NUR 104 Exam 4

1.25 points possible (graded, results hidden) 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 You have used 1 of 1 attempt Some problems have options such as save, reset, hints, or show answer. These options follow the Submit button. Answer submitted. NUR104_M4EQ0250 1.25 points possible (graded, results hidden) 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. You have used 1 of 1 attempt Some problems have options such as save, reset, hints, or show answer. These options follow the Submit button. Answer submitted. NUR104_M4EQ0176 1.25 points possible (graded, results hidden) 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 You have used 1 of 1 attempt Some problems have options such as save, reset, hints, or show answer. These options follow the Submit button. Answer submitted. NUR104_M4EQ0251 1.25 points possible (graded, results hidden) 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. You have used 1 of 1 attempt Some problems have options such as save, reset, hints, or show answer. These options follow the Submit button. Answer submitted. NUR104_M4EQ0252 1.25 points possible (graded, results hidden) 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 You have used 1 of 1 attempt Some problems have options such as save, reset, hints, or show answer. These options follow the Submit button. Answer submitted. NUR104_M4EQ0179 1.25 points possible (graded, results hidden) 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.” submitted You have used 1 of 1 attempt Some problems have options such as save, reset, hints, or show answer. These options follow the Submit button. Answer submitted. NUR104_M4EQ0180 1.25 points possible (graded, results hidden) 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.” You have used 1 of 1 attempt Some problems have options such as save, reset, hints, or show answer. These options follow the Submit button. Answer submitted. NUR104_M4EQ0181 1.25 points possible (graded, results hidden) 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.” You have used 1 of 1 attempt Some problems have options such as save, reset, hints, or show answer. These options follow the Submit button. Answer submitted. NUR104_M4EQ0182 1.25 points possible (graded, results hidden) 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 You have used 1 of 1 attempt Some problems have options such as save, reset, hints, or show answer. These options follow the Submit button. Answer submitted. NUR104_M4EQ0183 1.25 points possible (graded, results hidden) 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. You have used 1 of 1 attempt Some problems have options such as save, reset, hints, or show answer. These options follow the Submit button. Answer submitted. NUR104_M4EQ0253 1.25 points possible (graded, results hidden) 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. Request a high fiber diet from nutrition services. You have used 1 of 1 attempt Some problems have options such as save, reset, hints, or show answer. These options follow the Submit button. Answer submitted. NUR104_M4EQ0185 1.25 points possible (graded, results hidden) According to the American Nurses Association Scope and standards of practice, the RN provides safe, realistic care in a timely manner falls under which stage of the nursing process? Implementation Evaluation Assessment Diagnosis submitted You have used 1 of 1 attempt Some problems have options such as save, reset, hints, or show answer. These options follow the Submit button. Answer submitted. NUR104_M4EQ0186 1.25 points possible (graded, results hidden) Which actions by the unlicensed assistive personnel (UAP) when obtaining a blood pressure on a patient with a low BMI one day following a left mastectomy demonstrate appropriate delegation by the RN? Select all that apply. The UAP selected the appropriate cuff size. Recorded and reported the blood pressure to the RN within one hour. The blood pressure cuff was placed on the patient’s left arm. Noted patient’s position and extremity when the blood pressure was taken. Placed the cuff snugly over the patient’s gown. submitted You have used 1 of 1 attempt Some problems have options such as save, reset, hints, or show answer. These options follow the Submit button. Answer submitted. NUR104_M4EQ0187 1.25 points possible (graded, results hidden) Which statement by the RN best enhances and solicits interprofessional collaboration and communication? “That was a good idea but the doctor ordered it this way.” “I value your input however I don’t think that’s going to work.” “I value your opinion and would appreciate your input.” submitted “I appreciate your opinion, but I feel my idea is the best approach here.” You have used 1 of 1 attempt Some problems have options such as save, reset, hints, or show answer. These options follow the Submit button. Answer submitted. NUR104_M4EQ0188 1.25 points possible (graded, results hidden) How does the electronic health record (EHR) facilitate evidence-based nursing practice? It ensures clinical practice guidelines are implemented. Patient information can be integrated between multiple departments. submitted Aggregated patient data can be used to support nursing decisions. Nurses spend less time documenting allowing for more patient contact. You have used 1 of 1 attempt Some problems have options such as save, reset, hints, or show answer. These options follow the Submit button. Answer submitted. NUR104_M4EQ0189 1.25 points possible (graded, results hidden) According to guidelines for documenting in the electronic health record (EHR), what is the RN’s action when a documentation mistake is made? Report it to the nurse manager and record the data. Delete the entry and note time it was done. Strike through the entry once and