NUR3632 FOUNDATIONS EXAM 2
STUDY- COMPLETE QUESTIONS WITH
CORRECT ANSWERS
A nurse is irrigating the colostomy of a patient and is unable to get the
irrigation solution to flow. What would be the nurse's next action in this
situation?
Assist the patient to a prone position on a waterproof pad and try again.
Check the clamp on the tubing to make sure that the tubing is open.
Quickly pull the cone from the stoma and check for bleeding.
Remove the equipment and call the primary care provider. -
CORRECT ANSWER- b. If irrigation solution is not flowing, the nurse
should first check the clamp on the tubing to make sure the tubing is
open. Next, the nurse should gently manipulate the cone in the stoma
and check for a blockage of stool. If there is a blockage, the nurse
should remove the cone from the stoma, clean the area, and gently
reinsert. Alternately, the nurse could assist the patient to a side-lying or
sitting position in bed, place a waterproof pad under the irrigation sleeve,
and place the drainage end of the sleeve in a bedpan.
A nurse is planning care for a male adolescent patient who is admitted to
the hospital for treatment of a drug overdose. Which nursing actions are
related to the outcome identification and planning step of the nursing
process? Select all that apply.
The nurse formulates nursing diagnoses.
The nurse identifies expected patient outcomes.
The nurse selects evidence-based nursing interventions.
The nurse explains the nursing care plan to the patient.
The nurse assesses the patient's mental status.
The nurse evaluates the patient's outcome achievement. - CORRECT
ANSWER- b, c, d. During the outcome identification and planning step
of the nursing process, the nurse works in partnership with the patient
,and family to establish priorities, identify and write expected patient
outcomes, select evidence-based nursing interventions, and
communicate the plan of nursing care. Although all these steps may
overlap, formulating and validating nursing diagnoses occurs most
frequently during the diagnosing step of the nursing process. Assessing
mental status is part of the assessment step, and evaluating patient
outcomes occurs during the evaluation step of the nursing process.
A nurse on a busy surgical unit relies on informal planning to provide
appropriate nursing responses to patients in a timely manner. What are
examples of this type of planning? Select all that apply.
A nurse sits down with a patient and prioritizes existing diagnoses.
A nurse assesses a woman for postpartum depression during routine
care.
A nurse plans interventions for a patient who is diagnosed with epilepsy.
A busy nurse takes time to speak to a patient who received bad news.
A nurse reassesses a patient whose PRN pain medication is not
working.
A nurse coordinates the home care of a patient being discharged. -
CORRECT ANSWER- b, d, e. Informal planning is a link between
identifying a patient's strength or problem and providing an appropriate
nursing response. This occurs, for example, when a busy nurse first
recognizes postpartum depression in a patient, takes time to assess a
patient who received bad news about tests, or reassesses a patient for
pain. Formal planning involves prioritizing diagnoses, formally planning
interventions, and coordinating the home care of a patient being
discharged.
3. When helping a patient turn in bed, the nurse notices that his heels
are reddened and plans to place him on precautions for skin breakdown.
This is an example of what type of planning?
Initial planning
Standardized planning
Ongoing planning
Discharge planning - CORRECT ANSWER- c. Ongoing planning is
problem oriented and has as its purpose keeping the plan up to date as
new actual or potential problems are identified. Initial planning
addresses each problem listed in the prioritized nursing diagnoses and
,identifies appropriate patient goals and the related nursing care.
Standardized care plans are prepared plans of care that identify the
nursing diagnoses, outcomes, and related nursing interventions common
to a specific population or health problem. During discharge planning,
the nurse uses teaching and counseling skills effectively to help the
patient and family develop sufficient knowledge of the health problem
and the therapeutic regimen to carry out necessary self-care behaviors
competently at home.
. A nurse is prioritizing the following patient diagnoses according to
Maslow's hierarchy of human needs:
(1) Disturbed Body Image
(2) Ineffective Airway Clearance
(3) Spiritual Distress
(4) Impaired Social Interaction
Which answer choice below lists the problems in order of highest priority
to lowest priority based on Maslow's model?
2, 4, 1, 3
3, 1, 4, 2
2, 4, 3, 1
3, 2, 4, 1 - CORRECT ANSWER- a. 2, 4, 1, 3. Because basic needs
must be met before a person can focus on higher ones, patient needs
may be prioritized according to Maslow's hierarchy: (1) physiologic
needs, (2) safety needs, (3) love and belonging needs, (4) self-esteem
needs, and (5) self-actualization needs. #2 is an example of a
physiologic need, #4 is an example of a love and belonging need, #1 is
an example of a self-esteem need, and #3 is an example of a self-
actualization need.
