NSG 233 Med Surg 1 Exam 1 Questions and Answers (Verified Answers)

A patient has a nursing diagnosis of ineffective airway clearance related to retained secretions, excessive mucus, and ineffective cough as evidenced by adventitious breath sounds. What should the nurse include in the NCP as an appropriate NOC outcome and NIC intervention for this nursing diagnosis? 1. Aspiration Prevention (NOC) and Aspiration Procedures (NIC) 2. Respiratory Status: Gas Exchange (NOC) and Oxygen Therapy (NIC) 3. Respiratory Status: Ventilation (NOC) and Respiratory Monitoring (NIC) 4. Respiratory Status: Airway Patency (NOC) and Airway Management (NIC) - 4. Respiratory Status: Airway Patency (NOC) and Airway Management (NIC) A nurse teaches a student nurse about evidence-based nursing practice guidelines. Which statement, if made by the student nurse, indicates understanding of the teaching? 1. "Patient care is based on research findings instead of the expertise of the nurse." 2. "Patient preferences should not be considered if guidelines are supported by evidence." 3. "Nursing care provided is based on the best evidence for quality care and desired outcomes." 4. "Practice guidelines are used so that professional decisions about patient care are unnecessary." - 3. "Nursing care provided is based on the best evidence for quality care and desired outcomes. a nurse is caring for an older adult who has a new diagnosis of type 2 diabetes and reports to have difficulty following the diet plan and and taking his medication which of the following actions can the nurse take so the patient is more compliant? 1. as the dietitation to assist with meal planning 2. contact the clients support system 3. assess for age related cognitive awareness 4. encourage to use a daily medication dispenser de educational materials for at home usage - 1. as the dietitation to assist with meal planning 2. contact the clients support system 4. encourage to use a daily medication dispenser de educational materials for at home usage a nurse in a health care clinic is evaluating the level of wellness for clients using the illness-wellness continuum. The nurse should identify which of the following clients as at the center of the continuum.? 1. college student w influenza 2. older adult with new diagnosis of type 2 diabetes 3. New mother with a UTI 4. Young male with a long history of controlled arthritis - 4. Young male with a long history of controlled arthritis A nurse is evaluating clients at a health fair for modifiable variables affecting health and wellness. Which variables can the nurse identify as modifiable? a. smoking on occasion 2. BMI of 28 3. Alopecia 4. Trisomy 21 5. History of reflux - a. smoking on occasion 2. BMI of 28 5. History of reflux A nurse is caring for a patient who was just told she has breast cancer. The nurse evaluates the clients response. Which of the following statements reflects a lack of understanding of an illness perspective? a. " i have no family history of breast cancer" b. " I need a second opinion, there is no lump" c. " I am glad we live in a city where there is several large hospitals" d. "I will schedule my surgery next week over the holidays" - b. " I need a second opinion, there is no lump" an example of a nursing activity that best reflects the the ANA's definition of nursing is: 1. treating dysarythmias that occur in a patient in the coronary care unit 2. diagnosing a patient with a tube feed with risk of aspiration 3. establishing protocols for a patient in the emergency department 4. providing antianxiety drugs for a patient who has disturbed sleep disorder - 2. diagnosing a patient with a tube feed with risk of aspiration A nurse working on the med surg unit in an urban hospital would like to become certified in med surg nursing. The nurse knows this process might require: a. BSN b. Formal training in advanced nursing process c. experience for a certain amount of time in med surg nursing d. membership in a med surg speciality organization - c. experience for a certain amount of time in med surg nursing Nurse is providing care for a patient after R hip surgery. W/I a pay for performance center a critical role of the nurse is: a. ensure care is using minimal supplies b. discharge after # of approved days of care c. implement measures to decrease risk of infection d. assess how well patient is able to pay the health care costs - c. implement measures to decrease risk of infection Order Steps of Nursing Process: ---Evaluate is plan is effective ---identify any health problems ---collect patient info ---carry out plan ---Determine plan of action - 5, 2, 1, 4. 3 the linkages among NANDA-1 nursing diagnoses, NOC patient outcomes and NIC nursing interventions can be used to: a. evaluate patient outcomes b. provide guides for planning care c. predict nursing care results d. shorten care plans for patients - b. provide guides for planning care the nurse is caring for diabetic patient in a surgery unit who has had debridement of an infected toe. What is correct to delegate to a tech? a. check patients vitals b. monitor patients pain c. assess patients IV cath site d. evaluate patients pedal pulse - a. check patients vitals The nurse's role in addressing the National Patient Safety Goals established by the joint commission includes: a. answering monitor alarms in a timely manner b. use side rails and alarms when needed to prevent falls c. obtain an accurate list of patients meds upon admission d, memorize and implement all joint commisson rules e. encourage patients to be actively involved in their own health care - a. answering monitor alarms in a timely manner b. use side rails and alarms when needed to prevent falls c. obtain an accurate list of patients meds upon admission Advantages of using informatics in helath care delivery are: a. reduced need for nurses in acute care b. increased patient anonymity and confidentiality c. ability to achieve and maintain high standards of care d. access to standard plans of care for many health problems e. improved comm of patients health status to health care team - c. ability to achieve and maintain high standards of care d. access to standard plans of care for many health problems e. improved comm of patients health status to health care team When using evidence-based practice, the nurse: A. Must use clinical practice guidelines developed by national health agencies B. Should use findings from randomized controlled trials to plan care for all patient problems C. Uses clinical decision making and judgment to determine what evidence is appropriate