When does the nurse initiate discharge planning for a patient admitted with tonsillitis? - ANSWER:Upon
admission
What happens when the nurse formulates an early and structured discharge plan for a patient? -
ANSWER:The patient has a smooth transition to the home
A nurse is teaching a group of nursing students about priority setting. Which statement by the nursing
students is true about intermediate priority? - ANSWER:Intermediate priority needs to include impaired
physical mobility-intermediate priority involves non-emergent, non-life-threatening needs of the patient.
What are the characteristics of a well-written goals and expected outcomes? - ANSWER:observable,
time-limited, and patient-centered
The nurse is caring for a bleeding patient admitted to the health care facility following a motor vehicle
accident. Which interventions by the nurse are independent interventions? - ANSWER:assess and note
vital signs, auscultate for lung sounds, assess airway for obstructions
A patient, who is scheduled for a cholecystectomy, has expressed some concern about the procedure.
What actions should the nurse perform to reduce anxiety in the patient? - ANSWER:control the patient's
pain, use a calm approach in discussions, and work with the physician to provide factual medical
information
the nurse prepares for health care provider initiated and collaborative interventions. What should the
nurse do before implementing the interventions? - ANSWER:clarify orders, determine whether the
intervention is appropriate for the patient, and determine if collaboration of other care disciplines is
required
During the planning phase, the nurse works with the patient, family, and other caregivers to design
activities to assist the patient in achieving set goals. What is the term used to define these activities? -
ANSWER:Nursing interventions
Which interventions can be classified as independent interventions? - ANSWER:Elevating an edematous
extremity, repositioning the patient to achieve pain relief, and instructing a patient about the effects of
medications
A patient has been in the hospital for 2 days because of newly diagnosed diabetes. His medical condition
is unstable, and the medical staff is having difficulty controlling his blood sugar. The physician expects
that the the patient will remain hospitalized at least 3 more days. The nurse identifies one nursing
diagnosis as deficient knowledge regarding insulin administration related to inexperience with disease
management. What does the nurse need to determine before setting the goal of "patient will self-
administer insulin?" - ANSWER:goal within reach of patient, patient's cognitive function, availability of
family members to assist
, Which actions of the nurse contributes to the effective application of the nursing process while providing
patient-centered care? - ANSWER:recognizing the existence of a problem, acquiring and improving
assessment skills, and applying critical-thinking skills during care
Which statement made by the nurse is an example of applying the principle of patient-centered care
while focusing on alleviation of a patient's fear and anxiety? - ANSWER:"Let's talk about the concerns
that you have about going home."
What are the important factors to be considered when choosing nursing interventions? - ANSWER:Goals
and expected outcomes, feasibility of the interventions, characteristics of the nursing diagnosis, and
presence of an evidence base for the interventions
A patient is being discharged from the hospital following a surgical procedure. What is the role of the
nurse in discharge planning? - ANSWER:develop a plan for further care, ensure a smooth transition from
the hospital to another healthcare level, and anticipate and ID patient needs
The nurse is caring for a preoperative patient in a coronary care unit. After reviewing the nursing
diagnoses, the nurse prioritizes the nursing diagnoses. Which nursing diagnoses are considered to be
high priorities for the patient? - ANSWER:impaired gas exchange and decreased cardiac output
The nurse is developing a discharge plan for a patient. What should the nurse include in the discharge
plan? - ANSWER:necessary rehab techniques, counseling regarding nutrition and diet, and correct and
effective use of medications.
A patient signals the nurse by turning on the call light. The nurse enters the room and finds the patient's
drainage tube disconnected, 100 mL of fluid in the intravenous (IV) line, and the patient asking to be
turned. Which of the following does the nurse perform first?
A) Reconnect the drainage tubing
B) Inspect the condition of the IV dressing
C) Improve the patient's comfort and turn onto her side.
D) Obtain the next IV fluid bag from the medication room - ANSWER:a. Reconnect the drainage tubing.
Prevents fluid loss and reduces risk of infection spreading up the tube. Next the nurse turns patient for
comfort, and then the nurse can inspect the IV dressing last, after going to obtain the next IV fluid bag.
A nurse identifies several interventions to resolve patient's nursing diagnosis of impaired skin integrity.
Which of the following are written in error?
a. Apply a pressure-relief device to bed.
b. Turn the patient regularly from side to back to side.
c. Apply transparent dressing to sacral pressure ulcer.
d. Irrigate wound with 100mL normal saline until clear: 6am-2pm-8pm