Which of the following factors should be considered when choosing an intervention
for a patient's plan of care? (Select all that apply.)
1. The specific patient outcome against which to judge effectiveness of interventions
2. The timing of care activities routinely conducted on the care unit
3. The scientific evidence available in support of an intervention
4. The amount of time required for implementation in consideration of patient's
condition
5. The patient's values and beliefs regarding the intervention
Give this one a try later!
, 1. The specific patient outcome against which to judge effectiveness of
interventions
3. The scientific evidence available in support of an intervention
4. The amount of time required for implementation in consideration of
patient's condition
5. The patient's values and beliefs regarding the intervention
A nurse conducts an assessment of a 42-year-old woman at a health clinic. The
woman is married and lives in a condo with her husband. She reports having frequent
voiding and pain when she passes urine. The nurse asks whether she has to go to the
bathroom at night, and the patient responds, "Yes, usually twice or more." The patient
had an episode of diarrhea 1 week ago. She weighs 300 lb and reports having
difficulty cleansing herself after voiding or passing stool. Which of the following
demonstrate assessment findings that cluster to indicate the nursing diagnosis
Impaired Urination. (Select all that apply.)
1. Age 42
2. Dysuria
3. Difficulty performing perineal hygiene
4. Nocturia
5. Episode of diarrhea
Give this one a try later!
2. Dysuria
4. Nocturia
A nurse sends a text message to the oncoming nurse to report that a patient refuses
to take medication as ordered. What should the oncoming nurse do? (Select all that
apply).
1. Add this information to the board hanging at that patient's bedside.
2.Tell the nurse who sent the text that the text is a HIPAA violation.
3. Inform the nursing supervisor.
,4. Forward the text to the change nurse.
5. Thank the nurse for sending information.
Give this one a try later!
2. Tell the nurse who sent the text that the text is a HIPAA violation.
3. Inform the nursing supervisor.
A young male patient enters the emergency department with fever and signs of a
possible sexually transmitted infection. The nurse enters the patient's cubicle and
begins to enter a history on the computer screen. Before beginning the nurse
introduces himself and tells the patient all information will be held confidentially. The
nurse starts data collection by establishing eye contact with the patient and then
looks at the computer prompts to select a series of questions. As the nurse fills out
questions on the computer, the patient asks a question about his treatment. The nurse
states, "Let me get through these questions first." Which action interferes with the
nurse's ability to use connection as a communication skill.
1. Introducing self to patient
2. Using the computer as a prompt for questions
3. Making the nurse's questions a priority
4. Assuring the patient all information is confidential
Give this one a try later!
3. Making the nurse's questions a priority
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?
1. Providing hand-off report at change of shift
, 2. Enhancing the patients sleep hygiene
3. Administering IV fluids
4. Taking vital signs
Give this one a try later!
3. Administering IV fluids
A charge nurse is reviewing the steps of the nursing process with a group of nurses.
Which of the following data should the charge nurse identify as objective data?
(Select all that apply).
A. Respiratory rate is 22/min with even, unlabored respirations.
B. The client's partner states, "They said they hurt after walking about 10 minutes"
C. The client's pain rating is 3 on a scale of 0 to 10
D. The client's skin is pink, warm, and dry
E. The assistive personnel reports that the client walked with a limp.
Give this one a try later!
A. Respiratory rate is 22/min with even, unlabored respirations.
D. The client's skin is pink, warm, and dry
E. The assistive personnel reports that the client walked with a limp.
A nurse on a hospital unit is preparing to hand off care of a patient being discharged
to a home health nurse. Match the activities with the hand-off report categories.
Activities
1. Use a standard checklist for the report.
2. Encourage questions and clarification.
3. Offer specific information on how to reduce patient’s risks.
4. Give report at time when shift has ended and other nurses are requesting
information.
5. Explain how patient’s discharge was delayed by insufficient numbers of staff.
6. Organize time by preparing in advance what to report.
for a patient's plan of care? (Select all that apply.)
