EXCELSIOR COLLAGE NURS104 FINAL EXAM 1- 2021| 202
100% CORRECT
A patient states “I would like to be able to decrease my risk for heart disease. I started eating
better but there is more I can do.” What would be an appropriate NANDA-I nursing diagnosis for
the RN to apply in this situation?
Ineffective role performance
Risk-prone health behavior
Deficient knowledge
Readiness for enhanced health maintenance submitted
A team of RNs is researching the occurrence of pressure ulcers throughout the hospital. How
does the use of standardized language in electronic health record (EHR) assist with the research?
Compliance with privacy is ensured. submitted
Data retrieval is efficient.
Documentation is easy to understand.
Other disciplines clearly understand language.
Which technologic strategy is used when an organization needs to investigate changes that have
been made in the electronic health record?
Password changes submitted
Order entry review
Audit trails
Omission errors summaries
When developing the plan of patient care, which nursing order can delegated to the unlicensed
assistive personnel (UAP)?
Observe skin over bony prominences every 4 hours.
Review trends in vital signs every shift.
Turn and position every 2 hours; avoid supine positon. submitted
, Make sure all home care supplies are packed for discharge to home.
When developing the patient plan of care, the RN can assign patient care to which member of the
health care team?
Social worker.
Physical Therapist.
Registered nurse.
Unlicensed assistive personal. submitted
The RN demonstrates skill in implementing coordinated nursing care when making which
statements to a UAP? Select all that apply.
“After you give Ms. Huang her bath today, please report to me what her skin looks like.”
“Mr. Lopez’s buttocks were red yesterday. Within the next 30 minutes, turn him and report
any redness or open areas to me.”
“At the end of the shift, I want you to measure the urine output for Mr. Harding in room 34.”
“Take the vital signs now for Mr. Wayne in room 22, Mrs. Payne in room 3, and report them
to me. I gave them each blood pressure medications an hour ago.”
“Give Ms. Garcia in room 63 a bed bath today and make sure you listen carefully to
anything she says. She has been very sad due to the recent death of her sister.”
The Licensed Practical Nurse (LPN) is called home for a family emergency and did not finish
documenting the wound care given to the patient. The LPN provided the RN a report of
interventions performed. Which statement below is correctly documented by the RN for the
LPN?
“The LPN stated a dry sterile dressing was placed on the patient’s left, lateral foot at 2 PM.”
“A dry dressing was applied to the patient’s left lateral foot.”
“The LPN placed a dry sterile dressing on the patient’s left lateral foot before leaving.”
submitted
“The LPN placed a dry sterile dressing on the patient’s lateral left foot.”
, The nurse enters a room and discovers a patient lying on the floor and moaning. Which entry
meets the guidelines for documenting this event?
“The patient was emotionally disturbed when found on the floor.”
“The patient was found next to the bed so he must have fallen out of the bed.”
“The patient was conscious and crying out when found on the floor next to the bed.”
submitted
“The patient was hurt, crying and found on the floor next to the bed.”
Which NANDA-I nursing diagnosis is a priority for the patient that experiences a decrease in
blood pressure along with dizziness when changing position from supine to upright?
Risk for infection
Hypotension
Risk for falls submitted
Altered vital signs
During an assessment of the lower extremities of a patient, the RN is not able to palpate the
dorsalis pedis pulse in the right foot. Which intervention should the RN implement next to
assess pulse quality?
Assess capillary refill.
Check the EHR to determine if this is a new finding. submitted
Notify the primary care provider.
Utilize a Doppler ultrasound device to detect blood flow.
When developing a patient plan of care, which is an independent nursing action?
Administer a stool softener at bedtime every day. submitted
Collaborate with physical therapist to modify activity orders.
Provide distraction between doses of pain medication.
100% CORRECT
A patient states “I would like to be able to decrease my risk for heart disease. I started eating
better but there is more I can do.” What would be an appropriate NANDA-I nursing diagnosis for
the RN to apply in this situation?
Ineffective role performance
Risk-prone health behavior
Deficient knowledge
Readiness for enhanced health maintenance submitted
A team of RNs is researching the occurrence of pressure ulcers throughout the hospital. How
does the use of standardized language in electronic health record (EHR) assist with the research?
Compliance with privacy is ensured. submitted
Data retrieval is efficient.
Documentation is easy to understand.
Other disciplines clearly understand language.
Which technologic strategy is used when an organization needs to investigate changes that have
been made in the electronic health record?
Password changes submitted
Order entry review
Audit trails
Omission errors summaries
When developing the plan of patient care, which nursing order can delegated to the unlicensed
assistive personnel (UAP)?
Observe skin over bony prominences every 4 hours.
Review trends in vital signs every shift.
Turn and position every 2 hours; avoid supine positon. submitted
, Make sure all home care supplies are packed for discharge to home.
When developing the patient plan of care, the RN can assign patient care to which member of the
health care team?
Social worker.
Physical Therapist.
Registered nurse.
Unlicensed assistive personal. submitted
The RN demonstrates skill in implementing coordinated nursing care when making which
statements to a UAP? Select all that apply.
“After you give Ms. Huang her bath today, please report to me what her skin looks like.”
“Mr. Lopez’s buttocks were red yesterday. Within the next 30 minutes, turn him and report
any redness or open areas to me.”
“At the end of the shift, I want you to measure the urine output for Mr. Harding in room 34.”
“Take the vital signs now for Mr. Wayne in room 22, Mrs. Payne in room 3, and report them
to me. I gave them each blood pressure medications an hour ago.”
“Give Ms. Garcia in room 63 a bed bath today and make sure you listen carefully to
anything she says. She has been very sad due to the recent death of her sister.”
The Licensed Practical Nurse (LPN) is called home for a family emergency and did not finish
documenting the wound care given to the patient. The LPN provided the RN a report of
interventions performed. Which statement below is correctly documented by the RN for the
LPN?
“The LPN stated a dry sterile dressing was placed on the patient’s left, lateral foot at 2 PM.”
“A dry dressing was applied to the patient’s left lateral foot.”
“The LPN placed a dry sterile dressing on the patient’s left lateral foot before leaving.”
submitted
“The LPN placed a dry sterile dressing on the patient’s lateral left foot.”
, The nurse enters a room and discovers a patient lying on the floor and moaning. Which entry
meets the guidelines for documenting this event?
“The patient was emotionally disturbed when found on the floor.”
“The patient was found next to the bed so he must have fallen out of the bed.”
“The patient was conscious and crying out when found on the floor next to the bed.”
submitted
“The patient was hurt, crying and found on the floor next to the bed.”
Which NANDA-I nursing diagnosis is a priority for the patient that experiences a decrease in
blood pressure along with dizziness when changing position from supine to upright?
Risk for infection
Hypotension
Risk for falls submitted
Altered vital signs
During an assessment of the lower extremities of a patient, the RN is not able to palpate the
dorsalis pedis pulse in the right foot. Which intervention should the RN implement next to
assess pulse quality?
Assess capillary refill.
Check the EHR to determine if this is a new finding. submitted
Notify the primary care provider.
Utilize a Doppler ultrasound device to detect blood flow.
When developing a patient plan of care, which is an independent nursing action?
Administer a stool softener at bedtime every day. submitted
Collaborate with physical therapist to modify activity orders.
Provide distraction between doses of pain medication.
