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NURS 201 EXAM 2 | ALL QUESTIONS AND CORRECT
ANSWERS | ALREADY GRADED A+ | VERIFIED
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A 60-year-old patient complains of fatigue and difficulty breathing. He is diagnosed with chronic obstructive pulmonary disease (COPD). The nurse helps the patient sit in a semi-Fowler's position, and administers oxygen therapy as prescribed by the healthcare provider. What should be the expected outcome in this patient? ---------CORRECT ANSWER----------------
- The patient's respiratory rate will be 22 breaths per minute. The nurse is explaining the case management model to a group of nursing students. Which characteristics best describe the model? Select all that apply. ---------CORRECT ANSWER------------------ Multidisciplinary care plans are used.
- Case managers coordinate discharge planning.
- Communication with healthcare team members is important.
- The model serves to promote patient safety and quality. What are the components of the evaluation phase of the nursing process? Select all that apply. ---------CORRECT ANSWER------------------ Examining a condition or situation
- Judging if the desired change has occurred The nurse is caring for a 40-year-old patient undergoing chemotherapy. The patient reports nausea and vomiting. The nurse administers antiemetic medications as ordered. Which criteria would the nurse use to evaluate the patient's response to the care provided? Select all that apply. --------- CORRECT ANSWER------------------Outcome
- goal
Which characteristics of good feedback did the RN use when talking to the nursing assistant? Select all that apply. ---------CORRECT ANSWER--------- --------- Feedback focuses on one issue.
- Feedback offers concrete details.
- Feedback identifies ways to improve.
- Feedback focuses on changeable things. A patient is scheduled for surgery. The nurse is teaching interventions to the patient to decrease postoperative complications. Which level of intervention is required for the patient? ---------CORRECT ANSWER---------- -------Intermediate An intermediate priority is for situations that are ---------CORRECT ANSWER-----------------not an emergency nor life threatening for the patient A low-priority level is not directly related to ---------CORRECT ANSWER----- ------------the patient's illness or disease. Which strategies focus on improving the nurse-physician collaborative practice? Select all that apply. ---------CORRECT ANSWER------------------ Inviting the physician to attend the practice council meeting
- Participating in physician morning rounds
- Contacting the physician promptly to discuss patient problems A patient is admitted to the hospital for acute exacerbation of asthma. The patient outcomes include the patient being able to walk for 100 meters by the second day and not reporting breathlessness while walking. The patient's respiratory rate will remain normal while walking; the patient needs to be observed for breathlessness while walking. Which of these is
A philosophy of care includes the professional nursing staff's values. Which factors are essential to a philosophy of care? Select all that apply. --------- CORRECT ANSWER------------------ Selection of the management structure
- Selection of a nursing care delivery model A human response to health conditions that may develop in a vulnerable individual is a what kind of diagnosis? ---------CORRECT ANSWER----------- ------risk nursing diagnosis A human response to health conditions that exist in an individual or community is a what kind of diagnosis? ---------CORRECT ANSWER--------- --------actual nursing diagnosis What is A potential response to the health problem that can change by using specific nursing interventions ---------CORRECT ANSWER--------------- --related factor A risk nursing diagnosis describes ---------CORRECT ANSWER----------------
- human responses to health conditions or life processes that may develop in a vulnerable individual, family, or community. What are some examples of collaborative problems? ---------CORRECT ANSWER------------------ Paralysis
- Hemorrhage
- Wound infection Which is an example of an interpreting error in nursing diagnostic? --------- CORRECT ANSWER-----------------inaccurate understanding of cues
What does the P ing the acronym PES stand for? ---------CORRECT ANSWER-----------------Problem Which errors may occur when the nurse makes the nursing diagnosis prior to grouping all data? ---------CORRECT ANSWER-----------------Errors in data clustering The nurse is teaching nursing students about medical diagnoses. Which statements by the students indicate effective learning? Select all that apply. ---------CORRECT ANSWER------------------ "Osteoarthritis is a medical diagnosis."
- "Medical diagnoses are based on the results of diagnostic tests."
