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NUR 104 MIDTERM EXAMS
4 MODULES
A patient states “I would like to be able to decrease my risk for heart disease. I started eating better but there is more I can do.” What would be an appropriate NANDA-I nursing diagnosis for the RN to apply in this situation? Ineffective role performance Risk-prone health behavior Deficient knowledge Readiness for enhanced health maintenance submitted A team of RNs is researching the occurrence of pressure ulcers throughout the hospital. How does the use of standardized language in electronic health record (EHR) assist with the research? Compliance with privacy is ensured. submitted Data retrieval is efficient. Documentation is easy to understand. Other disciplines clearly understand language. Which technologic strategy is used when an organization needs to investigate changes that have been made in the electronic health record?
Password changes submitted Order entry review Audit trails Omission errors summaries When developing the plan of patient care, which nursing order can delegated to the unlicensed assistive personnel (UAP)? Observe skin over bony prominences every 4 hours. Review trends in vital signs every shift. Turn and position every 2 hours; avoid supine positon. submitted Make sure all home care supplies are packed for discharge to home. When developing the patient plan of care, the RN can assign patient care to which member of the health care team? Social worker. Physical Therapist. Registered nurse.
“The LPN placed a dry sterile dressing on the patient’s left lateral foot before leaving.” submitted “The LPN placed a dry sterile dressing on the patient’s lateral left foot.” You have used 1 of 1 attempt Some problems have options such as save, reset, hints, or show answer. These options follow the Submit button. Answer submitted.
NUR104_M4EQ
1.25 points possible (graded, results hidden) The nurse enters a room and discovers a patient lying on the floor and moaning. Which entry meets the guidelines for documenting this event? “The patient was emotionally disturbed when found on the floor.” “The patient was found next to the bed so he must have fallen out of the bed.” “The patient was conscious and crying out when found on the floor next to the bed.” submitted “The patient was hurt, crying and found on the floor next to the bed.” You have used 1 of 1 attempt Some problems have options such as save, reset, hints, or show Which NANDA-I nursing diagnosis is a priority for the patient that experiences a decrease in blood pressure along with dizziness when changing position from supine to upright? Risk for infection Hypotension Risk for falls submitted Altered vital signs During an assessment of the lower extremities of a patient, the RN is not able to palpate the dorsalis pedis pulse in the right foot. Which intervention should the RN implement next to assess pulse quality? Assess capillary refill. Check the EHR to determine if this is a new finding. submitted Notify the primary care provider. Utilize a Doppler ultrasound device to detect blood flow.
When developing a patient plan of care, which is an independent nursing action? Administer a stool softener at bedtime every day. submitted Collaborate with physical therapist to modify activity orders. Provide distraction between doses of pain medication. Request a high fiber diet from nutrition services. According to the American Nurses Association Scope and standards of practice, the RN provides safe, realistic care in a timely manner falls under which stage of the nursing process?
