Exam 1 – Med Surg Guide

A patient has a nursing diagnosis of ineffective airway clearance related to retained secretions, excessive mucus, and ineffective cough as evidenced by adventitious breath sounds. What should the nurse include in the NCP as an appropriate NOC outcome and NIC intervention for this nursing diagnosis? A) Aspiration Prevention (NOC) and Aspiration Procedures (NIC) B) Respiratory Status: Gas Exchange (NOC) and Oxygen Therapy (NIC) C)Respiratory Status: Ventilation (NOC) and Respiratory Monitoring (NIC) D) Respiratory Status: Airway Patency (NOC) and Airway Management (NIC) - Answer: d Rationale: If ineffective airway clearance is the nursing diagnosis, the outcome (NOC) would be focused on airway patency with interventions (NIC) focusing on airway management. The problem identified is not associated with aspiration, poor gas exchange, or impaired ventilation. An example of a nursing activity that reflects the ANA definition of nursing is: A. diagnosing a patient with a feeding tube as being at risk for aspiration. B. establishing protocols for treating pts in the ED C. providing antianxiety drugs for a patient who has disturbed sleep patterns. D. identifying and treating dysrhythmias that occur in a patient in the coronary care unit. - A A nurse is working on the medical-surgical unit at an urban hospital would like to become certified in a medical-surgical specialty. The nurse knows that this process would most likely require: A. a bachelor's degree in nursing. B. formal education in advanced nursing practice. C. experience for a specific period in medical-surgical nursing. D. membership in a medical-surgical nursing specialty organization. - C A nurse is providing care to a patient after right hip surgery. Within a pay-forperformance system, a critical role of the nurse is to: A. ensure that care is provided using a minimal amount of supplies. B. discharge the patient at completion of the number of approved days of care. C. implement measures to decrease the risk of the patient acquiring an infection. D. assess the patient's ability to pay for health care services at the time of admission. - C The nurse is assigned to care for a newly admitted patient. Number in order the steps for using the nursing process to prioritize care (Number 1 is the first step, and number 5 is the last step.) __Evaluate whether the plan was effective. __Identify any health problems. __Collect patient information. __Carry out the plan. __Determine a plan of action. - 1. Collect patient information. 2. Identify any health problems. 3. Determine a plan of action. 4. Carry out a plan. 5. Evaluate whether the plan was effective.