AcTUAl QUESTIoNS AND coRREcTlY WEll DEFINED ANSWERS lATEST
AlREADY gRADED A+
ADPIE - ANSWER-A=assessment
D=diagnosis
P=planning
I=implementation
E=evaluation
A goal specifies the expected behavior or response that indicates... - ANSWER-
Resolution of a nursing diagnosis or maintenance of a health state.
(if the goal is not met, the problem is not solved)
Which of these selections is an etiology for Acute pain versus a defining characteristic?
A. Complaint of pain as a 7 on a 0 to 10 scale
B. Disruption of tissue integrity
C. Dull headache
D. Discomfort while changing position - ANSWER-B. Disruption of tissue integrity
(think PES sx vs. etiology)
Assessment examples - ANSWER-auscultation, vitals, comfort level, obtain samples
An 18-year-old woman in the emergency department with fever and cough. The nurse
obtains her vital signs, auscultates her lung sounds, listens to her heart, sounds,
determines her level of comfort, and collects blood and sputum samples for analysis.
Which stand of practice is performed?
A. Diagnosis
B. Evaluation
,C. Assessment
D. Implementation - ANSWER-C. assessment
One purpose of using standard formal nursing diagnoses in practice is to
A. Form a language that can be encoded only by nurses
B. Distinguish the nurse's role from the physician's role
C. Allow for the communication of patient needs to assistive personnel
D. Help nurses focus on the scope of medical practice. - ANSWER-B. Distinguish the
nurse's role from the physician's role
(think which is the most important)
Appropriate documentation of a pt who has not heard his test results - ANSWER-"The pt
stated that he felt frustrated by the lack of information he received regarding his tests."
Avoid opinionated
I this the correct way to document?
The patient appears to be upset with his nurse because he wants his test results
immediately. - ANSWER-No
evidence-based practice - ANSWER-implementing interventions based on scientific
rationale (not standardized care plans, tradition, or court)
Before implementing an intervention, critical think to - ANSWER-determine whether an
intervention is appropriate for the given situation (not to evaluate effectiveness, establish
goals, or actively do something)
Evaluative measures regarding weight - ANSWER-Weight and food diary review
Which is the most correct?
A. Patient walked up and down hallway with assistance, tolerated well.
B. Patient up, out of bed, walked down hallway and back to room, tolerated well.
,C. Patient walked 50 feet and back down hallway with assistance from nurse. Spouse
also accompanied patient during walk.
D. Patient walked 50 feet and back down hallway with assistance from nurse. HR 88 and
regular before exercise, 94 and regular following exercise. - ANSWER-D. Distance (pt
walked 50 ft) specific (down hallway) what you did (with assistance from nurse). Vitals
with value and when taken (HR 88 and regular before exercise).
What are some of the defining characteristics of activity intolerance?
A. Decreased oral intake and decreased oxygen saturation when ambulating
B. Decreased oxygen saturation when ambulating and complaints of shortness of breath
C. Complaints of shortness of breath when getting out of bed and a productive cough.
D. Productive cough and decreased oral intake. - ANSWER-B. Decreased o2 sat w/amb
and c/o SOB (not productive cough, decreased PO)
1st thing you do if someone asks to go to the bathroom for the first time - ANSWER-
review activity orders
T/F you must intervene if a student documented a medication given by another student -
ANSWER-T
T/F you must intervene if a student included the date and time of all entries in the chart -
ANSWER-F
T/F you must intervene if a student stood with his back against the wall while
documenting on the computer - ANSWER-F-this actually helps maintain privacy
T/F you must intervene if a student signed all documentation electronically - ANSWER-F
Giving a med is which standard of practice - ANSWER-Implementation
, T/F: Does this follow all 7 guidelines for writing a goal (M MOTOR P-C) and outcome
statement? The patient will feed self at all mealtimes today without complaints of
shortness of breath. - ANSWER-True
M=measurable
M=mutual factors
O=one outcome
T=time limited
O=observable
R=realistic
P-C=patient-centered
T/F: Does this follow all 7 guidelines for writing a goal and outcome statement? The
nurse will monitor the patient's heart rhythm continuously this shift. - ANSWER-F
T/F: Does this follow all 7 guidelines for writing a goal and outcome statement? The
nurse will administer pain medication every 4 hours to keep the patient free from
discomfort. - ANSWER-F
T/F: Does this follow all 7 guidelines for writing a goal and outcome statement? The
patient will ambulate in hallways. - ANSWER-F
Which interventions for impaired tissue integrity related to poor wound healing
secondary to DM are correct?
1. Teach s/sx of infection
2. Help pt cope w/body image change
3. Dressing changes as ordered
4. Administer BG controll meds as ordered
5. Teach am how to change dressings - ANSWER-all
T/F evaluative measure: listening to lungs - ANSWER-T