Williams: deWit’s Fundamental Concepts and Skills for Nursing, 5th Edition

Williams: deWit’s Fundamental Concepts and Skills for Nursing, 5th Edition MULTIPLE CHOICE 1. The nurse is aware that one of the time flexible tasks to be accomplished would be: a. administering daily insulin 30 minutes before breakfast. b. taking the patient’s vital signs once a day. c. weighing the patient before breakfast. d. monitoring a critical patient’s vital signs every 15 minutes. ANS: B Daily vital signs can be taken at any time during the day, whereas the other tasks mentioned have a time constraint. DIF: Cognitive Level: Application REF: p. 73 OBJ: Theory #2 TOP: Care Delivery KEY: Nursing Process Step: Planning MSC:NCLEX: Physiological Integrity: Basic Care and Comfort 2. Prior to the nurse implementing a nursing procedure for a patient, the nurse should initially: a. question the rationale for the procedure. b. perform a physical assessment of the patient. c. check the agency manual for the procedure. d. mentally review the procedure. ANS: D Reviewing the procedure, checking the manual if uncertain, confirming the order for the procedure, assessing that there is no interference with the completion of the procedure, and identifying the patient are standard steps in deliberative nursing action. DIF:Cognitive Level: ApplicationREF:p. 76|Box 6-2 OBJ: Theory #1TOP: Care Delivery KEY: Nursing Process Step: Planning MSC:NCLEX: Physiological Integrity: Basic Care and Comfort 3. At the 7:00 AM handoff report, the nurse receives the report that patient A had a sleepless night related to pain and just fell asleep after an increased pain medication administration 1/2 hour ago. Patient B, who is scheduled for surgery at 8:30 AM, is also sleeping. How would an organized nurse plan the early morning activities? a. Wake patient A for breakfast. b. Perform time flexible tasks that can be done while both patients sleep. c. Prepare patient B now; allow patient A to sleep. d. Assign a nursing assistant to wake and help feed patient A. ANS: C Setting priorities and identifying time fixed tasks would indicate that patient B needs to be prepared for surgery. Patient A needs to sleep. DIF: Cognitive Level: Analysis REF: p. 73 OBJ: Theory #1 TOP: Care Delivery KEY: Nursing Process Step: Implementation MSC:NCLEX: Physiological Integrity: Basic Care and Comfort 4. Preparing a patient for a diagnostic test, and telling the patient what to expect during and after the test, is considered: a. an independent nursing action. b. the doctor’s responsibility. c. a dependent nursing action that requires the doctor’s authorization. d. an interdependent nursing action. ANS: A Patient education is an independent nursing action. DIF: Cognitive Level: Comprehension REF: p. 74 OBJ: Theory #2 TOP: Patient Education KEY: Nursing Process Step: Implementation MSC:NCLEX: Physiological Integrity: Basic Care and Comfort 5.The nurse explains that a multidisciplinary step-by-step approach to patient care is: a. documented in the nursing care plan in the patient’s medical record. b. not used often since managed care became part of health care. c. referred to as a clinical pathway and is used instead of a nursing care plan. d. more expensive than the traditional separation of health care services. ANS: C An outgrowth of managed care has been collaborative models of care called clinical pathways. DIF: Cognitive Level: Knowledge REF: p. 74 OBJ: Theory #1 TOP: Clinical Pathways KEY: Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment: Coordinated Care 6.The nurse documents interventions periodically during the shift in nurses’ notes primarily to: a. validate the number of nonlicensed personnel who interact with the patient. b. indicate that the nursing care plan has been implemented. c. briefly summarize activities during the shift. d. confirm that the nursing diagnoses in the care plan are appropriate. ANS: B The nursing care must be documented in the nurses’ notes to prove that interventions were implemented. In some facilities documentation is required at least every 2 hours. DIF: Cognitive Level: Comprehension REF: p. 76 OBJ: Theory #3 TOP: Documentation KEY: Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment: Coordinated Care 7.The nurse compares actual nursing outcomes to the expected nursing outcomes in order to: a. prepare the patient to be discharged from the facility. b. determine if the patient’s health problems have been treated. c. calculate charges for nursing services during the patient’s hospital stay. d. determine if progress is made or to determine if revisions are needed.