- "A primary healthcare provider is licensed to describe medical diagnoses." A patient complains of pain when swallowing solid food. The nurse asks the patient if he or she has a history of substance abuse that has caused this pain. What kind of diagnostic error does the nurse make in this scenario? -- -------CORRECT ANSWER-----------------Errors in data collection The nurse is reviewing a patient's list of nursing diagnoses in the medical record. The most recent nursing diagnosis is diarrhea related to intestinal colitis. Why is this an incorrectly stated diagnostic statement? --------- CORRECT ANSWER-----------------It identifies the medical diagnosis instead of the patient's response to the diagnosis.
A goal describes a desired change in a patient's condition or behavior. For which patient is a short-term goal appropriate? ---------CORRECT ANSWER-----------------A patient who has acute pain related to incisional trauma A group of nursing students is being taught independent nursing interventions. Which interventions should be included in the teaching? Select all that apply. ---------CORRECT ANSWER------------------ Health promotion
- Assisting with daily activities
- Repositioning a patient for pain relief The nurse is assessing patients in a medical unit. What priority level is assigned to the patient diagnosed with decreased gas exchange? --------- CORRECT ANSWER-----------------High priority There are seven guidelines that the nurse should keep in mind while writing goals and expected outcomes. ---------CORRECT ANSWER----------------- they are
- patient-centered goals or outcomes,
- a singular goal or outcome,
- observable,
- measurable,
- time-limited,
- mutual factors
- realistic.
The nursing process is an essential component of nursing practice. When using a five-step nursing process, what is the third step? ---------CORRECT ANSWER-----------------Planning what does "ANd PIE" stand for? ---------CORRECT ANSWER----------------- Assessment, Nursing diagnosis, Planning, Implementation, and Evaluation Which nursing intervention is included in the standard care plan while caring for a critically ill patient? ---------CORRECT ANSWER----------------- suggesting the patient use a chlorhexidine mouthwash regularly A patient diagnosed with pancreatitis complains of pain in the abdomen. The patient has vomited three times, and has a temperature of 101° F. Following an initial interview and assessment, the nurse prepares a nursing care plan. The nurse formulates a diagnosis of acute pain. What could be the related factor for this diagnostic label? ---------CORRECT ANSWER------ -----------Inflammation of the pancreas The nurse is caring for a patient with a hearing impairment. What should the nurse do when communicating with this patient? Select all that apply. -- -------CORRECT ANSWER------------------ Maintain eye contact
- nod the head in affirmation
- lean forward during conversation The nurse is assessing a patient's data for the related factor of the nursing diagnosis. Which statements are true regarding the related factor? Select all that apply. ---------CORRECT ANSWER------------------ The related factor is within the domain of nursing practice.
- In the case of a risk nursing diagnosis, the risk factor is the related factor.
-----CORRECT ANSWER------------------ "The nursing diagnostic statements emphasize following traditional practice guidelines."
- "The nursing diagnostic statements align the role of the nurses with other health care providers."
- "The nursing diagnostic statements help the nurses focus on the scope of medical practice as a whole." A nurse is teaching a group of nursing students about the use of NANDA-I terminologies in the medical record entry. Which statements made by the student indicate the need for further education? Select all that apply. --------
- CORRECT ANSWER------------------"NANDA-I diagnoses do not take into consideration evidence-based diagnoses."
- "NANDA-I diagnoses are refined by the primary health care provider on a regular basis." The nurse is teaching a group of students about the application of nursing diagnosis to care planning. Which statements indicate effective learning? Select all that apply. ---------CORRECT ANSWER------------------ "Nursing diagnoses direct the planning process and the selection of nursing interventions."
- "Nursing diagnosis of damaged skin directs a nurse to apply a support surface to a patient's bed and initiate a turning schedule." The nurse uses various assessments to collect data about a patient. Which statements are true about the types of assessments? Select all that apply. - --------CORRECT ANSWER------------------ Emergency assessment is performed when the patient's situation is life threatening.
- Ongoing assessment is performed and continued throughout the patient's healthcare experience.
- Focused assessment is done after a patient's general problems have been identified, when a patient has a complaint, or describes a new problem.
