The nurse has admitted an 80 yo patient with altered mental status diagnosed with pneumonia to the
med surg unit. which action will the nurse take to help prevent the patient from falling?
- implement strict bedrest
-review patients medications
- implement universal fall precautions
- provide the patient with a bedside toilet - Answers - implement universal fall precautions
which action by the nurse reflects critical thinking while implementing interventions with patients?
- implement interventions as per standing orders without question
- review all potential complications associated with the interventions
- carry out the interventions before reviewing for any complications
- perform interventions as per prescriptions given by the health care provider - Answers - review all
potential complications associated with the interventions
Which action will the nurse take before implementing health care provider initiated interventions?
select all that apply
- clarify questionable prescriptions
- implement procedures automatically
-administer medications without question
-decide if the intervention is appropriate for the pt.
-determine if collaboration with others is needed - Answers - clarify questionable prescriptions
-decide if the intervention is appropriate for the pt.
-determine if collaboration with others is needed
which evaluative criterion would the nurse use to measure nursing care for a patient who is SOB?
select all that apply
- observe the patients level of comfort
-measure respiratory rate
-ask the patient if breathing is easier
-administer a bronchodilator
-instruct the patient to perform deep breathing - Answers - observe the patients level of comfort
-measure respiratory rate
-ask the patient if breathing is easier
A patient has a sprained ankle. the nurse applies cold compresses on the affected ankle and instructs
the patient to keep the leg elevated. which standard of practice is the nurse performing?
- assessment
- diagnosis
- evaluation
- implementation - Answers - implementation
an 18 yo patient is in the emergency department with a fever and cough. the nurse obtains vitals,
auscultates lung sounds, determines pts level of comfort, and collects blood and sputum samples.
which standard of practice is performed?
- assessment
- diagnosis
- evaluation
- implementation - Answers - assessment
The nurse is reading the reports of a patients laboratory tests. which standard of practice is the nurse
performing?
, - assessment
- diagnosis
- evaluation
- implementation - Answers - assessment
Which action does the nurse take right before implementing interventions?
- review care plan
- decide if outcomes remain appropriate
- reassess patient
- compare assessment findings to validate existing nursing diagnoses - Answers - reassess patient
The nurse notes a patient has a diagnosis of risk for fall owing to the left sided weakness which has
impaired their gait. which intervention would the nurse anticipate implementing to address the
nursing diagnosis?
- explain the fall risks associated with the patients stroke
- explain the potential effects of medications on their balance
- implement endurance training after the patient is competent in using a walker
- teach the patient strengthening exercises in collaboration with physical therapy - Answers - explain
the fall risks associated with the patients stroke
Which action would the nurse perform when modifying a care plan after the patients progress has
been evaluated? select all that apply
- evaluate interventions
- redefine nursing diagnoses
- reassess patient factors
- conclude the evaluation process
- continue unrealistic outcome time frames - Answers - evaluate interventions
- redefine nursing diagnoses
- reassess patient factors
which action would the nurse take in documenting patient care? Select all that apply
- record pertinent health and drug info
- use correction fluid to correct wrong info
- record meds given & any drug rxn
- document discontinued meds
- leave blank spaces in the nursing notes
- sign with initials - Answers - record pertinent health and drug info
- record meds given & any drug rxn
- document discontinued meds
how would the nurse support a culture of safety? select all that apply
-completing incident reports when appropriate
-completing incident reports for near misses
-communicating product concerns to an immediate supervisor
-identifying person responsible for incident
- experimenting with using newest equiptment - Answers -completing incident reports when
appropriate
-completing incident reports for near misses
-communicating product concerns to an immediate supervisor
which info would the nurse document after performing endotracheal suctioning? select all that apply
-color of secreditons
-amount of secretions
-respiratory assessments before/after suction