1. Which of the following nursing actions demonstrates that the nurse
understands the nursing process?
a) Prioritizing patient goals, documenting all
... [Show More] health records precisely,
conducting the health history, and documenting the nursing diagnosis
b) Reviewing health record, documenting patient goals, identifying etiology
of the nursing problem, and evaluating treatment outcome.
c) Assessing for allergies, administering analgesic, obtaining baseline vital
signs, and documenting nursing diagnosis as acute pain
d) Obtaining vital signs, documenting nursing diagnosis as acute pain,
administering analgesic, and evaluating comfort level
d) Obtaining vital signs, documenting nursing diagnosis as acute pain,
administering analgesic, and evaluating comfort level
Rationale: Steps of the nursing process in order are: Assessment, Diagnosis,
Planning, Implementation, and Evaluation. Assessment is the systematic
collection of data to determine the patient's health status and any actual or
potential health problems. Nursing diagnoses are actual or potential health
problems that can be managed by independent nursing interventions.
Planning is the development of goals and outcomes. Implementation is the
actualization of the plan of care through nursing interventions. Evaluation
is the determination of the patient’s responses to the nursing interventions
and the extent to which the outcomes have been achieved.
2. The nurse educator is planning a teaching session for nursing students
related to treatment and management of gestational diabetes. The nurse
educator arranges for a dietitian, pharmacist, and physician assistant to
participate in the lesson plan. Which professional nurse competency is the
nurse educator demonstrating?
a) Evidence-based practice
b) Patient-centered care
c) Interdisciplinary teamwork
d) Quality improvement measures
c)Interdisciplinary teamwork
Rationale: By integrating interdisciplinary core competencies into their
respective curricula the nurse educator is demonstrating interdisciplinary
teamwork. A case-study approach planning care around individual patient
preferences is an example of patient-centered care. Conducting an
evidence-based literature review related to gestational diabetes reflects
evidence-based practice. Providing education related to
measures/indicators or tools used to assess the level of care provided
within a system of care to populations of patients with gestational diabetes
exemplifies a quality improvement measure.
3. A nursing student observes the home care nurse provide education to a
patient with congestive heart failure (CHF). The nurse teaches the patient
how to read food labels and calculate sodium content. The nursing student
recognizes that the home care nurse is aware of which of the following
basic principles of patient education?
a) The home care nurse is providing hospital discharge instructions
b) The home care nurse has a physician order to teach a 2-g sodium diet
c) Patients are required to learn about their therapeutic nutritional regimen
d) Patient instruction related to self-care activities promotes patient
independence
d) Patient instruction related to self-care activities promotes patient
independence
Rationale: Teaching is a function of nursing to assist patients to alter
lifestyle patterns that increase health risk. By teaching the client how to
calculate sodium content of foods the nurse is facilitating independence in
nutrition disease management. Patients have the right to decide whether or
not to learn. Teaching is an independent function of nursing and does not
require a physician’s order. Teaching related to food labels in the patient
home is an appropriate environment for this client. The nurse can use
actual foods from the patient’s kitchen.
4. A nurse working in the intensive care unit (ICU) refers to the Institute for
Healthcare Improvement (IHI) Ventilator Bundle prior to planning patient
care. The nurse realizes nursing interventions outlined in the bundle will
improve patients’ outcomes. Which of the following statement best
describes how IHI-established nursing interventions should be included in
each bundle?
a) Nursing interventions found within the IHI bundles were selected based
on the ability to provide optimal time management for the nurse
b) Best practice derived from valid and reliable research studies guided
nursing interventions being added to the IHI bundles
c) Nurse case managers serving as patient advocates recommended nursing
interventions to be included in the IHI bundles based on patient preference
d) Hospitals, physicians, and nurses worked collaboratively to design
patient care activities included in IHI bundles
b) Best practice derived from valid and reliable research studies guided
nursing interventions being added to the IHI bundles
Rationale: Bundles include evidence-based practices. Hospitals, physicians,
and nurses work collaboratively to provide care directed by bundles.
Nurses advocate on behalf of the patient. Effective time management is a
key element in the provision of care, however; IHI-based bundles on
evidence-based practice.
5. A 54-year-old woman on a fixed income has had an electrocardiogram
(ECG) as part of her annual physical examination. Her physician notes an
abnormal Q wave on an otherwise unremarkable ECG. What legislation
supports this focus on disease prevention, health promotion, and
management of chronic conditions?
a) Building a Safer Health System Act
b) The Patient Protection and Affordable Care Act
c) Healthcare Research and Quality Improvement Bill
d) A New Health System for the 21st Century Bill
b) The Patient Protection and Affordable Care Act [Show Less]