NURS 3000 Exam 2 UPDATED ACTUAL Questions and CORRECT
Answers
Setting priorities establishing a preferential sequence for addressing nursing diagnoses and
interventions
- Physiologic needs (survival needs) Maslow's Hierarchy of Human Needs:
- Safety and security needs
- Love and belonging needs
- Self-esteem needs
- Self-actualization needs.
which need takes priority? physiologic needs such as air, food, and water are basic to life and receive higher
priority than the need for security or activity.
what is a goal or desired outcome in care planning describe, in terms of observable client responses, what the nurse hopes to
achieve by implementing the nursing interventions.
example of broad goal Improved nutritional status.
example of specific desired outcome Gain 5 lb by April 25.
Goals/desired outcomes purpose - Provide direction for planning nursing interventions
- Serve as criteria for evaluating client progress
- Enable the client and nurse to determine when the problem has been resolved
- Help motivate the client and nurse by providing a sense of achievement
goals need to be SMART (specific, measurable, attainable, realistic, timely)
Short-term goal Client will raise right arm to shoulder height by Friday
Long-term goal Client will regain full use of right arm in 6 weeks
short term goals useful for clients who require healthcare for a short time or are frustrated by long-term
goals that seem difficult to attain and who need the satisfaction of achieving a
short-term goal.
long term goals useful for guiding planning for their discharge to long-term agencies, home care, those who
live at home and have chronic health problems and for clients in nursing homes,
extended care facilities, and rehabilitation centers.
Independent interventions activities that nurses are licensed to initiate on the basis of their knowledge and
skills
planning and providing special mouth care for a client independent interventions example
after diagnosing alteration in mucous membrane integrity
, Dependent interventions activities carried out under the orders or supervision of a licensed physician or
other healthcare provider authorized to write orders to nurses
for a medical order of "Progressive ambulation, as Dependent interventions example
tolerated," a nurse might write the following:
Dangle for 5 min, 12 hours post op
example for a medical order of "Progressive ambulation, #1 Dangle for 5 min, 12 hours postop.
as tolerated," a nurse might write #2 Stand at bedside 24 hours postop; observe for pallor, dizziness, and weakness.
#3 Check pulse before and after ambulating. Do not progress if pulse is greater
than 110.
Implementation doing and documenting the activities that are the specific nursing actions needed
to carry out the interventions
The nurse performs or assigns the nursing activities for implementation example
the interventions that were developed in the planning
step and then concludes the implementing step by
recording nursing activities and the resulting client
responses.
what is delegation allowing a delegatee to perform a specific nursing activity, skill, or procedure that
is beyond the delegatee's traditional role and not routinely performed
- Right task Five Rights of Delegation
- Right circumstances
- Right person
- Right directions and communication
- Right supervision and evaluation
examples of tasks that can be delegated Taking of vital signs on stable clients, Basic hygiene techniques, Bedmaking, Client
transfers and ambulation, Personal care, Food service, Documentation,
Safety measures (including fire, safety, and disaster preparedness, and infection
control), Performing basic life support (cardiopulmonary resuscitation [CPR]),
Basic preventative and restorative care and procedures, Basic observation
procedures such as weighing and measuring, Postmortem care, Gastrostomy
feedings in established systems, Administering nonparenteral medications,
Administering injections
Performing simple dressing changes, Suctioning of chronic tracheostomies
examples of tasks that can not be delegated Assessment, Interpretation of data, Making a nursing diagnosis, Creation of a
nursing care plan, Evaluation of care effectiveness, Care of invasive lines,
Administering intravenous medications, Insertion of nasogastric tubes, Client
education, Performing triage, Giving telephone advice, Tasks requiring sterile
technique, and Obtaining orders from physicians
RN's ultimate responsibility for client care The nurse is accountable for any delegation of care and for evaluation of the care
that has been implemented and each nurse or other licensed or unlicensed
healthcare provider is responsible for his or her own actions. Anyone who feels
unqualified to perform an assigned or delegated task must decline to perform it.