1. The specific patient outcome against which to judge effectiveness of interventions
2. The timing of care activities routinely conducted on the care unit
3. The scientific evidence available in support of an intervention
4. The amount of time required for implementation in consideration of patient's
condition
5. The patient's values and beliefs regarding the intervention
Give this one a try later!
, 1. The specific patient outcome against which to judge effectiveness of
interventions
3. The scientific evidence available in support of an intervention
4. The amount of time required for implementation in consideration of
patient's condition
5. The patient's values and beliefs regarding the intervention
A nurse conducts an assessment of a 42-year-old woman at a health clinic. The
woman is married and lives in a condo with her husband. She reports having frequent
voiding and pain when she passes urine. The nurse asks whether she has to go to the
bathroom at night, and the patient responds, "Yes, usually twice or more." The patient
had an episode of diarrhea 1 week ago. She weighs 300 lb and reports having
difficulty cleansing herself after voiding or passing stool. Which of the following
demonstrate assessment findings that cluster to indicate the nursing diagnosis
Impaired Urination. (Select all that apply.)
1. Age 42
2. Dysuria
3. Difficulty performing perineal hygiene
4. Nocturia
5. Episode of diarrhea
Give this one a try later!
2. Dysuria
4. Nocturia
A nurse sends a text message to the oncoming nurse to report that a patient refuses
to take medication as ordered. What should the oncoming nurse do? (Select all that
apply).
1. Add this information to the board hanging at that patient's bedside.
2.Tell the nurse who sent the text that the text is a HIPAA violation.
3. Inform the nursing supervisor.
,4. Forward the text to the change nurse.
5. Thank the nurse for sending information.
Give this one a try later!
2. Tell the nurse who sent the text that the text is a HIPAA violation.
3. Inform the nursing supervisor.
A young male patient enters the emergency department with fever and signs of a
possible sexually transmitted infection. The nurse enters the patient's cubicle and
begins to enter a history on the computer screen. Before beginning the nurse
introduces himself and tells the patient all information will be held confidentially. The
nurse starts data collection by establishing eye contact with the patient and then
looks at the computer prompts to select a series of questions. As the nurse fills out
questions on the computer, the patient asks a question about his treatment. The nurse
states, "Let me get through these questions first." Which action interferes with the
nurse's ability to use connection as a communication skill.
1. Introducing self to patient
2. Using the computer as a prompt for questions
3. Making the nurse's questions a priority
4. Assuring the patient all information is confidential
Give this one a try later!
3. Making the nurse's questions a priority
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?
1. Providing hand-off report at change of shift
, 2. Enhancing the patients sleep hygiene
3. Administering IV fluids
4. Taking vital signs
Give this one a try later!
3. Administering IV fluids
A charge nurse is reviewing the steps of the nursing process with a group of nurses.
Which of the following data should the charge nurse identify as objective data?
(Select all that apply).
A. Respiratory rate is 22/min with even, unlabored respirations.
B. The client's partner states, "They said they hurt after walking about 10 minutes"
C. The client's pain rating is 3 on a scale of 0 to 10
D. The client's skin is pink, warm, and dry
E. The assistive personnel reports that the client walked with a limp.
Give this one a try later!
A. Respiratory rate is 22/min with even, unlabored respirations.
D. The client's skin is pink, warm, and dry
E. The assistive personnel reports that the client walked with a limp.
A nurse on a hospital unit is preparing to hand off care of a patient being discharged
to a home health nurse. Match the activities with the hand-off report categories.
Activities
1. Use a standard checklist for the report.
2. Encourage questions and clarification.
3. Offer specific information on how to reduce patient’s risks.
4. Give report at time when shift has ended and other nurses are requesting
information.
5. Explain how patient’s discharge was delayed by insufficient numbers of staff.
6. Organize time by preparing in advance what to report.
