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1. A nurse is focusing on acute and chronic care of individuals and families
within a community while enhancing patient autonomy. Which type of nursing
care is the nurse providing?: Community- based
2. The nurse is reviewing a patient's database for significant changes and dis-
covers that the patient has not voided in over 8 hours. The patient's kidney
function lab results are abnormal, and the patient's oral intake has significantly
decreased since previous shifts. Which step of the nursing process should the
nurse proceed to after this review?: diagnosis.
After a thorough assessment, the nurse should proceed to analyzing the data and formulating a nursing diagnosis
before proceeding with developing the plan of care and determining appropriate interventions. The evaluation phase
involves determining whether the interventions were effective.
3. A nurse is conducting a nursing health history. Which component will the
nurse address?: PT expectations
4. Two nurses are having a discussion at the nurses' station. One nurse is a
new graduate who added, "Patient needs improved bowel function related to
constipation" to a patient's care plan. The nurse's colleague, the charge nurse
says, "I think your diagnosis is possibly worded incorrectly. Let's go over it
together." A correctly worded diagnostic statement is:: Constipation related to inadequate
fluid intake
5. A patient has a diagnosis of pneumonia. Which entry should the nurse chart
to help with financial reimbursement?: Used incentive spirometer to encourage coughing and deep
breathing. Lung congested upon auscultation in lower lobes bilaterally. Pulse ox 86%. Oxygen per nasal cannula applied
at 2 L/min per standing order.
6. A nurse adds the following diagnosis to a patient's care plan: Constipation
related to decreased gastrointestinal motility secondary to pain medication
administration as evidenced by the patient reporting no bowel movement in
seven days, abdominal distention, and abdominal pain. Which element did the
nurse write as the defining characteristic?: Abdominal distention
Abdominal distention, no reported bowel movement, and abdominal pain are the defining characteristics. Decreased
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