The nurse is designing a plan of care for a patient who is has been diagnosed with pneumonia. The nurse determines that the patient is experiencing impaired gas exchange in the lungs. Which components of the assessment data can be part of the related factors for this patient? Select all that apply. ---------CORRECT ANSWER------------------ Decreased ventilatory effort due to fatigue
- Accumulation of secretions within the alveoli The nurse is assigned to a 78-year-old patient who just entered the hospital with symptoms of H1N1 flu. The nurse finds the patient to be short of breath with an increased respiratory rate of 30 breaths per minute. He lost his wife just a month ago. The nurse's knowledge about this patient would result in which type of assessment approach at this time? Select all that apply. ---------CORRECT ANSWER------------------ A problem-focused approach
- Using multiple visits to gather a complete database A patient has arrived at the emergency department (ED) complaining of fatigue and memory loss. While performing the health assessment, which back-channeling techniques may the nurse use during the patient interview? Select all that apply. ---------CORRECT ANSWER------------------ "I see."
- "Go on"
- "All right"
- Maintain good eye contact and show interest in what the patient is saying. When obtaining data for an assessment, the nurse must substantiate or confirm the accuracy of the information by using another source or another method. This is known as validating. Which statements are the examples of this process? Select all that apply. ---------CORRECT ANSWER---------------- -- Validate the findings with information from the patient's family.
- Turn the patient every 2 hours from supine to prone to right side. Ethical care is part of a priority setting. Which nursing intervention indicates delivering ethical care? ---------CORRECT ANSWER----------------- Discussing the condition with the patient Nursing intervention plays a vital role in achieving desired outcomes. What are the categories of nursing interventions? Select all that apply. --------- CORRECT ANSWER------------------ Collaborative interventions
- Nurse-initiated intervention
- Physician-initiated interventions The nurse gives information to nursing students about nursing interventions classification. What are the levels of the nursing interventions classification model? Select all that apply. ---------CORRECT ANSWER------------------ Domains
- Classes
- Interventions The nurse is preparing a nursing care plan for a patient with a hernia. What are the basic concepts that a nursing care plan should emphasize? Select all that apply. ---------CORRECT ANSWER------------------ Nursing diagnoses
- Specific nursing interventions
- Goals and expected outcomes Planning is an integral part of the nursing process. What processes are involved in the planning phase? Select all that apply. ---------CORRECT ANSWER------------------ Setting priorities
- Prescribing nursing interventions
- Identifying patient-centered goals Regarding home healthcare, which statement describes the unique difference between a hospital's nursing care plan and the home care plan? ---------CORRECT ANSWER-----------------The patient and family need to be able to provide most of the healthcare. What are some of the chief components of the nursing process? Select all that apply. ---------CORRECT ANSWER------------------ Diagnosis
- Assessment
- Implementation
- planning
- evaluation What actions should the nurse perform to reduce anxiety in the patient? Select all that apply. ---------CORRECT ANSWER------------------ Use a calm approach in discussions.
- Work with the physician to provide factual medical information. The nurse conducts health awareness training programs at a community center. What kind of action is this? ---------CORRECT ANSWER--------------- --primary prevention The nurse is caring for a preoperative patient in a coronary care unit. After reviewing the nursing diagnoses, the nurse prioritizes them. Which nursing diagnoses are considered high priorities for the patient? Select all that apply. ---------CORRECT ANSWER------------------ Reduced oxygenation
Which factors must be considered when choosing a nursing intervention to address a patient problem? Select all that apply. ---------CORRECT ANSWER------------------ Outcomes that have been set for the patient
- Research evidence supporting the intervention
- Likelihood of successfully completing the intervention
- Nature of the nursing diagnosis The nurse is discussing the features of having an effective phone consultation with a healthcare provider. What tips are helpful for making phone consultations? Select all that apply. ---------CORRECT ANSWER----- ------------- Assess the patient thoroughly before making the call.
- Have the complete information about the problem before the call.
- Understand the reason behind the call and think through some possible solutions.
