Test Bank For Davis Advantage for Understanding Medical-Surgical Nursing, 7th Edition By Linda S. Williams

Test Bank For Davis Advantage for Understanding Medical-Surgical Nursing, 7th Edition By Linda S. Williams. The nurse is planning care and setting goals for a newly admitted patient. Who should the nurse include when conducting these nursing actions? 1. Patient 2. Nurse manager 3. Hospital chaplain 4. Patient’s health care provider (HCP) ANS: 1 Chapter: Chapter 1 Critical Thinking and the Nursing Process Objective: 4. Identify the role of a licensed practical nurse/licensed vocational nurse is using the nursing process. Page: 6 Heading: Prioritize Care Integrated Process: Communication and Documentation Client Need: SECE—Management of Care Cognitive Level: Application [Applying] Concept: Communication Difficulty: Moderate Feedback 1 Planning care and setting goals is an action performed with the patient. The patient must be in agreement with the plan for it to be successful in meeting the desired outcomes. 2 The nurse manager may or may not be aware of the patient’s care needs. 3 The hospital chaplain may not be aware of the patient’s needs. 4 The focus of nursing care is different from that of the HCP. PTS: 1 CON: Communication 7. While caring for a patient 4 hours after a surgical procedure, the LPN/LVN notes serosanguineous drainage on the dressing. Which statement should the nurse use to document this finding? 1. “Normal drainage noted.” 2. “Moderate drainage recently noted.” 3. “Scant serosanguineous drainage seen on dressing.” 4. “Pale pink drainage 2 cm by 1 cm noted on dressing.” ANS: 4 Chapter: Chapter 1 Critical Thinking and the Nursing Process Objective: 6. Document subjective and objective data. Page: 5 Heading: Documentation of Data Integrated Process: Communication and Documentation Client Need: PHYS—Physiological Adaptation Cognitive Level: Application [Applying] Concept: Communication NURSING TEST BANK Difficulty: Moderate Feedback 1 These statements are interpretations of the data and use words that have vague meanings, which should be avoided when documenting. 2 These statements are interpretations of the data and use words that have vague meanings, which should be avoided when documenting. 3 These statements are interpretations of the data and use words that have vague meanings, which should be avoided when documenting. 4 Objective data are pieces of factual information obtained through physical assessment and diagnostic tests that are observable or knowable through the five senses. The nurse should document exactly what is seen. PTS: 1 CON: Communication 8. The nurse is caring for a patient using the nursing process. Which step should the nurse take first? 1. Implementation 2. Planning 3. Nursing diagnosis 4. Assessment ANS: 4 Chapter: Chapter 1 Critical Thinking and the Nursing Process Objective: 4. Identify the role of a licensed practical nurse/licensed vocational nurse in using the nursing process. Page: 4 Heading: Data Collection Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: SECE: Coordinated Care Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 The steps of the nursing process are data collection/assessment, nursing diagnosis, planning, implementation, and evaluation. 2 The steps of the nursing process are data collection/assessment, nursing diagnosis, planning, implementation, and evaluation. 3 The steps of the nursing process are data collection/assessment, nursing diagnosis, planning, implementation, and evaluation. 4 Assessment, or data collection, is the first step in the nursing process and is used to evaluate a patient’s condition before providing care. The other steps, in order, are nursing diagnosis, planning, implementation, and evaluation. PTS: 1 CON: Patient-Centered Care 9. The nurse is administering morphine to a patient reporting a pain level of 8 on a 0-to-10 scale. This describes which step of the nursing process? NURSING TEST BANK 1. Assessment 2. Nursing diagnosis 3. Implementation 4. Evaluation ANS: 3 Chapter: Chapter 1 Critical Thinking and the Nursing Process Objective: 4. Identify the role of a licensed practical nurse/licensed vocational nurse in using the nursing process. Page: 8 Heading: Identify Interventions Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: SECE – Coordination of Care Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 Administering medication does not describe assessment. 