NUR 225 Exam 2 with verified detailed solutions ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\||
Ms. Kelley is a 47-year-old female admitted to the post-surgical unit following removal of
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her gallbladder. She has a history of hyperlipidemia (elevated serum lipids), depression, and
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asthma (lung disease that causes bronchoconstriction, coughing, and thick bronchial
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secretions). Ms. Kelley's vital signs are T 37.9° C (100.2° F), P 112 and regular, R 24 shallow ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\||
and labored, BP 142/88, and continuous pulse oximetry reading of 89% on 2 liters of oxygen
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via nasal cannula. The patient denies pain but states that her chest feels "heavy." Lung
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auscultation reveals adventitious breath sounds (expiratory wheezes) with diminished ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\||
sounds bilaterally at the lung bases. The patient appears restless and slightly diaphoretic.
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She asks you, "Why does the machine keep beeping?" Her abdomen is flat but tender from
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the surgical puncture sites. Her dressings are clean, dry, and intact. ;
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The nurse writes "Ineffective airway clearance" as the beginning of a nursing diagnosis.
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Based on Ms. Kelley's data, what should be written in the "related to" to portion of the
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statement? - ✔✔Bronchoconstriction ||//\\|| ||//\\||
Increased production of mucus ||//\\|| ||//\\|| ||//\\||
The nurse is admitting Ms. Kelley. How should the nurse prioritize Ms. Kelley's nursing
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diagnoses? Begin with the highest priority diagnosis first. - ✔✔Ineffective airway clearance ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\||
Impaired gas exchange ||//\\|| ||//\\||
Ineffective peripheral tissue perfusion ||//\\|| ||//\\|| ||//\\||
Acute pain ||//\\||
Activity intolerance ||//\\||
Anxiety
Match each patient evidence with the corresponding nursing diagnosis. - ✔✔Low oxygen
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saturation and arterial oxygen levels ||//\\|| ||//\\|| ||//\\|| ||//\\||
, Ineffective peripheral tissue perfusion ||//\\|| ||//\\|| ||//\\||
Complaints of fatigue, dropping oxygen saturation with walking ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\||
Activity intolerance ||//\\||
Irritability, verbalization of nervousness ||//\\|| ||//\\|| ||//\\||
Anxiety ||//\\||
Complaints of difficulty breathing, purse-lip breathing ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\||
Ineffective breathing pattern ||//\\|| ||//\\||
When developing nursing diagnoses for a patient with oxygenation and perfusion problems,
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selection and individualization of nursing diagnoses is dependent on what nursing activity?
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- ✔✔Appropriate data clustering
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Accurate and thorough data collection ||//\\|| ||//\\|| ||//\\|| ||//\\||
A new nurse who is being oriented to the unit is establishing patient-centered goals for Ms.
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Kelley. The nurse documents "The patient will ambulate." What goal writing criteria is it
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missing? - ✔✔The goal should be time-limited. ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\||
What resources are used to develop individualized patient-centered goals? - ✔✔Nursing
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diagnoses
Assessment data ||//\\||
Ms. Kelley is a 47-year-old female admitted to the post-surgical unit following removal of
||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\||
her gallbladder. She has a history of hyperlipidemia (elevated serum lipids), depression, and
||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\||
asthma (lung disease that causes bronchoconstriction, coughing, and thick bronchial
||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\||
secretions). Ms. Kelley's vital signs are T 37.9° C (100.2° F), P 112 and regular, R 24 shallow ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\||
and labored, BP 142/88, and continuous pulse oximetry reading of 89% on 2 liters of oxygen
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via nasal cannula. The patient denies pain but states that her chest feels "heavy." Lung
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auscultation reveals adventitious breath sounds (expiratory wheezes) with diminished ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\||
sounds bilaterally at the lung bases. The patient appears restless and slightly diaphoretic.
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She asks you, "Why does the machine keep beeping?" Her abdomen is flat but tender from
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the surgical puncture sites. Her dressings are clean, dry, and intact. ;
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The nurse writes "Ineffective airway clearance" as the beginning of a nursing diagnosis.
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Based on Ms. Kelley's data, what should be written in the "related to" to portion of the
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statement? - ✔✔Bronchoconstriction ||//\\|| ||//\\||
Increased production of mucus ||//\\|| ||//\\|| ||//\\||
The nurse is admitting Ms. Kelley. How should the nurse prioritize Ms. Kelley's nursing
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diagnoses? Begin with the highest priority diagnosis first. - ✔✔Ineffective airway clearance ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\||
Impaired gas exchange ||//\\|| ||//\\||
Ineffective peripheral tissue perfusion ||//\\|| ||//\\|| ||//\\||
Acute pain ||//\\||
Activity intolerance ||//\\||
Anxiety
Match each patient evidence with the corresponding nursing diagnosis. - ✔✔Low oxygen
||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\||
saturation and arterial oxygen levels ||//\\|| ||//\\|| ||//\\|| ||//\\||
, Ineffective peripheral tissue perfusion ||//\\|| ||//\\|| ||//\\||
Complaints of fatigue, dropping oxygen saturation with walking ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\||
Activity intolerance ||//\\||
Irritability, verbalization of nervousness ||//\\|| ||//\\|| ||//\\||
Anxiety ||//\\||
Complaints of difficulty breathing, purse-lip breathing ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\||
Ineffective breathing pattern ||//\\|| ||//\\||
When developing nursing diagnoses for a patient with oxygenation and perfusion problems,
||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\||
selection and individualization of nursing diagnoses is dependent on what nursing activity?
||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\||
- ✔✔Appropriate data clustering
||//\\|| ||//\\|| ||//\\|| ||//\\||
Accurate and thorough data collection ||//\\|| ||//\\|| ||//\\|| ||//\\||
A new nurse who is being oriented to the unit is establishing patient-centered goals for Ms.
||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\||
Kelley. The nurse documents "The patient will ambulate." What goal writing criteria is it
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missing? - ✔✔The goal should be time-limited. ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\|| ||//\\||
What resources are used to develop individualized patient-centered goals? - ✔✔Nursing
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diagnoses
Assessment data ||//\\||