Answers
Setting priorities establishing a preferential sequence for addressing nursing diagnoses and
interventions
- Physiologic needs (survival needs) Maslow's Hierarchy of Human Needs:
- Safety and security needs
- Love and belonging needs
- Self-esteem needs
- Self-actualization needs.
which need takes priority? physiologic needs such as air, food, and water are basic to life and receive higher
priority than the need for security or activity.
what is a goal or desired outcome in care planning describe, in terms of observable client responses, what the nurse hopes to
achieve by implementing the nursing interventions.
example of broad goal Improved nutritional status.
example of specific desired outcome Gain 5 lb by April 25.
Goals/desired outcomes purpose - Provide direction for planning nursing interventions
- Serve as criteria for evaluating client progress
- Enable the client and nurse to determine when the problem has been resolved
- Help motivate the client and nurse by providing a sense of achievement
goals need to be SMART (specific, measurable, attainable, realistic, timely)
Short-term goal Client will raise right arm to shoulder height by Friday
Long-term goal Client will regain full use of right arm in 6 weeks
short term goals useful for clients who require healthcare for a short time or are frustrated by long-term
goals that seem difficult to attain and who need the satisfaction of achieving a
short-term goal.
long term goals useful for guiding planning for their discharge to long-term agencies, home care, those who
live at home and have chronic health problems and for clients in nursing homes,
extended care facilities, and rehabilitation centers.
Independent interventions activities that nurses are licensed to initiate on the basis of their knowledge and
skills
planning and providing special mouth care for a client independent interventions example
after diagnosing alteration in mucous membrane integrity
, Dependent interventions activities carried out under the orders or supervision of a licensed physician or
other healthcare provider authorized to write orders to nurses
for a medical order of "Progressive ambulation, as Dependent interventions example
tolerated," a nurse might write the following:
Dangle for 5 min, 12 hours post op
example for a medical order of "Progressive ambulation, #1 Dangle for 5 min, 12 hours postop.
as tolerated," a nurse might write #2 Stand at bedside 24 hours postop; observe for pallor, dizziness, and weakness.
#3 Check pulse before and after ambulating. Do not progress if pulse is greater
than 110.
Implementation doing and documenting the activities that are the specific nursing actions needed
to carry out the interventions
The nurse performs or assigns the nursing activities for implementation example
the interventions that were developed in the planning
step and then concludes the implementing step by
recording nursing activities and the resulting client
responses.
what is delegation allowing a delegatee to perform a specific nursing activity, skill, or procedure that
is beyond the delegatee's traditional role and not routinely performed
- Right task Five Rights of Delegation
- Right circumstances
- Right person
- Right directions and communication
- Right supervision and evaluation
examples of tasks that can be delegated Taking of vital signs on stable clients, Basic hygiene techniques, Bedmaking, Client
transfers and ambulation, Personal care, Food service, Documentation,
Safety measures (including fire, safety, and disaster preparedness, and infection
control), Performing basic life support (cardiopulmonary resuscitation [CPR]),
Basic preventative and restorative care and procedures, Basic observation
procedures such as weighing and measuring, Postmortem care, Gastrostomy
feedings in established systems, Administering nonparenteral medications,
Administering injections
Performing simple dressing changes, Suctioning of chronic tracheostomies
examples of tasks that can not be delegated Assessment, Interpretation of data, Making a nursing diagnosis, Creation of a
nursing care plan, Evaluation of care effectiveness, Care of invasive lines,
Administering intravenous medications, Insertion of nasogastric tubes, Client
education, Performing triage, Giving telephone advice, Tasks requiring sterile
technique, and Obtaining orders from physicians
RN's ultimate responsibility for client care The nurse is accountable for any delegation of care and for evaluation of the care
that has been implemented and each nurse or other licensed or unlicensed
healthcare provider is responsible for his or her own actions. Anyone who feels
unqualified to perform an assigned or delegated task must decline to perform it.
