intervention is appropriate for the patient. 5 Determine if the collaboration of other care disciplines is required.

The nurse is planning routine care for a patient. What are the resources that will be reviewed while planning care? Select all that apply. 1 Nursing literature 2 Standard protocols 3 Procedure manuals 4 Consent form 5 Nursing interventions classification

The nurse identifies several interventions to resolve the patient's nursing diagnosis of deteriorated skin condition. Which actions are written in error? Select all that apply. 1 Turn the patient regularly from side to back to side. 2 Provide perineal care, using Dove soap and water, every shift and after each episode of urinary incontinence. 3 Apply a pressure-relief device to bed. 4 Apply transparent dressing to sacral pressure ulcer. 5 Irrigate wound with 100 mL normal saline until clear: 6:00 AM, 2:00 PM, 8:00 PM.

Which outcome statements for the goal, "Patient will achieve a gain of 10 lb (4.5 kg) in body weight in a month" are worded incorrectly? Select all that apply. 1 Patient will eat at least three fourths of each meal by the end of week 1. 2 Patient will verbalize relief of nausea and have no episodes of vomiting in 1 week. 3 Patient will eat foods with high-calorie content by the end of week 1. 4 Give patient liquid supplements 3 times a day. 5 Provide patient high-calorie meals 3 times a day.

A patient has been in the hospital for 2 days because of newly diagnosed diabetes. His medical condition is unstable, and the medical staff is having difficulty controlling his blood sugar. The physician expects that the patient will remain hospitalized at least 3 more days. The nurse identifies one nursing diagnosis as deficient knowledge regarding insulin administration related to inexperience with disease management. What does the nurse need to determine before setting a goal that the patient will self-administer insulin? Select all that apply. 1 The goal is within the patient's reach. 2 The nurse's competency in teaching about insulin 3 The patient's cognitive function 4 Availability of the patient's support network to assist 5 The patient's social support network

Following an initial assessment of a patient, the nurse is charting the nursing goals and expected patient outcomes. What characteristics of nursing goals and expected outcomes should the nurse keep in mind when charting? Select all that apply. 1 Observable 2 Measurable 3 Patient centered 4 Healthcare provider-centered 5 No time limit

An 82-year-old patient who resides in a nursing home is at risk for falling, has pain-related decrease in mobility and wanders throughout the facility due to cognitive impairment. The nursing staff identified several goals of care, including achieving pain relief for the patient. Which outcome is related to this goal? 1 Patient will express fewer nonverbal signs of discomfort. 2 Patient will follow a set care routine. 3 Patient will walk correctly using a walker. 4 Patient will exit a low bed without falling.

How should the nurse document the expected outcome statement after assessing the apical pulse in a patient? 1 The patient has a normal apical pulse. 2 The patient's apical pulse values are stable. 3 The patient has acceptable apical pulse values. 4 The patient's apical pulse is 80 beats per minute.

Dependent nursing requires a primary healthcare provider's order. What are examples of dependent nursing interventions? Select all that apply. 1 Monitoring blood pressure 2 Inserting a Foley catheter 3 Dressing a surgical incision wound 4 Administering an intravenous drug 5 Teaching a patient to do deep breathing exercises

Which nursing intervention is included in the standard care plan while caring for a critically ill patient? 1 Collecting blood samples for frequent patient testing 2 Instructing the family to leave the patient alone for some time 3 Instructing the family to use old family remedies for the patient 4 Suggesting the patient use a chlorhexidine mouthwash regularly

The nurse is attending to a patient recently diagnosed with diabetes. Following an initial assessment, the nurse writes down several nursing-sensitive patient outcomes. Which nursing-sensitive patient outcomes are written correctly? Select all that apply. 1 The patient will administer a self-injection of insulin and control his diet. 2 The patient will administer a self-injection by discharge. 3 The patient will appear less anxious. 4 The body temperature will remain at or below 98.6° F. 5 The heart rate will remain between 70 to 90 beats per minute.

What are the characteristics of well-written goals and expected outcomes? Select all that apply. 1 Priority 2 Observable 3 Nonmeasurable 4 Time-limited 5 Patient-centered

The nurse is analyzing a patient for nursing-sensitive patient outcomes. Which statements about nursing-sensitive patient outcomes are correct? Select all that apply. 1 The patient will appear less anxious. 2 Body temperature will remain at 98.6° F. 3 The patient will maintain better eye contact during conversations. 4 The patient will self-administer an injection and demonstrate infection control measures. 5 Oxygen saturation will remain at 100%.

