Fundamentals: Introduction to the nursing process – Flashcards

What are the advantages of proper nursing documentation? (select all that apply) It promotes repetition of care for a group of patients. It limits the omission of patient care. It serves as proof of nursing interventions. It evaluates the effectiveness of nursing interventions. It establishes good communication among the health care team.

The nurse is caring for a 50-year-old patient. The patient had the gall bladder removed and it is day two post-surgery. The nurse finds that the patient is uncomfortable and in pain. The nurse also notices some oozing from the site of the surgery. What nursing actions are needed for the patient? Identify the exact problem, provide necessary nursing actions and then evaluate the outcome. Identify the exact problem, plan appropriate nursing action, perform the necessary nursing actions, and then obtain information from the patient if required. Gather information about his problem, identify the exact problem, plan appropriate nursing action, perform the required nursing actions, and then evaluate the outcome. Identify the problem, perform necessary nursing action if required, and explain to the patient that pain and discomfort after surgery is common and that he has to bear it for a few days.

What are the different types of nursing diagnoses, according to the North American Nursing Diagnosis Association (NANDA)? (Select all that apply) Risk diagnoses Acute diagnoses Actual diagnoses Chronic diagnoses Health promotion diagnoses

A patient is diagnosed with urinary stress incontinence. The nurse identifies it as which type of diagnosis? Actual Risk Health Promotion Chronic

The nurse finds that the patient outcomes have not been achieved after the implementation of interventions. The nurse also identifies aspects of the nursing care plan that need to be modified. Which step of the nursing process do these actions address? Planning Diagnosis Evaluation Assessment

The nurse knows that each time a patient is evaluated; the nursing care plan may need to be modified. What actions should the nurse perform when modifying a care plan after a patient has been evaluated? (Select all that apply) Reassess patient factors. Evaluate the interventions. Redefine nursing diagnoses. Conclude the evaluation process. Continue unrealistic outcome time frames.

Which activities will be included in the planning phase of the nursing process while preparing the nursing care plan? (Select all that apply) The nurse establishes short and long-term goals. The nurse collects and organizes the patient data. The nurse prioritizes the patient's nursing diagnoses. The nurse identifies interventions to address patient goals. The nurse identifies problems, risks, and patient thoughts.

A patient is reporting pain of 9 out of 10 on the pain scale. Which interventions are useful to provide pain relief during the post-procedure recovery phase? Initiate alternate therapies for pain relief. Place the patient in a comfortable position. Restrict the use of pillows for back support. Medicate the patient with acetaminophen. Medicate the patient with morphine sulfate (Avinza).

The nurse identified that the patient has pain of 7 on a scale of 1-10; he winces during movement; and he expresses discomfort over the incisional area. He guards the area by resisting movement. The incision appears to be healing, but there is natural swelling. What would be the related factor in a three-part nursing diagnostic statement? Acute pain Natural swelling Related to incisional trauma Wincing, guarding, restricting turning and positioning

The nurse finds new assessment data in a patient with fever and vomiting. Which step of the nursing process would involve revision of the nursing care plan? Planning Evaluation Assessment Implementation

What could be the effect of an incorrect nursing diagnosis? It could affect the quality of patient care. It could affect the patient's cost of treatment. It would get corrected automatically in the system. It could produce a psychological disorder in the patient.

Which step of the nursing process involves the gathering of information while providing patient care? Planning Diagnosis Assessment Implementation

During the evaluation phase of the nursing process, which data would the nurse consider? Did the patient meet the goals and outcomes established? Are the established patient goals realistic and measurable? Could any of the interventions have a negative impact on the patient? Is there any new data identified that should be taken into consideration? Does the nursing care plan need any modifications in response to the changes in patient needs?

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

A nurse is caring for a patient who has undergone coronary artery bypass graft surgery. Identify the nursing interventions that are examples of direct care for this patient? Administering medications Inserting an intravenous line Keeping the patient's room infection free Counseling the patient about required care Keeping all of the patient's paperwork updated

The nurse is determining the short-term and long-term goals for a patient. What point should the nurse consider to differentiate between a short-term goal and a long-term goal? A short-term goal is achieved in a week. A short-term goal is patient-centric. A short-term goal is realistic. A short-term goal is measurable.

