NURSING MISC - Nursing Process Adaptive Quiz 1.

When delivering patient care, which intervention does the nurse perform as part of the evaluation process? Recognizes unmet outcomes Which type of problem is a high priority? One related to life-threatening needs of the patients Which patient problem would be a high priority? Chest pain Which problem would the nurse add to the care plan after evaluating a diabetic patient who had a problem with glucose control but is now restless and asking many questions about an upcoming procedure on the big toe? Anxiety Which level of prevention describes a nurse administering a vaccine to an infant? Primary prevention. Setting a time frame for outcomes of care determines which purpose? When the patient is expected to respond in the desired manner Which action would a student nurse take when asked to perform a procedure that the student nurse has been trained in but has not performed in the hospital? Select all that apply. One, some, or all responses may be correct. Check the hospital’s procedure manual to obtain more information Ask an experienced nurse for supervision and guidance during the procedure. Verbalize the steps of the procedure with an instructor before performing it. Which response would the nurse make for a patient who expresses confusion about how to manage a leg wound after discharge? Explain and demonstrate the necessary action to the patient Which outcome is correctly written and would the nurse add to the plan of care about the patient’s apical pulse? The patient’s apical pulse will be at least 70 beats per minute. Which action demonstrates nursing competency when evaluating a patient? Select all that apply. One, some, or all responses may be correct. Reflect on the situation. Understand a patient situation. Recognize errors or omissions. Examine the results of care according to clinical data collected. Compare achieved effects with goals and expected outcome Which action describes an independent nursing intervention? Select all that apply. One, some, or all responses may be correct. Offering counseling for coping Initiating early mobility protocols Instructing patients on side effects of medications Positioning patients to prevent pressure injury formation Which feature is true about standing orders? Allow a quick response to a rapidly changing clinical situation Which expected outcome is written in measurable terms? 1 Patient will be pain free. 2 Patient will have less pain. 3 Patient will take pain medication every 4 hours. Correct4 Patient will report pain acuity less than 4 on a scale of 0 to 10. Using a scale for the patient’s report of pain acuity is measurable because it is the only outcome statement that allows the nurse to obtain an actual measure of the patient’s pain. "Patient will be pain free" is a goal, not an expected outcome. "Patient will have less pain" is vague and not measurable. "Patient will take pain medication every 4 hours" is an intervention, not an expected outcome. Which intervention performed by the nurse is an independent nursing intervention? Select all that apply. One, some, or all responses may be correct. Correct1 Teaching the patient about deep-breathing exercises 2 Starting an intravenous (IV) infusion 3 Administering analgesic medications Correct4 Assisting the patient in taking a bed bath Correct5 Repositioning a patient for relief from pain Teaching the patient about deep-breathing exercises, assisting the patient with a bed bath, and repositioning the patient can be performed independently by the nurse. Independent nursing interventions are activities that do not need an order from another health care provider.