“I value your opinion and would appreciate your input.” submitted “I appreciate your opinion, but I feel my idea is the best approach here.” How does the electronic health record (EHR) facilitate evidence-based nursing practice? It ensures clinical practice guidelines are implemented. Patient information can be integrated between multiple departments. submitted Aggregated patient data can be used to support nursing decisions. Nurses spend less time documenting allowing for more patient contact. You have used 1 of 1 attempt Some problems have options such as save, reset, hints, or show According to guidelines for documenting in the electronic health record (EHR), what is the RN’s action when a documentation mistake is made? Report it to the nurse manager and record the data. Delete the entry and note time it was done. Strike through the entry once and rewrite the correct data. submitted Address the mistake and enter the corrected new information. The RN applies the NANDA-I nursing diagnosis Ineffective airway clearance and encourages the patient to cough and deep breathe after surgery. Which evaluative statement reflects the ANA Standards of Practice for Evaluation competency of documenting the results of the evaluation? The patient expectorated a large amount of yellow sputum after the interventions. The patient was able to take deep breaths after the interventions. The patient was able to cough and deep breathe three times. The patient coughed effectively after the interventions. submitted According to the ANA Standards of Nursing Practice, the RN elicits the patient’s values, preferences, and expressed needs during which phase of the nursing process? Assessment submitted Outcome Implementation Evaluation The RN assesses a patient’s radial pulse and notes it is difficult to palpate and then disappears
when slight pressure is applied. Using the number scale associated with pulse quality, what number should be assigned to this finding? 0
The RN assigned the unlicensed assistive personnel (UAP) to obtain a patient’s vital signs. The UAP reports the blood pressure is 200/100 mm Hg. Which intervention is a priority for the RN? Assign an RN to assess the blood pressure. Assess the patient and re-check the blood pressure. submitted Instruct the UAP to repeat the blood pressure. Administer anti-hypertensive medication as prescribed. The student nurse asks the RN to explain the difference between a comprehensive physical assessment and a focused physical assessment. Which is the appropriate response by the RN? “A focused physical assessment is limited to an overall patient problem.” “A focused physical assessment requires an order from a health care provider.” “A comprehensive physical assessment includes a health history and a complete head-to- toe.” submitted “A comprehensive physical assessment is completed, at every interaction with the patient.” Which information included in the RN’s documentation for a patient who is unhappy with care demonstrates the RN requires additional teaching?
“Patient complained of generalized pain and discomfort while awake.” “Call placed at 1000 to health care provider, to clarify pain medication frequency.” “Patient used incentive device with 10 repetitions, productive cough with yellow tinged sputum.” “Patient refused oral pain medication, stated intravenous medications work better.” submitted What is the purpose of nursing informatics? Use data to support decision-making. submitted Decrease the need for multiple face to face meetings. Reduce the likelihood of patient privacy issues. Enhance the non-verbal communication method. What method does the RN use to recognize significant cues when analyzing patient data to identify health problems? Compare patient data to population norms. Seek out data that supports the health problem. submitted Focus on a specific body system.
Request professors to change course assignments after first visit.
Limit interaction with classmates until improvement. Take anti-anxiety medication as prescribed every day. Verbalize feeling of control in stressful situations by next visit.submitted The RN recognizes which patient statement provides information about health belief locus of control? “I have decided not to perform breast self-examination.” “I try to eat foods that are low in fat.” submitted “I schedule a physical examination every year.” “My Illness is the result of my bad behavior.” The registered nurse working in a college health clinic assesses a student who states “I’m usually too tired to go out on the weekends. I spend time alone in the dorm room and don’t communicate with a close friend because of an issue with another student.” The RN interprets this as which type of coping mechanism? Denial Rationalization Identification Avoidance submitted
Which nursing intervention demonstrates the RN applies clinical guidelines when communicating with a patient who has impaired speech? Offer the use of headphones.
Tactile The RN enters the room and initiates a conversation with an adult patient who was just given a poor prognosis. Which statement made by the RN is most therapeutic?
“This is an upsetting diagnosis, I know a nurse who had the same thing.” “I can come back so you can have some time to yourself.” submitted “You seem upset right now; would it help to talk about your illness?” “You’ll get through this; I have cared for many patients who are very ill.” Which intervention observed by the RN while the unlicensed assistive personnel (UAP) obtains a blood pressure indicates the need for further education? Immediately inflates the cuff to a higher level when the first sound is heard. submitted Measures the blood pressure in both arms for the initial reading and records both readings. Uses a pediatric cuff for an emaciated patient with very little muscle mass. Places the cuff on bare skin two inches above the antecubital space. Which intervention should the RN implement as a health promotion activity? Volunteer to make quilts for a homeless shelter. Teach a patient with a broken tibia how to use crutches. Refer a patient to home care during a clinic visit. Present the dangers of smoking to a class of seventh graders. submitted
