Med Surg #1 Exam 1

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) - correct answer 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." - correct answer 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 - correct answer 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 - correct answer 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 - correct answer 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" - correct answer 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 - correct answer 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 - correct answer 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 - correct answer 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 - correct answer 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 - correct answer 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 - correct answer 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 - correct answer 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 - correct answer 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 - correct answer 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 - correct answer 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. - correct answer 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. - correct answer c. Seek information about the cancer and treatment options.