Answers
Which action would the nurse undertake first when beginning to formulate a patient's plan of
care
a- list possible treatment options
b-identify realistic outcome indicators
c- consult with healthcare team members
d- rank patient concerns from assessment data - ANS d
which resource is most helpful when prioritizing identified nursing diagnoses
a- nursing interventions classification
b- gordon's functional health patterns
c- maslow's hierarchy of needs
d- nursing outcomes classification - ANS c
if a patient is exhibiting signs and symptoms of each of these nursing diagnoses, which should
the nurse address first while planning care?
a- fatigue
b- acute pain
c- lack of knowledge
d- disturbed body image - ANS b
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,which statement illustrates a characteristic of goals within the care planning process?
a- goals are vague objectives communicating expectations for improvement
b- short-term goals need not be measurable, unlike long term goals
c- goal attainment can be measured by identifying nursing interventions
d- long term goals are helpful in judging a patient's progress - ANS d
which nursing goal is written correctly for a patient with the nursing diagnosis for risk for
infection after abdominal surgery?
a- nurse will encourage use of sterile technique during each dressing change
b- patient's WBC will remain within normal range throughout hospitalization
c- patient's visitors will be instructed in proper handwashing before direct interaction with
patient
d- patient will understand the importance of cleaning around the incision with a clean cloth
during bath time - ANS b
If the nurse chooses the Nursing Outcome Classification (NOC), Appetite (1014) for a
chemotherapy patient, which outcome indicators would be acceptable for evaluation of goal
attainment? (Select all that apply.)
a. Expressed desire to eat
b. Report that food smells good
c. Use of relaxation techniques before meals
d. Preparation of home-cooked meals for self and family
e. Uses nutritional information on labels to guide selections - ANS a, b, d
which action by the nurse would be most important in developing a patient-centered plan of
care for an alert, oriented adult
a- providing a written copy of care options to the patient and family
b- collaborrating with the patient's social worker to determine resources
c- listening to patient's concerns and beliefs about proposed treatment
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, d- engaging the patient's family, friends or care providers in conversation - ANS c
which interventions can the nurse initiate independently while providing patient care?
a- ordering blood transfusion
b- auscultating lung sounds
c- monitoring skin integrity
d- apply heel protectors
e- adjusting antibiotic dosages - ANS b,c,d
the nurse notices that a patient is becoming short of breath and anxious. which intervention is
dependent nursing action, requiring the order of a PCP?
a- elevating the head of the patient's bed
b- administering oxygen by nasal cannula
c- assessing the patient's O2 saturation
d- elevating the patient's peripheral circulation - ANS b
which situation indicates the greatest need for collaborative interventions provided by several
health care team members?
a- hospice referral
b- physical assessment
c- activities of daily living
d- health history interview - ANS a
what should the nurse consider before implementation of all nursing interventions
a- potential communication barriers
b- diverse cultural practices
c- scope of nursing practice
d- functional status of patient
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