. A nurse is using critical pathway methodology for choosing
interventions for a patient who is receiving chemotherapy for breast
cancer. Which nursing actions are characteristics of this system being
used when planning care? Select all that apply.
The nurse uses a minimal practice standard and is able to alter care to
meet the patient's individual needs.
The nurse uses a binary decision tree for stepwise assessment and
intervention.
, The nurse is able to measure the cause-and-effect relationship between
pathway and patient outcomes.
The nurse uses broad, research-based practice recommendations that
may or may not have been tested in clinical practice.
The nurse uses preprinted provider orders used to expedite the order
process after a practice standard has been validated through research.
The nurse uses a decision tree that provides intense specificity and no
provider flexibility. - CORRECT ANSWER- a, c. A critical pathway
represents a sequential, interdisciplinary, minimal practice standard for a
specific patient population that provides flexibility to alter care to meet
individualized patient needs. It also offers the ability to measure a cause-
and-effect relationship between pathway and patient outcomes. An
algorithm is a binary decision tree that guides stepwise assessment and
intervention with intense specificity and no provider flexibility. Guidelines
are broad, research-based practice recommendations that may or may
not have been tested in clinical practice, and an order set is a preprinted
provider order used to expedite the order process after a practice
standard has been validated through analytical research.
A nurse is identifying outcomes for a patient who has a leg ulcer related
to diabetes. An example of an affective outcome for this patient is:
Within 1 day after teaching, the patient will list three benefits of
continuing to apply moist compresses to leg ulcer after discharge.
By 6/12/15, the patient will correctly demonstrate application of wet-to-
dry dressing on leg ulcer.
By 6/19/15, the patient's ulcer will begin to show signs of healing (e.g.,
size shrinks from 3″ to 2.5″).
By 6/12/15, the patient will verbalize valuing health sufficiently to
practice new health behaviors to prevent recurrence of leg ulcer. -
CORRECT ANSWER- d. Affective outcomes describe changes in
patient values, beliefs, and attitudes. Cognitive outcomes (a) describe
increases in patient knowledge or intellectual behaviors; psychomotor
outcomes (b) describe the patient's achievement of new skills. c is an
outcome describing a physical change in the patient.
A nurse is preparing a clinical outcome for a 32-year-old female runner
who is recovering from a stroke that caused right-sided paresis. An
example of this type of outcome is:
STUDY- COMPLETE QUESTIONS WITH
CORRECT ANSWERS
A nurse is irrigating the colostomy of a patient and is unable to get the
irrigation solution to flow. What would be the nurse's next action in this
situation?
Assist the patient to a prone position on a waterproof pad and try again.
Check the clamp on the tubing to make sure that the tubing is open.
Quickly pull the cone from the stoma and check for bleeding.
Remove the equipment and call the primary care provider. -
CORRECT ANSWER- b. If irrigation solution is not flowing, the nurse
should first check the clamp on the tubing to make sure the tubing is
open. Next, the nurse should gently manipulate the cone in the stoma
and check for a blockage of stool. If there is a blockage, the nurse
should remove the cone from the stoma, clean the area, and gently
reinsert. Alternately, the nurse could assist the patient to a side-lying or
sitting position in bed, place a waterproof pad under the irrigation sleeve,
and place the drainage end of the sleeve in a bedpan.
A nurse is planning care for a male adolescent patient who is admitted to
the hospital for treatment of a drug overdose. Which nursing actions are
related to the outcome identification and planning step of the nursing
process? Select all that apply.
The nurse formulates nursing diagnoses.
The nurse identifies expected patient outcomes.
The nurse selects evidence-based nursing interventions.
The nurse explains the nursing care plan to the patient.
The nurse assesses the patient's mental status.
The nurse evaluates the patient's outcome achievement. - CORRECT
ANSWER- b, c, d. During the outcome identification and planning step
of the nursing process, the nurse works in partnership with the patient
,and family to establish priorities, identify and write expected patient
outcomes, select evidence-based nursing interventions, and
communicate the plan of nursing care. Although all these steps may
overlap, formulating and validating nursing diagnoses occurs most
frequently during the diagnosing step of the nursing process. Assessing
mental status is part of the assessment step, and evaluating patient
outcomes occurs during the evaluation step of the nursing process.
A nurse on a busy surgical unit relies on informal planning to provide
appropriate nursing responses to patients in a timely manner. What are
examples of this type of planning? Select all that apply.
A nurse sits down with a patient and prioritizes existing diagnoses.
A nurse assesses a woman for postpartum depression during routine
care.
A nurse plans interventions for a patient who is diagnosed with epilepsy.
A busy nurse takes time to speak to a patient who received bad news.