for a specific clinical situation D. Statistically analyzes the relationship of nursing interventions to patient outcomes to establish evidence for the most appropriate patient interventions - c. uses clinical decision making and judgement to determine what evidence is appropriate for a specific clinical situation. Which patient would the nurse determine is at highest risk for untreated hypertension? a.62-year-old Asian American female who is able to read b.74-year-old upper middle class female who is not married c.46-year-old African American male without health insurance d.58-year-old white male who has a high school education - c. 46-year-old African American male without health insurance Which intervention by a nurse would best help to reduce health care disparities? a. The nurse becomes fluent in the languages of the most common minority groups in the country. b. The nurse monitors differences in the prevalence of specific diseases in the population served. c. The nurse encourages individuals from minority populations to choose careers in the health professions. d. The nurse uses guidelines for the management of common diseases that are based on the patient's gender, age, and culture. - c. The nurse encourages individuals from minority populations to choose careers in the health professions. A patient who is newly diagnosed with cancer is scheduled to consult with an oncologist in several days. What would be the best coping strategy for the nurse to recommend at this time? a. Talk to family and friends about negative feelings. b .Go away for a few days to forget about the situation. c. Seek information about the cancer and treatment options. d. Wait to see what the oncologist recommends for treatment. - c. Seek information about the cancer and treatment options. The nurse plans to teach a patient how to use imagery to manage pain. Which statement by the nurse would be appropriate? a. "Place your pain in the image of a form you can destroy." b. "Tell me what you hear, smell, or feel in your special place." c. "Listen to music to divert your attention away from the pain." d. "Visualize the distress until you feel more calm and relaxed." - b. "Tell me what you hear, smell, or feel in your special place." The nurse teaches a patient about meditation. Which statement, if made by the patient, indicates an understanding of the instructions? a. "I can learn how to meditate in 20 minutes or less." b. "I need to be in a quiet room without distractions." c. "I will start out by meditating for about 20 minutes." d. "I should practice meditation three times each week." - a. "I can learn how to meditate in 20 minutes or less." An older adult patient in the hospital complains of sleep deprivation. Which intervention may improve sleep patterns for this patient? a. Decrease noise and dim the lights at bedtime. b. Administer an opioid pain medication to induce sleep. c. Set the room temperature at 78 degrees F to induce drowsiness. d. Offer to give the patient a back massage until he falls asleep. - a. Decrease noise and dim the lights at bedtime. A patient at the outpatient clinic is complaining of insomnia and anxiety. He tells you that he recently lost his job and is not able to pay the bills. Which response would be the most appropriate? a. "Can you tell me what is happening in your life?" b. "You are healthy and will be able to find another job." c. "If you stop focusing on your problems, you will sleep better." d. "Did you receive a severance package from your employer?" - a. "Can you tell me what is happening in your life?" A patient who has been treated with morphine by patient-controlled analgesia (PCA) is discharged from the hospital with instructions that all of the following medications may be used for pain. Which medication will the nurse instruct the patient to use first? a. Aspirin b. Ibuprofen c. Acetaminophen (Tylenol) d. Oxycodone/acetaminophen (Percocet) - d. Oxycodone/acetaminophen (Percocet) The nurse is caring for a patient after abdominal surgery. Which action by the nurse is most appropriate for analgesic titration of the prescribed pain medication? a. Limit use of pain medication to avoid dependence on opioid analgesics. b. Determine with the patient the analgesic dosage required for pain relief. c. Teach the patient to increase the time between doses of pain medication. d. Assist patient to plan the distribution of a specific total dose of analgesic over a 24-hour period. - Determine with the patient the analgesic dosage required for pain relief. The nurse teaches a student nurse about managing chronic pain when caring for older patients. Which statement, if made by the student nurse, indicates an understanding of the teaching? a. "Chronic pain is not an inevitable part of aging." b. "Older patients who are confused do not experience pain." c. "Older patients tolerate pain better than younger patients." d. "Opioids should not be used for chronic pain in the older patients." - a. "Chronic pain is not an inevitable part of aging." A nurse on a medical-surgical unit is caring for a group of clients. The nurse should notify the rapid response team for which of the following clients? A. client who has an ulcer on r heel and blood glucose is 300 mg/dL B. Client who reports right calf pain and shortness of breath C. Client who has blood on a pressure dressing in the femoral area following a cardiac cath D. Client who has dark red coloration of L toes and absent pedal pulse - B. Client who reports right calf pain and shortness of breath A nurse is caring for a client who displays signs of stage 3 parkinsons disease. which of the following actions should the nurse include in the plan of care? A. Recommend a community support group B. Integrate a daily exercise routine C. Provide a walker for ambulation D. Perfom ADLs for client - C. Provide a walker for ambulation A nurse is developing a plan of care for the nutritional needs of a client who has stage 4 Parkinson's. Which actions should the nurse include in the plan of care? a. Provide 3 large balanced meals a day b. Record diet and fluid intake c. Doc. weight every other week d. Place patient in folwers pos. to eat e. offer nutritional supplements b/w meals - b. Record diet and fluid intake e. offer nutritional supplements b/w meals A nurse is reinforcing teaching w a client who has parkinson's and has a new prescription for bromocriptmine. What should the nurse include in teaching? A. rise slow when standing b. expect dark colored urine c. avoid foods w tyramine d. report skin discoloration - A. rise slow when standing