rewrite the correct data. submitted Address the mistake and enter the corrected new information. You have used 1 of 1 attempt Some problems have options such as save, reset, hints, or show answer. These options follow the Submit button. Answer submitted. NUR104_M4EQ0254 1.25 points possible (graded, results hidden) The RN applies the NANDA-I nursing diagnosis Ineffective airway clearance and encourages the patient to cough and deep breathe after surgery. Which evaluative statement reflects the ANA Standards of Practice for Evaluation competency of documenting the results of the evaluation? The patient expectorated a large amount of yellow sputum after the interventions. The patient was able to take deep breaths after the interventions. The patient was able to cough and deep breathe three times. The patient coughed effectively after the interventions. submitted You have used 1 of 1 attempt Some problems have options such as save, reset, hints, or show answer. These options follow the Submit button. Answer submitted. NUR104_M4EQ0191 1.25 points possible (graded, results hidden) According to the ANA Standards of Nursing Practice, the RN elicits the patient’s values, preferences, and expressed needs during which phase of the nursing process? Assessment submitted Outcome Implementation Evaluation You have used 1 of 1 attempt Some problems have options such as save, reset, hints, or show answer. These options follow the Submit button. Answer submitted. NUR104_M4EQ0192 1.25 points possible (graded, results hidden) The RN assesses a patient’s radial pulse and notes it is difficult to palpate and then disappears when slight pressure is applied. Using the number scale associated with pulse quality, what number should be assigned to this finding? 0 2 3 1 submitted You have used 1 of 1 attempt Some problems have options such as save, reset, hints, or show answer. These options follow the Submit button. Answer submitted. NUR104_M4EQ0255 1.25 points possible (graded, results hidden) The RN recognizes that which event creates the potential for a breach in patient confidentiality? Giving the end of shift report in the nursing conference room. Discussing a patient condition with the charge nurse in the manager’s office. Calling the patient’s health care proxy in an emergency. Storing passwords in locked supply cabinet. submitted You have used 1 of 1 attempt Some problems have options such as save, reset, hints, or show answer. These options follow the Submit button. Answer submitted. NUR104_M4EQ0194 1.25 points possible (graded, results hidden) Which technique is used when the RN strikes the middle finger of the hand resting on the patient’s abdomen with the middle finger of the dominant hand to create a sound? Effleurage Percussion submitted Vibration Palpation You have used 1 of 1 attempt Some problems have options such as save, reset, hints, or show answer. These options follow the Submit button. Answer submitted. NUR104_M4EQ0195 1.25 points possible (graded, results hidden) The RN assigned the unlicensed assistive personnel (UAP) to obtain a patient’s vital signs. The UAP reports the blood pressure is 200/100 mm Hg. Which intervention is a priority for the RN? Assign an RN to assess the blood pressure. Assess the patient and re-check the blood pressure. submitted Instruct the UAP to repeat the blood pressure. Administer anti-hypertensive medication as prescribed. You have used 1 of 1 attempt Some problems have options such as save, reset, hints, or show answer. These options follow the Submit button. Answer submitted. NUR104_M4EQ0256 1.25 points possible (graded, results hidden) The student nurse asks the RN to explain the difference between a comprehensive physical assessment and a focused physical assessment. Which is the appropriate response by the RN? “A focused physical assessment is limited to an overall patient problem.” “A focused physical assessment requires an order from a health care provider.” “A comprehensive physical assessment includes a health history and a complete head-totoe.” submitted “A comprehensive physical assessment is completed, at every interaction with the patient.” You have used 1 of 1 attempt Some problems have options such as save, reset, hints, or show answer. These options follow the Submit button. Answer submitted. NUR104_M4EQ0257 1.25 points possible (graded, results hidden) Which information included in the RN’s documentation for a patient who is unhappy with care demonstrates the RN requires additional teaching? “Patient complained of generalized pain and discomfort while awake.” “Call placed at 1000 to health care provider, to clarify pain medication frequency.” “Patient used incentive device with 10 repetitions, productive cough with yellow tinged sputum.” “Patient refused oral pain medication, stated intravenous medications work better.” submitted You have used 1 of 1 attempt Some problems have options such as save, reset, hints, or show answer. These options follow the Submit button. Answer submitted. NUR104_M4EQ0198 1.25 points possible (graded, results hidden) What is the purpose of nursing informatics? Use data to support decision-making. submitted Decrease the need for multiple face to face meetings. Reduce the likelihood of patient privacy issues. Enhance the non-verbal communication method. You have used 1 of 1 attempt Some problems have options such as save, reset, hints, or show answer. These options follow the Submit button. Answer submitted. NUR104_M4EQ0258 1.25 points possible (graded, results hidden) What method does the RN use to recognize significant cues when analyzing patient data to identify health problems? Compare patient data to population norms. Seek out data that supports the health problem. submitted Focus on a specific body system.