2 Administering medication does not describe nursing diagnosis. 3 Administering medication describes the implementation process, since an action is being taken to help the patient meet a desired outcome. 4 Administering medication does not describe the evaluation phase of the nursing process. PTS: 1 CON: Patient-Centered Care 10. The nurse is developing an outcome for a patient with exacerbation of asthma. Which is the most appropriate outcome for this patient? 1. The patient will not experience shortness of breath. 2. The patient will have a respiratory rate of 16 to 20 per minute. 3. The patient will ambulate without reporting shortness of breath. 4. The patient will not require use of an inhaler. ANS: 2 Chapter: Chapter 1 Critical Thinking and the Nursing Process Objective: 3. Describe the thinking that occurs in each step of the nursing process. Page: 8 Heading: Establish Outcomes Integrated Process: Clinical Problem-solving (Nursing Process) Client Need: SECE: Coordinated Care Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 This is a vague outcome and is not measurable. 2 This is a measurable outcome and is not vague. 3 This is a vague outcome and is not measurable. NURSING TEST BANK 4 This is a vague outcome and is not measurable. PTS: 1 CON: Patient-Centered Care 11. The nurse suspects a patient is experiencing adverse effects to a newly prescribed antihypertensive medication. After being informed that the effects are expected, the nurse remains concerned and conducts an Internet search on the patient’s manifestations. Which critical thinking behavior did the nurse implement? 1. Sense of justice 2. Intellectual courage 3. Intellectual empathy 4. Intellectual perseverance ANS: 4 Chapter: Chapter 1 Critical Thinking and the Nursing Process Objective: 2. Describe attitudes and skills that promote critical thinking. Page: 2 Heading: Intellectual Perseverance Integrated Process: Caring Client Need: Psychosocial Integrity Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 A sense of justice examines motives when making decisions. 2 Intellectual courage looks at other points of view, even when the nurse does not agree with them. 3 Intellectual empathy understands how another person feels when making decisions. 4 Intellectual perseverance is not giving up. PTS: 1 CON: Patient-Centered Care 12. The nurse is identifying outcomes for a patient with fluid volume deficit. Which outcome should the nurse use to guide this patient’s care? 1. Patient’s intake will be measured daily. 2. Patient’s intake will be 3,000 mL daily. 3. Fluids will be at the bedside for the patient. 4. Fluids the patient likes will be at the bedside. ANS: 2 Chapter: Chapter 1 Critical Thinking and the Nursing Process Objective: 3. Describe the thinking that occurs in each step of the nursing process. Page: 7 Heading: Establish Outcomes Integrated Process: Clinical Problem-solving (Nursing Process) Client Need: SECE: Coordinated Care Cognitive Level: Application [Applying] NURSING TEST BANK Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 These statements are nursing actions. 2 This outcome provides objective measurable data. 3 These statements are nursing actions. 4 These statements are nursing actions. PTS: 1 CON: Patient-Centered Care 13. The nurse is formulating nursing diagnoses for a patient with chronic obstructive pulmonary disease (COPD). Which diagnosis is of the highest priority? 1. Activity intolerance 2. Impaired gas exchange 3. Risk for injury 4. Deficient knowledge ANS: 2 Chapter: Chapter 1 Critical Thinking and the Nursing Process Objective: 7. Prioritize patient care activities based on the Maslow hierarchy of human needs. Page: 6 Heading: Prioritize Care Integrated Process: Clinical Problem-solving (Nursing Process) Client Need: SECE: Coordinated Care Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Difficult Feedback 1 Although activity intolerance is a nursing diagnosis for a patient with COPD, it is not the highest priority. 2 Impaired gas exchange is the highest priority according to Maslow. 