Nurs 333 Ch. 19

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The nurse enters a patient’s room and finds that the patient was incontinent of liquid stool. The patient has recurrent redness in the perineal area, and there is concern that he is developing a pressure ulcer. The nurse cleanses the patient, inspects the skin, and applies a skin barrier ointment to the perineal area. She calls the ostomy and wound care specialist and asks that he visit the patient to recommend skin care measures. Which of the following describe the nurse’s actions? (Select all that apply.) A) The application of the skin barrier is a dependent care measure. B) The call to the ostomy and wound care specialist is an indirect care measure. C) The cleansing of the skin is a direct care measure. D) The application of the skin barrier is a direct care measure.
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The call to the ostomy and wound care specialist is an indirect care measure. The cleansing of the skin is a direct care measure. The application of the skin barrier is a direct care measure.
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During the implementation step of the nursing process, a nurse reviews and revises the nursing plan of care. Place the following steps of review and revision in the correct order: A) Review the care plan. B) Decide if the nursing interventions remain appropriate. C) Reassess the patient. D) Compare assessment findings to validate existing nursing diagnoses.
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Reassess the patient. Review the care plan. Compare assessment findings to validate existing nursing diagnoses. Decide if the nursing interventions remain appropriate.
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A nurse checks a physician’s order and notes that a new medication was ordered. The nurse is unfamiliar with the medication. A nurse colleague explains that the medication is an anticoagulant used for postoperative patients with risk for blood clots. The nurse’s best action before giving the medication is to: A) Have the nurse colleague check the dose with her before giving the medication. B) Consult with a pharmacist to obtain knowledge about the purpose of the drug, the action, and the potential side effects. C) Ask the nurse colleague to administer the medication to her patient. D) Administer the medication as prescribed and on time.
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Consult with a pharmacist to obtain knowledge about the purpose of the drug, the action, and the potential side effects.
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When does implementation begin as the fourth step of the nursing process? A) During the assessment phase B) Immediately in some critical situations C) After the care plan has been developed D) After there is mutual goal setting between nurse and patient
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After the care plan has been developed
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Before consulting with a physician about a patient’s need for urinary catheterization, the nurse considers the fact that the patient has urinary retention and has been unable to void on her own. The nurse knows that evidence for alternative measures to promote voiding exists, but none has been effective, and that before surgery the patient was voiding normally. This scenario is an example of which implementation skill? A) Cognitive B) Interpersonal C) Psychomotor D) Consultative
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Cognitive
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The nurse enters a patient’s room, and the patient asks if he can get out of bed and transfer to a chair. The nurse takes precautions to use safe patient handling techniques and transfers the patient. This is an example of which physical care technique? A) Meeting the patient’s expressed wishes B) Indirect care measure C) Protecting a patient from injury D) Staying organized when implementing a procedure
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Protecting a patient from injury
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In which of the following examples is a nurse applying critical thinking attitudes when preparing to insert an intravenous (IV) catheter? (Select all that apply.) A) Following the procedural guideline for IV insertion B) Seeking necessary knowledge about the steps of the procedure from a more experienced nurse C) Showing confidence in performing the correct IV insertion technique D) Being sure that the IV dressing covers the IV site completely
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Seeking necessary knowledge about the steps of the procedure from a more experienced nurse Showing confidence in performing the correct IV insertion technique
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Which steps does the nurse follow when he or she is asked to perform an unfamiliar procedure? (Select all that apply.) A) Seeks necessary knowledge B) Reassesses the patient’s condition C) Collects all necessary equipment D) Delegates the procedure to a more experienced staff member E) Considers all possible consequences of the procedure
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Seeks necessary knowledge Collects all necessary equipment Considers all possible consequences of the procedure
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A nurse is talking with a patient who is visiting a neighborhood health clinic. The patient came to the clinic for repeated symptoms of a sinus infection. During their discussion the nurse checks the patient’s medical record and realizes that he is due for a tetanus shot. Administering the shot is an example of what type of preventive intervention? A) Tertiary B) Direct care C) Primary D) Secondary
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Primary
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A nurse is orienting a new graduate nurse to the unit. The graduate nurse asks, “Why do we have standing orders for cases when patients develop life-threatening arrhythmias? Is not each patient’s situation unique?” What is the nurse’s best answer? A) Standing orders are used to meet our physician’s preferences. B) Standing orders ensure that we are familiar with evidence-based guidelines for care of arrhythmias. C) Standing orders allow us to respond quickly and safely to a rapidly changing clinical situation. D) Standing orders minimize the documentation we have to provide.
