ADPIE NCLEX Questions And Answers Already Graded A+

A new nurse who is being oriented to the subacute care unit is expected to follow existing standards when providing patient care. Which nursing actions are examples of those standards? select all that apply. a. monitoring patient status ever hour b. using intuition to troubleshoot patient problems c. turning a patient on bed rest every 2 hours d. becoming a nurse mentor to the student nurse e. administering pain medication ordered by the physician f. becoming involved in the community nursing events - ace A new RN is being oriented to a nursing unit that is currently understaffed and is told that the UAP's have been trained to obtain the initial nursing assessment. What is the best response of the RN? a. allow the UAP's to do the admission assessment and report the findings to the RN. b. Do his or her own admission assessments but don't interfere with the practice if other professional RN's seem comfortable with the practice. c. tell the charge nurse that he or she chooses not to delegate the admission assessment until further clarification is received from administration. d. contact his or her labor representative and complain about the practice. - c A nurse assesses a patient and formulates the following nursing diagnosis: Risk for impaired asking integrity relates to the prescribed bed rest as evidenced by reddened areas of skin on the heels and back. Which phrase represents the etiology of the diagnostic statement? a. Risk for impaired skin integrity b. related to prescribed bed rest c. as evidenced by d. as evidenced by reddened areas of skin on heels and back - b A nurse develops a detailed plan of care for a 16 yearly old female who is a new single mother of a premature infant. The plan includes collaborative care measures and home health care visits. Whenpresented with the plan the patient states "We will be fine on our own. I don't need any more care." What wold be the nurses best response? a. "You know you personal situation better than I do so I will respect your wishes." b. "If you don't accept these services your baby's health will suffer." c. "Let's take a look at the plan again and see if we can adjust it to fit your needs." d. "Im going to assign your case to a social worker so she can explain the services better." - c A nurse is about to perform pin site care for a patient who has a halo traction installed. What is the first nursing action that should be taken prior to performing this care? a. administer pain medication b. reassess the patient c. prepare the equipment d. explain the procedure to the patient - b A nurse is attempting to improve care on the pediatric ward of a hospital. Which nursing improvements might the nurse employ when following the recommendation of the Institute of Medicines Committee on Quality of Health Care in America? Select all that apply. a. basing patients care on continuous healing relationships. b. customizing care to reflect the competencies of the staff. c. using evidence based decision making d. having c charge nurse as the source of control e. using safety as a systems priority f. recognizing the need for secrecy to protect patient privacy. - ace A nurse is caring for a patient who is diagnosed with congestive heart failure. Which statement below is NOT an example of a well stated nursing intervention? a. offer patient 60 mL water or juice every 2 hours while awake for a total minimum PO intake of 500 mL b. teach patient the necessity of carefully monitoring fluid intake and output: remind patient each shift to mark off fluid intake on record at bedside. c. walk with patient to bathroom for toileting every 2 hours d. manage patients pain - dA nurse is caring for an elderly male patient who is receiving fluids for dehydration. Which outcome for this patient is correctly written? a. offer the patient 60 mL fluid every day for 2 hours while awake. b. during the next 24 hours period, the patients fluid intake will total at least 2000 mL c. teach the patient to importance of drinking enough fluids to prevent dehydration by 1/15/15 d. at the next visit 12/23/15. the patient will know that he should drink at least 3 liters of water per day. - b A nurse is caring for an older adult patient who presents with labored respirations, productive cough, and fever. What would be appropriate nursing diagnoses for this patient? Select all that apply. a. Bronchial pneumonia b. Impaired gas exchange c. Ineffective airway clearance d. Potential complications: sepsis e. Infection related to pneumonia f. Risk for septic shock - bcf A nurse is collecting evaluative data for a patient who is finished receiving chemotherapy for an osteosarcoma. Which nursing action represents this step of the nursing process? a. the nurse collects data to identify health problems. b. the nurse collects data to identify patient strengths. c. the nurse collects data to justify terminating the plan of care. d. the nurse collects data to measure outcome achievement. - d A nurse is collecting more patient data to confirm a diagnosis of emphysema for a 68 year old male patient. What type of diagnosis does this intervention seek to confirm? a. actual b. possible c. riskd. collaborative - b A nurse is counseling a 60 year old female patient who refuses to look at or care for a new colostomy. She tells the nurse "I don't care what i look like anymore, I don't even feel like washing my hair, let alone changing this bag." The nurse diagnosis Altered health maintenance. This is an example of what type of problem? a. collaborative problem b. interdisciplinary problem c. medical problem d. nursing problem - d