3 A risk for diagnosis is not a priority because the patient is only at risk for the problem, it is not an actual problem as of yet. 4 According to Maslow, deficient knowledge is not a priority. PTS: 1 CON: Patient-Centered Care 14. An RN delegates a patient care assignment to the LPN/LVN. Which phase of the nursing process should the LPN/LVN perform independently? 1. Assessment 2. Planning care 3. Implementation 4. Nursing diagnosis ANS: 3 Chapter: Chapter 1 Critical Thinking and the Nursing Process NURSING TEST BANK Objective: 4. Identify the role of a licensed practical nurse/licensed vocational nurse in using the nursing process. Page: 22 Heading: Role of the Licensed Practical Nurse/Licensed Vocational Nurse Integrated Process: Clinical Problem-Solving (Nursing Process) Client Need: SECE: Coordinated Care Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 The LPN/LVN assists the RN with collecting data, formulating nursing diagnoses, and in determining outcomes and planning care to meet patient needs. 2 The LPN/LVN assists the RN with collecting data, formulating nursing diagnoses, and in determining outcomes and planning care to meet patient needs. 3 The LPN/LVN independently provides direct patient care. 4 The LPN/LVN assists the RN with collecting data, formulating nursing diagnoses, and in determining outcomes and planning care to meet patient needs. PTS: 1 CON: Patient-Centered Care 15. The LPN/LVN is reviewing a care plan for a patient who underwent abdominal surgery 2 hours ago and has a priority nursing diagnosis of acute pain. Which intervention should the nurse implement first? 1. Teach the patient how to splint the abdomen when coughing. 2. Assist the patient with early ambulation. 3. Encourage the patient to increase fluid intake. 4. Administer hydromorphone (Dilaudid) per order as needed for pain. ANS: 4 Chapter: Chapter 1 Critical Thinking and the Nursing Process Objective: 7. Prioritize patient care activities based on the Maslow hierarchy of human needs. Page: 6 Heading: Prioritize Care Integrated Process: Clinical Problem-solving Process (Nursing Process) Client Need: SECE: Coordinated Care Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Difficult Feedback 1 Splinting is important, but if the patient is in pain, he or she will not likely retain information. 2 Early ambulation is important, but does not address the diagnosis of acute pain. 3 The patient may need to increase fluid intake, but this is not a priority NURSING TEST BANK intervention. 4 The patient has a nursing diagnosis of acute pain; this intervention should be implemented first. PTS: 1 CON: Patient-Centered Care 16. Which critical thinking trait is demonstrated when the LPN/LVN is unsure of how to perform a dressing change and asks the RN for assistance? 1. Intellectual courage 2. Intellectual integrity 3. Intellectual humility 4. Intellectual empathy ANS: 3 Chapter: Chapter 1 Critical Thinking and the Nursing Process Objective: 2. Describe attitudes and skills that promote good critical thinking. Page: 2 Heading: Intellectual Humility Integrated Process: Communication and Documentation Client Need: Psychosocial Integrity Cognitive Level: Comprehension (Understanding) Concept: Communication Difficulty: Moderate Feedback 1 Intellectual courage allows the nurse to look at other points of view even if he or she does not agree. 2 Intellectual integrity is holding oneself to the same level of standards one expects others to meet. 3 The LPN/LVN is demonstrating intellectual humility, which is having the ability to ask for assistance when he or she is unsure. 4 Intellectual empathy allows the nurse to put himself or herself in the patient’s shoes. PTS: 1 CON: Communication 17. During morning report, the LPN/LPN is assigned a group of patients. Which patient should the LPN/LPN see first? 1. A patient scheduled for magnetic resonance imaging (MRI) due to back pain 2. A patient reporting constipation and stomach cramps 3. A 2-day postsurgical patient reporting pain at a level of 6 4. A patient with pneumonia who is short of breath and anxious ANS: 4 Chapter: Chapter 1 Critical Thinking and the Nursing Process Objective: 7. Prioritize patient care activities based on the Maslow hierarchy of human needs. Page: 3 Heading: Prioritize Care NURSING TEST BANK Integrated Process: Clinical Problem-solving Process (Nursing Process) Client Need: SECE: Coordinated Care Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Difficult