- Give feedback on the outcomes of previous recommendations. The nurse is caring for a patient sustained a knee injury during a football game. The knee requires arthroplasty. The nurse finds that the patient is anxious about his ability to play after the surgery. The nurse determines the patient has anxiety and selects it as a diagnostic label; the nurse clusters its defining characteristics. The goal is for the patient to express acceptance of his health status by the day of discharge. What are the expected outcomes for the goal? Select all that apply. ---------CORRECT ANSWER------------------ The patient describes the effects surgery will have on his recovery.
- The patient discusses the surgical outcomes with the surgeon in 24 hours.
- The patient is certain of his good performance in a football match within 12 weeks.
The nurse assesses a 78-year-old patient who weighs 240 lb (108.9 kg) and is partially immobilized because of a stroke. The nurse turns the patient and finds that the skin over the sacrum is very red and the patient does not feel sensation in the area. The patient has had fecal incontinence on and off for the last 2 days. The nurse identifies the nursing diagnosis of risk for bed sores. Which goals are appropriate for the patient? Select all that apply. ---------CORRECT ANSWER------------------ Patient will have normal bowel function within 72 hours.
- Patient's skin will remain intact through discharge. Which outcome statements for the goal, "Patient will achieve a gain of 10 lb (4.5 kg) in body weight in a month" are worded incorrectly? Select all that apply. ---------CORRECT ANSWER------------------ Patient will verbalize relief of nausea and have no episodes of vomiting in 1 week.
- Give patient liquid supplements 3 times a day.
- Provide patient high-calorie meals 3 times a day. When does implementation begin as the fourth step of the nursing process? ---------CORRECT ANSWER-----------------After the care plan has been developed What are acceptable components of a comprehensive nursing care plan? Select all that apply. ---------CORRECT ANSWER------------------Infection risk
- Respiratory rate of 24 breaths per minute
- Oxygen at 2 liters per nasal cannula
Which option is true regarding a goal that specifies the expected behavior or response? ---------CORRECT ANSWER-----------------Resolution of a nursing diagnosis or maintenance of a healthy state What should the nurse do while documenting and reporting the evaluation of interventions in the care of a patient? ---------CORRECT ANSWER--------- --------If a patient is not progressing, the nurse should report it to the primary health care provider. The nurse teaches interventions to a patient who is diagnosed with a urinary tract infection. During the follow-up visit, the patient's laboratory report shows an absence of infection. What is the appropriate nursing action in this situation? ---------CORRECT ANSWER----------------- Discontinuing the care plan During a follow-up visit, the nurse finds that the patient has symptoms of asthma despite receiving treatment to manage the disease. What is the priority nursing action? ---------CORRECT ANSWER----------------- Performing a reassessment A patient with diabetes who is immobile and does not ambulate, reports back discomfort. The nurse performs a back massage for the patient and changes the bed linens. What would be the suitable nursing-sensitive outcome for this issue? ---------CORRECT ANSWER-----------------The patient will have reduced back pain. A patient is admitted to the hospital with a respiratory infection. Following coughing and deep-breathing exercises, the nurse finds that the patient continues to have congested lungs. What should the nurse do? ---------
CORRECT ANSWER-----------------Increase frequency of coughing and deep-breathing exercises. The nurse is evaluating a patient's care plan. Which action does the nurse perform to redefine the diagnosis? ---------CORRECT ANSWER----------------
- Revise the patient's problem list. Which statements correctly describe the evaluation process? Select all that apply. ---------CORRECT ANSWER------------------Evaluation is an ongoing process.
- Evaluation involves making clinical decisions.
- Evaluation requires the use of assessment skills. A pediatric patient who sustained an injury a week ago is brought to the hospital by his mother. On examination, the nurse finds purulent drainage on the wound and a temperature of 38 °C. In addition, the patient is crying continuously. The patient is treated for acute symptoms and discharged with home health care follow up. Which goal statement is appropriate for the home health nurse's plan of care? ---------CORRECT ANSWER----------- ------The wound will completely heal by the time of discharge. You are the charge nurse on a surgical unit. You are doing staff assignments for the 3:00 PM to 11:00 PM shift. Which patient do you assign to the licensed practical nurse (LPN)? ---------CORRECT ANSWER-- ---------------The patient who had a vaginal hysterectomy 2 days ago and is being discharged tomorrow