For a diagnosis of impaired skin integrity, what could be the possible related factors? . Age extremes Fluid retention Maturational crisis Impaired sensation Physical immobilization

Which step of the nursing process involves collaboration with and delegation of patient care activities to other health care team members? Assessment Planning Implementation Evaluation

The nurse is assessing a patient who arrives at the outpatient clinic with high-grade fever. The nurse observes that the patient has a temperature of 102°F. The patient reports abdominal discomfort, sleep disturbance, and severe headache. The patient's mother reports that the patient had two episodes of vomiting. Which is the secondary data gathered by the nurse? Vomiting Headache 102°F temperature Abdominal discomfort

The registered nurse overhears a statement while the licensed practical nurse (LPN) is collecting data from a patient. Which statement documented by the LPN does the nurse need to validate immediately? The patient's height is 162 cm, and weight is 84 kg. The patient reports bleeding at the surgical wound incision. The patient has white color patches over the face and hands. The patient's blood pressure is 120/82 mm of Hg; it was 130/90 mm of Hg yesterday.

The nurse prepares a plan of care for a patient who is diagnosed with depression. What concerns should the nurse address during the implementation phase of the nursing process? . Providing patient-centered care and safety Gathering information with complete accuracy and thoroughness Identifying the specific and realistic nature of the outcomes Identifying new patient data to modify the existing nursing care plan Determining any negative impact of nursing interventions on the patient

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 of the following patient care goals are long term? Patient will self-administer insulin. Patient will achieve glucose control. Patient will describe steps for preparing insulin in a syringe. Patient will explain relationship of insulin to blood glucose control.

What are the components of the evaluation phase of the nursing process? Determining the goals Examining a condition or situation Documenting the expected outcomes Assessing the patient for nursing needs Judging if the desired change has occurred

A 60-year-old patient complains of fatigue and difficulty breathing. He is diagnosed with chronic obstructive pulmonary disease (COPD). The nurse helps the patient to sit in a semi-Fowler's position and administers oxygen therapy as prescribed by the healthcare provider. Following a reevaluation of the patient, why does the nurse document the results? To revise the care plan. To document the patient's progress. To replicate the care in another patient. To determine a better expected outcome. To indicate that the nurse has provided care.

Which factors may have a significant impact on the implementation phase of the nursing process? Protocol Prescription Standing order Clinical pathways Medical records

A patient is admitted to the hospital with a diagnosis of inguinal hernia. The nurse performs a comprehensive nursing assessment. What is the purpose of this activity? Arrive at the final diagnosis. Interpret and validate the data collected. Collect data with which to plan and evaluate care. Establish a database about the patient's needs and health problems. Explain the medications to the patient and make sure he follows the recommendations.

A nurse assesses a 78-year-old patient who weighs 240 pounds (108.9 kg) 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 goals are appropriate for the patient? Patient will begin a weight-loss program. Patient's skin condition will improve by discharge. Patient's skin will remain intact through discharge. Patient will be turned every 2 hours within 24 hours. Patient will have normal bowel function within 72 hours.

A nurse is caring for a 79-year-old patient. The patient has been a diabetic for 10 years and comes to the hospital for regular check-ups. The nurse finds that the patient has developed a non-healing wound on the left foot. The nurse is dressing the patient's wound. While performing the dressing, the nurse is unsure about the dilution of the antiseptic solution to be used. What should the nurse do? Refer to the clinical practice protocol. Ask a colleague who knows about it Skip the use of antiseptic and continue dressing. Wait until the health care provider makes rounds.

The nurse identified that the patient has pain of 7 on a scale of 1-10; he winces during movement, and he expresses discomfort over the incisional area. He guards the area by resisting movement. The incision appears to be healing, but there is natural swelling. What would be the diagnosis label in a three-part nursing diagnostic statement? Acute pain Natural swelling Related to incisional trauma Wincing, guarding, restricting turning and positioning

The nurse is attending to a patient in a coronary care unit. She is revising the care plan after evaluating the patient outcomes. Which steps of the nursing processes is the nurse performing? Planning Diagnosis Evaluation Assessment Implementation

Following an initial interview and the assessment of a patient, the nurse is preparing a nursing care plan. Which diagnoses are considered as actual nursing diagnoses? Hypothermia Wandering Impaired social interaction Loneliness in a depressive patient Risk for infection