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Standing orders allow us to respond quickly and safely to a rapidly changing clinical situation
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A nurse on a cancer unit is reviewing and revising the written plan of care for a patient who has the nursing diagnosis of nausea. Place the following steps in their proper order: A) The nurse revises approaches in the plan for controlling environmental factors that worsen nausea. B) The nurse enters data in the assessment column showing new information about the patient’s nausea. C) The nurse adds the current date to show that the diagnosis of nausea is still relevant. D) The nurse decides to use the patient’s self-report of appetite and fluid intake as evaluation measures.
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The nurse enters data in the assessment column showing new information about the patient’s nausea. The nurse adds the current date to show that the diagnosis of nausea is still relevant. The nurse revises approaches in the plan for controlling environmental factors that worsen nausea. The nurse decides to use the patient’s self-report of appetite and fluid intake as evaluation measures.
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When a nurse properly positions a patient and administers an enema solution at the correct rate for the patient’s tolerance, this is an example of what type of implementation skill? A) Interpersonal B) Cognitive C) Collaborative D) Psychomotor
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Psychomotor
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The nurse reviews a patient’s medical record and sees that tube feedings are to begin after a feeding tube is inserted. In recent past experiences the nurse has seen patients on the unit develop diarrhea from tube feedings. The nurse consults with the dietitian and physician to determine the initial rate that will be ordered for the feeding to lessen the chance of diarrhea. This is an example of what type of direct care measure? A) Preventive B) Controlling for an adverse reaction C) Consulting D) Counseling
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Controlling for an adverse reaction
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A nurse is starting on the evening shift and is assigned to care for a patient with a diagnosis of impaired skin integrity related to pressure and moisture on the skin. The patient is 72 years old and had a stroke. The patient weighs 250 pounds and is difficult to turn. As the nurse makes decisions about how to implement skin care for the patient, which of the following actions does the nurse implement? (Select all that apply.) A) Review the set of all possible nursing interventions for the patient’s problem B) Review all possible consequences associated with each possible nursing action C) Consider own level of competency D) Determine the probability of all possible consequences
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Review the set of all possible nursing interventions for the patient’s problem Review all possible consequences associated with each possible nursing action Determine the probability of all possible consequences
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Activities of Daily Living
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Activities usually performed in the course of a normal day in the patient’s life such as eating, dressing, bathing, brushing the teeth, or grooming.
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Adverse reaction
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Any harmful, unintended effect of a medication, diagnostic test, or therapeutic intervention.
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counseling
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Problem-solving method used to help patients recognize and manage stress and enhance interpersonal relationships. It helps patients examine alternatives and decide which choices are most helpful and appropriate.
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implementation
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Initiation and completion of the nursing actions necessary to help the patient achieve health care goals.
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Instrumental activities of daily living
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Activities necessary for independence in society beyond eating, grooming, transferring, and toileting; include such skills as shopping, preparing meals, banking, and taking medications.
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Nursing intervention
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Any treatment based on clinical judgment and knowledge that a nurse performs to enhance patient outcomes.
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Preventative Nursing actions
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Nursing actions directed toward preventing illness and promoting health to avoid the need for primary, secondary, or tertiary health care.
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Standing order
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Written and approved documents containing rules, policies, procedures, regulations, and orders for the conduct of patient care in various stipulated clinical settings.
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Direct care interventions
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treatments performed through interactions with patients. For example: medication administration, insertion of an intravenous (IV) infusion, or counseling during a time of grief.
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Indirect care interventions
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treatments performed away from the patient but on behalf of the patient or group of patients. For example: actions for managing the patient’s environment (e.g., safety and infection control), documentation, and interdisciplinary collaboration.
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Clinical practice guideline
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a systematically developed set of statements that helps nurses, physicians, and other health care providers make decisions about appropriate health care for specific clinical situations
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Five preparatory activities for the implementation process:
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reassessing the patient, reviewing and revising the existing nursing care plan, organizing resources and care delivery, anticipating and preventing complications, and implementing nursing interventions.
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Cognitive skills
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involve the application of critical thinking in the nursing process.
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Interpersonal skills
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essential for effective nursing action. Develop a trusting relationship, express a level of caring, and communicate clearly with a patient and his or her family
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Psychomotor skills
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require the integration of cognitive and motor activities. For example, when giving an injection you need to understand anatomy and pharmacology (cognitive) and use good coordination and precision to administer the injection correctly (motor).
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Primary prevention
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aimed at health promotion includes health education programs, immunizations, and physical and nutritional fitness activities
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Secondary prevention
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focuses on people who are experiencing health problems or illnesses and who are at risk for developing complications or worsening conditions
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Tertiary prevention
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involves minimizing the effects of long-term illness or disability, including rehabilitation measures.
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Patient adherence
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means that patients and families invest time in carrying out required treatments

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