5,6,7 FINAL EXAM

5,6,7 FINAL EXAM 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 patients Vital Signs once a day C. Weighing the patient before Breakfast D. Monitering a critical patients vita signs every 15 minutes - ANS-B. Taking the patients vital signs once a day Prior to the nurse implementing a nursing procedure for a patient, the nurse should initially: a. question the rational 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. Mentally review the procedure At the 7:00 AM handoff report, the nurse recieves the report that the patient 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 8:30am , is also sleeping. How would an organized nurse plan the early morning activities? A. Wake patient A for breakfast B. Perform flexible time task that can be done while both patients sleep. C. Prepare patient B now and allow patient A to sleep. D. Assign a nursing assistant to wake and help feed patient A. - ANS-C. Prepare patient B now ; allow patient A to sleep. Preparing a patient for a diagnostic test, and telling the patient wha to expect during and after the test is considered? A. An independent nursing action B. The docters responsibility. C. A dependent nursing action that requires the docters authorization D. An interdependent nursing action - ANS-A . Patient education is an independent nursing action The nursing documents interventions periodically during the shift in nurses notes primarily to: A. Validate the number of non licensed personnel who interact with the patient B. Indicate that the nursing care plan has been implemented C. Briefly summarize activites during the shift D. Confirm that the nursing dianoses in the care plan are appropriate - ANS-B . Indicate that the nursing care plan has been implemented 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 health problems heave been treated C. Calculate charges for nursing services during the patients hospital stay D. Determine if the progress is made or to determine if revisions are needed. - ANSDetermine if progress is made or to determine if revisions are needed. The nurse is aware that the nursing audit is a valuable process used to: A. determine whether a particular patient recieved the care indicated B. evaluate whether nursing care for a group of patients meets the standards of care in the facility. C. determine the cost of nursing care in the hospital in order to set rates for daily care. D. identify careless or negligent nursing care to protect the facility from lawsuits - ANSB. evaluate whether nursing care for a group of patients meets the standards of care in the facility. The nurse evaluates that the patient has met the outcome of feeding himself independently. The nurse should: A. inactivate the nursing diagnosis from the care plan B. notify the primary care provider that the patient can now feed himself C. Document the ability to self-feed and mark the nursing diagnosis as resolved. D. inform the RN to document the self- feeding and to cancel the nursing diagnosis. - ANS-C document the ability to self-feed and mark the nursing diagnosis as resolved An example of an appropriately worded nursing goal or outcome for the nursing diagnosis of " Risk for falls related to weakness" would be: A. nurse will assist the patient to the bathroom every two hours . B. patient will be free of injury from falls. C. Patient will call for assistance when ambulating for the next week. D. Nurse will keep room well lit 24 hours a day. - ANS-C. patient will call for assistance when ambulating for the next week.D. place a towel on the bed and turn the patient to the operated side. - ANS-C. Reinforce the wet dressing and document Nurses design interventions that are appropriate for a patient that are: A. based on primary care providers order and medical diagnosis. B. Expected to help the patient meets the goals most quickly. C. used to evaluate whether the nursing care plan should be revised. D. based on cost effectiveness and staff availability. - ANS-B. Expected to help the patient meet the goals most quickly. Before preforming a catheterization, the inexpierenced nurse should: A. close the door or curtains to provide the patient with privacy. B. Provide necessary education and explanation of the procedure to the patient. C. observe the rules of standard precautions to protect herself from exposure to blood or bodily fluids. D. review the agency procedure manual for the accepted way of preforming the procedure. - ANS-D. review the agencys procedure manual for the accecpted way of performing the procedure. During morning care in a skilled nursing facility, the student nurse notices that the patient who is at risk for impaired skin integrity has developed a small open area on his sacrum. To best address this situation the student would first? A. position the patinet to lie on his side, document it and inform the head nurse. B. position the patient on his side and encourage him to massage around the area. C. report to the primary care provider so that the nurse care plan can be revised D. Tell the nursing assistant to change the patient position every two hours. - ANS-A. Position the patient to lie on his side, document it, and inform the head nurse. The nurse giving a patient a back massage is preforming an intervention considered to be: A. dependent action B. an interdependent action C. a semi dependent nursing action D. a dependent action - ANS-D. Dependent nursing action THe nurse is caring for a group of patients would show cultural sensitivity to assign an older male nursing assitant to the care of: A. a 45 year old white male patient with uncontrolled diabetes B. a 50 year old hispanic man with a broken leg C. a 55 year old japanese man with irritable bowel syndrome D. a 60 year old muslim women with pneumonia. - ANS-C. a 55-year-old japanese man with irritable bowel syndrome The nurse is assesing a patinet who just returned from a bowel resection 1 hour ago. The nurse notes a dressing over the suture line that is wet with sero sanguineous drainage. The nurse should intially: A. perform a sterile dressing change B. Document and report the wet dressing to the charge nurse C. reinforce the wet dressing and document D. place a towel on the bed and turn the patient to the operated side. - ANS-C. Reinforce the wet dressing and document