FUNDAMENTALS NR226 REVIEW - WEEKS 1 AND 2 QUESTIONS
WITH COMPLETE SOLUTION
Formulating nursing diagnosis
-PES
-consists of a problem (health issue) RELATED TO a cause (etiology) as evidenced by
(signs/sympoms)
i.e :ineffective breathing pattern related to pain in the chest when breathing after surgery
Components of goals
Subject: patient, characteristic of pt
Action/Verb: one per goal
Performance criteria: standards to evaluate quality of performance
Target Time: how what when deadline
Special Conditions: modifiers only if needed to clarify
i.e: Client will ambulate unassisted with crutches by discharge
A nurse on a medical-surgical unit has received change-of-shift report and will
care for four clients. Which of the following tasks should the nurse delegate to an
assistive personnel (AP)?
A.Updating the plan of care for a client who is postoperative
B.Reinforcing teaching with a client who is learning to walk using quad cane
C.Reapplying a condom catheter for a client who has urinary incontinence
D.Applying sterile dressing to a pressure injury
C. reapplying a condom catheter for a client with urinary incontinence - non-invasive
and safe, and has nothing to do with assessment, patient education, or evaluation which
are all RN jobs
A nurse is preparing an in-service program about delegation. Which of the
following are components of the five rights of delegation? (Select all that apply.)
a. Right task.
b. Right circumstance.
c. Right person.
d. Right supervision.
e. Right direction and communication
A nurse receives a prescription for an antibiotic for a client who has cellulitis. The
nurse checks the client's medical record, discovers that the client is allergic to
the antibiotic, and calls the provider to request a prescription for a different
antibiotic. Which of the following critical thinking attitudes did the nurse
demonstrate?
Responsibility
A charge nurse is talking with a newly licensed nurse and is reviewing nursing
interventions that does not require a provider's prescription. Which of the
following interventions should the charge nurse include? (Select all that apply.)
A.Writing a prescription for morphine sulfate as needed for pain
, B.Inserting a nasogastric tube to relieve gastric distention
C.Showing the client how to use progressive muscle relaxation
D.Performing daily bath after the evening meal E.Repositioning the client every 2
hours to reduce pressure injury risk
C. Showing a client how to use progressive muscle relaxation
D. Performing a daily bath after the evening meal
E. Repositioning client every 2hr to reduce pressure ulcer risk
An RN is making assignments for client care to a licensed practical nurse (LPN)
at the beginning of the shift. Which of the following assignments should the LPN
question?
A. Assisting a client who is 24 hr postoperative to use an incentive spirometer
B. Collecting a clean-catch urine specimen from a client who was admitted on the
previous shift
C. Providing nasopharyngeal suctioning for a client who has pneumonia
D. Replacing the cartridge and tubing on a patient-controlled analgesia (PCA)
pump
D. CORRECT: The RN is responsible for maintaining the PCA pump.
A nurse manager of a medical-surgical unit is assigning care responsibilities for
the oncoming shift. A client is awaiting transfer back to the unit from the PACU
following thoracic surgery. To which staffnmember should the nurse assign to
this client?
A. Charge nurse
B. RN
C. Licensed practical nurse (LPN)
D. Assistive personnel (AP)
B. CORRECT: A client returning from surgery requires assessment and establishment
of a plan of care.RNs are responsible for assessment (especially when a client is
potentially unstable),
list at least five tasks the delegating nurse must perform when supervising and
evaluating a delegatee.
Provide supervision, either directly or indirectly.
Provide clear directions and understandable expectations of the task(s) to perform (time
frames, what to report).
Monitor performance.
Provide feedback.
Intervene if necessary (unsafe clinical practice).
◯ Evaluate the client, and determine client outcomes status.
◯ Evaluate client care tasks, and identify needs for performance improvement
activities and additional resources.
How do we measure pain for adults, children, clients who can't verbalize?
Wong-baker FACES pain rating scale
WITH COMPLETE SOLUTION
Formulating nursing diagnosis
-PES
-consists of a problem (health issue) RELATED TO a cause (etiology) as evidenced by
(signs/sympoms)
i.e :ineffective breathing pattern related to pain in the chest when breathing after surgery
Components of goals
Subject: patient, characteristic of pt
Action/Verb: one per goal
Performance criteria: standards to evaluate quality of performance
Target Time: how what when deadline
Special Conditions: modifiers only if needed to clarify
i.e: Client will ambulate unassisted with crutches by discharge
A nurse on a medical-surgical unit has received change-of-shift report and will
care for four clients. Which of the following tasks should the nurse delegate to an
assistive personnel (AP)?
A.Updating the plan of care for a client who is postoperative
B.Reinforcing teaching with a client who is learning to walk using quad cane
C.Reapplying a condom catheter for a client who has urinary incontinence
D.Applying sterile dressing to a pressure injury
C. reapplying a condom catheter for a client with urinary incontinence - non-invasive
and safe, and has nothing to do with assessment, patient education, or evaluation which
are all RN jobs
A nurse is preparing an in-service program about delegation. Which of the
following are components of the five rights of delegation? (Select all that apply.)
a. Right task.
b. Right circumstance.
c. Right person.
d. Right supervision.
e. Right direction and communication
A nurse receives a prescription for an antibiotic for a client who has cellulitis. The
nurse checks the client's medical record, discovers that the client is allergic to
the antibiotic, and calls the provider to request a prescription for a different
antibiotic. Which of the following critical thinking attitudes did the nurse
demonstrate?
Responsibility
A charge nurse is talking with a newly licensed nurse and is reviewing nursing
interventions that does not require a provider's prescription. Which of the
following interventions should the charge nurse include? (Select all that apply.)
A.Writing a prescription for morphine sulfate as needed for pain
, B.Inserting a nasogastric tube to relieve gastric distention
C.Showing the client how to use progressive muscle relaxation
D.Performing daily bath after the evening meal E.Repositioning the client every 2
hours to reduce pressure injury risk
C. Showing a client how to use progressive muscle relaxation
D. Performing a daily bath after the evening meal
E. Repositioning client every 2hr to reduce pressure ulcer risk
An RN is making assignments for client care to a licensed practical nurse (LPN)
at the beginning of the shift. Which of the following assignments should the LPN
question?
A. Assisting a client who is 24 hr postoperative to use an incentive spirometer
B. Collecting a clean-catch urine specimen from a client who was admitted on the
previous shift
C. Providing nasopharyngeal suctioning for a client who has pneumonia
D. Replacing the cartridge and tubing on a patient-controlled analgesia (PCA)
pump
D. CORRECT: The RN is responsible for maintaining the PCA pump.
A nurse manager of a medical-surgical unit is assigning care responsibilities for
the oncoming shift. A client is awaiting transfer back to the unit from the PACU
following thoracic surgery. To which staffnmember should the nurse assign to
this client?
A. Charge nurse
B. RN
C. Licensed practical nurse (LPN)
D. Assistive personnel (AP)
B. CORRECT: A client returning from surgery requires assessment and establishment
of a plan of care.RNs are responsible for assessment (especially when a client is
potentially unstable),
list at least five tasks the delegating nurse must perform when supervising and
evaluating a delegatee.
Provide supervision, either directly or indirectly.
Provide clear directions and understandable expectations of the task(s) to perform (time
frames, what to report).
Monitor performance.
Provide feedback.
Intervene if necessary (unsafe clinical practice).
◯ Evaluate the client, and determine client outcomes status.
◯ Evaluate client care tasks, and identify needs for performance improvement
activities and additional resources.
How do we measure pain for adults, children, clients who can't verbalize?
Wong-baker FACES pain rating scale