A nurse reassesses a patient whose PRN pain medication is not
working.
A nurse coordinates the home care of a patient being discharged. -
CORRECT ANSWER- b, d, e. Informal planning is a link between
identifying a patient's strength or problem and providing an appropriate
nursing response. This occurs, for example, when a busy nurse first
recognizes postpartum depression in a patient, takes time to assess a
patient who received bad news about tests, or reassesses a patient for
pain. Formal planning involves prioritizing diagnoses, formally planning
interventions, and coordinating the home care of a patient being
discharged.
3. When helping a patient turn in bed, the nurse notices that his heels
are reddened and plans to place him on precautions for skin breakdown.
This is an example of what type of planning?
Initial planning
Standardized planning
Ongoing planning
Discharge planning - CORRECT ANSWER- c. Ongoing planning is
problem oriented and has as its purpose keeping the plan up to date as
new actual or potential problems are identified. Initial planning
addresses each problem listed in the prioritized nursing diagnoses and
,identifies appropriate patient goals and the related nursing care.
Standardized care plans are prepared plans of care that identify the
nursing diagnoses, outcomes, and related nursing interventions common
to a specific population or health problem. During discharge planning,
the nurse uses teaching and counseling skills effectively to help the
patient and family develop sufficient knowledge of the health problem
and the therapeutic regimen to carry out necessary self-care behaviors
competently at home.
. A nurse is prioritizing the following patient diagnoses according to
Maslow's hierarchy of human needs:
(1) Disturbed Body Image
(2) Ineffective Airway Clearance
(3) Spiritual Distress
(4) Impaired Social Interaction
Which answer choice below lists the problems in order of highest priority
to lowest priority based on Maslow's model?
2, 4, 1, 3
3, 1, 4, 2
2, 4, 3, 1
3, 2, 4, 1 - CORRECT ANSWER- a. 2, 4, 1, 3. Because basic needs
must be met before a person can focus on higher ones, patient needs
may be prioritized according to Maslow's hierarchy: (1) physiologic
needs, (2) safety needs, (3) love and belonging needs, (4) self-esteem
needs, and (5) self-actualization needs. #2 is an example of a
physiologic need, #4 is an example of a love and belonging need, #1 is
an example of a self-esteem need, and #3 is an example of a self-
actualization need.
. A nurse is using critical pathway methodology for choosing
interventions for a patient who is receiving chemotherapy for breast
cancer. Which nursing actions are characteristics of this system being
used when planning care? Select all that apply.
The nurse uses a minimal practice standard and is able to alter care to
meet the patient's individual needs.
The nurse uses a binary decision tree for stepwise assessment and
intervention.
, The nurse is able to measure the cause-and-effect relationship between
pathway and patient outcomes.
The nurse uses broad, research-based practice recommendations that
may or may not have been tested in clinical practice.
The nurse uses preprinted provider orders used to expedite the order
process after a practice standard has been validated through research.
The nurse uses a decision tree that provides intense specificity and no
provider flexibility. - CORRECT ANSWER- a, c. A critical pathway
represents a sequential, interdisciplinary, minimal practice standard for a
specific patient population that provides flexibility to alter care to meet
individualized patient needs. It also offers the ability to measure a cause-
and-effect relationship between pathway and patient outcomes. An
algorithm is a binary decision tree that guides stepwise assessment and
intervention with intense specificity and no provider flexibility. Guidelines
are broad, research-based practice recommendations that may or may
not have been tested in clinical practice, and an order set is a preprinted
provider order used to expedite the order process after a practice
standard has been validated through analytical research.
A nurse is identifying outcomes for a patient who has a leg ulcer related
to diabetes. An example of an affective outcome for this patient is:
Within 1 day after teaching, the patient will list three benefits of
continuing to apply moist compresses to leg ulcer after discharge.
By 6/12/15, the patient will correctly demonstrate application of wet-to-
dry dressing on leg ulcer.
By 6/19/15, the patient's ulcer will begin to show signs of healing (e.g.,
size shrinks from 3″ to 2.5″).
By 6/12/15, the patient will verbalize valuing health sufficiently to
practice new health behaviors to prevent recurrence of leg ulcer. -
CORRECT ANSWER- d. Affective outcomes describe changes in
patient values, beliefs, and attitudes. Cognitive outcomes (a) describe
increases in patient knowledge or intellectual behaviors; psychomotor
outcomes (b) describe the patient's achievement of new skills. c is an
outcome describing a physical change in the patient.
A nurse is preparing a clinical outcome for a 32-year-old female runner
who is recovering from a stroke that caused right-sided paresis. An
example of this type of outcome is:
