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A comprehensive q&a resource covering key aspects of the nursing process, including assessment, data validation, nursing diagnosis (actual, risk, wellness), goal setting (short-term and long-term), interventions (independent, dependent, interdependent), and documentation. it's valuable for nursing students to test their knowledge and understanding of these fundamental concepts. The questions delve into various scenarios and clinical situations, enhancing practical application of theoretical knowledge.
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Nursing process ANS:->> a systematic problem-solvingprocess that guides all nursing actions Assessment ANS:->>the systematic gathering of information related to the physiological, psychiological, sociocultural, devlopmental, and spiritual status of anindividual, group, or community. What is the purpose of an assessment? ANS:->> obtaindata to allow you to help the patient Where do we get Primary sources from? ANS:->>Subjective and Objective Where do we get secondary sources from? ANS:->>Family/friends, health record, healthcare team Subjective Data (Client States) Objective Data (Nurse observes) ANS:->>" My throathurts when i swallow" Parenteral ANS:->> any route other than through thealimentary canal (passage from mouth to anus) IV therapy ANS:->>the administration of fluids, electrolytes, medications, or nutrients by the venousroute What type of technique is used every time you start (initiate) or work with (maintain) an IV site or infusion?
What happens to the $$ your facility receives if a clientin your care gets a
CRBSI (catheter releated bloodstream infection)? ANS:->> The hospital must pay Lab value for serum osmolality ANS:->> 275 - 295 Primary source ( Client states or Nurse Observes) Secondarysource (everything else) ANS:->>" My heartfeels like it's beating fast" "I am feeling short of breath at night"
Suppose a patient has told you that he has never hadhigh B/P, but you obtain an abnormal BP reading of 180/98 mm Hg. How would you validate? **ANS:-
** Check the BP in the patient's other arm Wait a few minutes and take the raeding again in thesame arm Retake the BP using a different sphygmomanometerCompare the reading
stays up late partying and sleeps most of teh day. Despite a previous close relationship with her parents,she barley talks to them when they contact her.
Todd may have at least one actual nursing diagnosis (Impairied Walking or perhaps Impaired Physcial Mobility), related to his alck of peripheral sensation; however; no signs and symptoms were given in the scenario to support that diagnosis. What diagnosis typeis this?
Todd's loss of lower limb sensation is a risk, factor for adiagnosis of Risk for Falls even though Todd has no symptoms is what type of diagnosis?
All surgical patients have at least some risk for developing infection, so do not routinely write Risk for infection or surgical site infection on every surgical care plan. Instead, write potential complication of suregry: infection (incision and systemtic)
Suppose that Todd tells you that he prays, participatesin religious actvities,
Long term goals- ANS:->>those you expect the patientto achieve within a few hours or days are changes in health status that you wish to achieveover a longer period of time What type of goal is this - describe pain as <3 on a 1 - 10 scale within 30 min after recieving analesic
What type of goal is this- Limits food intake to 1,500calories per day
What type of goal is this- Infant will double birthweight within 5 mo
Within 3 mo after physical therapy treatments, willdress self expect for buttons
Intervention ANS:->>any treatment, based on clinicaljudgement and knowledge, that a nurse performs to enhance patient outcomes Independent Interventions ANS:->>one that RNs are accountable for and are licensed to presribe, perform, or delegaet based on tehir knolwedge and skills.
Nurse A makes a nursing diagnosis of Anxiety related todeficient knolwedge about barium enema; she swrites a nursing order to teach the pateint what to expect from the upcoming diagostic test
Dependent Intervention ANS:->>one that is prescribeby a physician or advanced practice nurse but carried out by the nurse Nurse B reads a prescription in a patient's chart: "Givecephalothin sodium (Keflin) 1 g IV [through the intravenous line] before suregry, and tehn every 6 hours for 24 hours. " She prepares and administers themedication
Interdependent ANS:->>one that is carried out incollaboration with other health team members (physcial therapists, physicians) Nurse C notes that a client newly diagnosed with diabetes has been seen by a dietitian, who taught andpro vided materials about a diabetic diet. The nurse observes the clients's menu chocies. She notes that theclient is eating candy brought by visitors. She explains to the client how concentrated sugar affects his diabetes; she also communicates her assessments and teaching to the dieitian.
Which of these abbreviations you would not use? A. Drugs B. .5/0. C. QD D. QOD E.AD, AS, AU, and OD, OS, OU F.Units or IC G. SQ ANS:->>all the above Handoffs ANS:->>to provide continuity of care amongall team members who provide care to the same clients How long have to sign order?
For TO order what must you do
F. Order co-signed ANS:->>all the above What are the steps in a nursing process? ANS:->>Assess, Diagnose, Plan, Implement, Evaluate Once a nurse accesses a client's condition andidentifies appropriate nursing diagnosis, a A. Plan is developed for nursing care B. Physical assessment begins C. List of priorities is determined D. Review of assessment is conducted with other team members ANS:->>A. Plan is developed for nursing care Planning is a category of nursing behaviors in which:
and expected outcomes are established Priorities are establish to help the nurse anticipate andsequence nursing interventions when a client has multiple problesm or alterations. Priorities are determined by the clinet's:
- Reevaluating and creating anew nursing diagnosis and outcome A nurse is performing an assessment on a client who has been admitted for hip replacement surgery the next day. The client is tearful and appears very anxious.The nurse is considering "anxiety" as a nursing diagnosis but does not have enough information. Which would be the appropriate action? 1.Assume the anxiety is related to surgery.
ANS:->>4. Ask the client if thereis anything in particular he or she is anxious about. Which describes the correct way to state a nursingdiagnosis?
ANS:->>3. A problem and anetiology linked by a connecting phrase Which are examples of a direct-care nursingintervention? Select all that apply.
According to Maslow's Hierarchy of Needs, what is theappropriate order of priority of the client needs?
When creating a care plan, which describes outcomesthat can be influenced by nursing interventions?
Which nursing interventions are considered direct-careinterventions? Select All That Apply.
The abbreviations "AEB" and "AMB" are considered connecting phrases for which portion of the nursingplan?
During an assessment, the nurse notes that the clienthas an elevated temperature. Which type of data is this?
Which describes benefits of the comprehensive writtennursing care plan? Select all that apply.
Why is the diagnosis step critical to the nursingprocess?
and follow-up evaluation.
hospital.
diagnosis.
A nurse has delegated the task of turning a client every2 hours to a nursing assistant in order to prevent skin breakdown. Who has accountability for the actions being performed and the outcome?
who delegated the task Which describes components of implementation in thenursing process? Select all that apply.
Which is a valid goal statement for measuring andmanaging pain?
Which statement correctly identifies an outcome goalfrom the nursing diagnosis of "potential for skin breakdown related to immobility"?
client's skin will remain intact and healthy.