A goal describes a desired change in a patient's condition or behavior. For which patient is a short-term goal appropriate? 1 A patient who has undergone cancer therapy 2 A patient who requires rehabilitation post amputation 3 A patient who is diagnosed with diabetic neuropathy 4 A patient who has acute pain related to incisional trauma

The nurse has collected data from a patient during the initial interview. The nurse clusters the collected data and prepares a care plan. What are acceptable components of a comprehensive nursing care plan? Select all that apply. 1 Infection risk 2 Respiratory rate of 24 breaths per minute 3 Administering medications 4 Preparing a patient for a diagnostic study 5 Oxygen at 2 liters per nasal cannula

Critical thinking is required for selection of suitable interventions for the patient. What abilities will the nurse have that will help decide suitable nursing interventions? Select all that apply. 1 Functioning within a particular setting of the healthcare unit 2 Directing the consultation to the right professional 3 Knowing the scientific rationale for the intervention 4 Aligning a consultation to identify the problems of the patient 5 Possessing the necessary psychomotor and interpersonal skills

Ethical care is part of a priority setting. Which nursing intervention indicates delivering ethical care? 1 Administering morphine for pain relief 2 Discussing the condition with the patient 3 Assessing the patient for any signs of organ failure 4 Referring the patient for appropriate diagnostic interventions

A consultation is helpful in identifying ways to manage conditions or issues. Place the steps of consultation in their correct sequence. 1. Identify the problems associated with the patient. 2. Direct the consultation to the right professional. 3. Provide the consultant with relevant information about the problem area. 4. Avoid prejudice against the patient that could influence the consultants. 5. Be available to discuss the consultant's findings and recommendations. 6. Incorporate the consultant's recommendations into the care plan.

The nurse is caring for a patient who has undergone nephrectomy. Which interventions performed by the nurse require an order from another healthcare professional? Select all that apply. 1 Getting an x-ray of the chest to rule out pulmonary complications 2 Administering an antibiotic to prevent infection 3 Starting an intravenous infusion of normal saline 4 Instructing the patient to splint the incision when coughing 5 Instructing the patient about the side effects of the medication

What is the measurable criterion used to evaluate goal achievement? 1 Consultation 2 Critical thinking 3 Communication 4 Expected outcome

The nursing process is an essential component of nursing practice. When using a five-step nursing process, what is the third step? 1 Planning 2 Assessment 3 Implementation 4 Nursing diagnosis

The nurse develops a care plan with the following interventions for a patient with nausea. Which is an example of a collaborative intervention? 1 Provide frequent mouth care. 2 Maintain intravenous (IV) infusion at 100 mL/hr. 3 Administer prochlorperazine via rectal suppository. 4 Consult with dietitian on initial foods to offer patient.

Which nursing interventions fall under the category of nurse-initiated interventions? Select all that apply. 1 Inserting a Foley catheter 2 Starting an intravenous infusion 3 Elevating an edematous extremity 4 Repositioning the patient to relieve pain 5 Informing about the side effects of medications

Which interventions can be classified as nurse-initiated interventions? Select all that apply. 1 Starting an intravenous infusion 2 Elevating an edematous extremity 3 Preparing a patient for diagnostic tests 4 Repositioning the patient to achieve pain relief 5 Instructing a patient about the effects of medications

The nurse is discussing the features of having an effective phone consultation with a healthcare provider. What tips are helpful for making phone consultations? Select all that apply. 1 Prepare a detailed explanation of the problem during the call. 2 Assess the patient thoroughly before making the call. 3 Have the complete information about the problem before the call. 4 Understand the reason behind the call and think through some possible solutions. 5 Give feedback on the outcomes of previous recommendations

A patient has been in the hospital for 2 days because of newly diagnosed diabetes. His medical condition is unstable, and the medical staff is having difficulty controlling his blood sugar. The physician expects that the patient will remain hospitalized at least 3 more days. The nurse identifies one nursing diagnosis as deficient knowledge regarding insulin administration related to inexperience with disease management. Which patient care goals are long-term goals? 1 Patient will explain relationship of insulin to blood glucose control. 2 Patient will self-administer insulin. 3 Patient will achieve glucose control. 4 Patient will describe steps for preparing insulin in a syringe.

The nurse is teaching a group of student nurses when it's appropriate to consult other health care professionals regarding the nursing care of patients. Which actions do the nurses learn to perform for a phone consultation? Select all that apply. 1 Assess the patient before making the call. 2 Ask the consultant to summarize the problem. 3 Keep at hand the necessary patient information. 4 Influence the consultant as per the nurse's understanding. 5 Avoid bias by not sharing subjective and emotional conclusions

What are the important factors to be considered when choosing nursing interventions? Select all that apply. 1 Acceptability to the healthcare provider 2 Goals and expected outcomes 3 Presence of an evidence base for the interventions 4 Feasibility of the interventions 5 Characteristics of the nursing diagnosis

The various steps involved in the consultation process are described below. What is the correct sequence in which consultations should be done? Arrange the responses in a sequence. 1. Identify the general problem area. 2. Direct the consultation to the right professional. 3. Provide the consultant with relevant information about the problem area. 4. Do not prejudice or influence consultants. 5. Discuss the consultant's findings and recommendations.

A group of nursing students is being taught to avoid errors in writing nursing interventions. Which statements are correctly stated nursing interventions? Select all that apply. 1 Turn the patient every 2 hours. 2 Perform blood glucose measurements. 3 Measure blood glucose before each meal: 7:00 AM, 11:00 AM, and 5:00 PM. 4 Turn the patient every 2 hours from supine to prone to right side. 5 Give sitz bath.