NUR104 - Quiz Study Guide Week 5
A pre-operative client states “I do not know what to expect after surgery.” How should
the RN respond?
Ask
... [Show More] the healthcare provider to answer the client’s questions.
Assess the client’s knowledge of the planned procedure.
Inform the charge nurse of the client’s knowledge deficit.
Educate the client about what to expect after the procedure.
Student feedback: Review the data collecting steps of nursing process in Treas, page 44.
Rationale: The RN should always assess and validate a client’s knowledge level when they don’t understand something. While it is ultimately the provider’s responsibility to explain procedures to the client, there are many questions the RN can answer that are within their scope of practice.
Reference: Treas, L., Wilkinson, J., Barnett, K. & Smith, M. (2018). Basic nursing: Thinking, doing, and caring (2nd ed). Philadelphia, PA: F.A. Davis. Pg. 44
An immobile client reports a new, red, sore area on their heel. What assessment will the RN complete first?
Assess the client’s nutritional status.
Assess the client’s self-care ability.
Assess the client’s comfort level.
Assess the client’s skin surfaces.
Student Feedback: Review the assessment step in the nursing process, especially focused assessment, in Treas pages 43,44.
Rationale: If a client reports possible skin integrity concerns, a full skin assessment should be conducted to determine if there are other areas of concern, first. Assessing nutrition, self-care ability and comfort are important, but the most important.
Reference: Treas, L., Wilkinson, J., Barnett, K. & Smith, M. (2018). Basic nursing: Thinking, doing, and caring (2nd ed). Philadelphia, PA: F.A. Davis. Pg. 43-44
What is the primary reason the RN evaluates a client’s progress toward the identified outcome?
It identifies whether the healthcare provider’s actions were effective.
It identifies if interventions were effective in meeting an outcome.
It identifies what additional problems the client might have.
It identifies if the nurse-client relationship can be terminated.
Student Feedback: Review evaluation final step of nursing process in Treas, page 115.
Rationale: The evaluation step of the nursing process helps the RN identify whether the interventions implemented by the RN have caused the outcome to be met.
Reference: Treas, L., Wilkinson, J., Barnett, K. & Smith, M. (2018). Basic nursing: Thinking, doing, and caring (2nd ed). Philadelphia, PA: F.A. Davis. Pg. 115-121
Question 4
5 / 5 pts Which deliberate, systematic problem-solving approach is used by the RN to meet a person’s health care needs?
Critical thinking
Nursing process
Reflective thinking
Concept mapping
Student feedback: Review the nursing process and see how the other processes fit into nursing process in Treas, pages 27-38 (especially 33).
Rationale: The nursing process is a problem - solving approach to meet client and nursing needs. Components are assessment, diagnosis, planning, implementation, and evaluation. Critical thinking is a process of insightful thinking based on knowledge that displays a willingness to ask questions when developing solutions. Critical thinking enhances clinical decisions by the RN. RN’s use critical thinking for decisions related to the nursing process
Reference: Treas, L., Wilkinson, J., Barnett, K. & Smith, M. (2018). Basic nursing: Thinking, doing, and caring (2nd ed). Philadelphia, PA: F.A. Davis. Pg. 33
Which action by the RN demonstrates critical thinking for a client that has a NANDA-I
nursing diagnosis of Deficient fluid volume?
Documenting a client’s intake and output for the previous 8 hours.
Evaluating a client’s intake and output for the previous 24 hours.
Adding additional fluids to the client’s tray to increase fluid intake.
Assessing a client’s understanding of fluid intake and providing education.
Student Feedback: Review how critical thinking impacts nurses decision making and action, in Treas, pages 28-32.
Rationale: Critical thinking requires the RN to use disciplined reasoning to discover a problem and formulate a solution. For a client who is fluid volume deficient, assessing their intake and understanding, combined with intervening with education signals higher level thinking, or critical thinking, required of the RN.
Reference: Treas, L., Wilkinson, J., Barnett, K. & Smith, M. (2018). Basic nursing: Thinking, doing, and caring (2nd ed). Philadelphia, PA: F.A. Davis. Pg. 28-32
What are characteristics of nursing diagnoses? Select all that apply.
They are prioritized based on Maslow’s Hierarchy.
They are focused on body systems and disease processes.
They are formed by recognizing patterns or data clusters.
They are developed by NANDA International (NANDA-I).
They are based on data obtained from client assessments.
Student Feedback: Review nursing diagnosis step of nursing process in Treas, pages, 56-62.
Rationale: Nursing diagnoses are prioritized based on Maslow’s Hierarchy, formed by recognizing patterns of data, developed by NANDA lnternational, and are based on data obtained from a client assessment.
Reference: Treas, L., Wilkinson, J., Barnett, K. & Smith, M. (2018). Basic nursing: Thinking, doing, and caring (2nd ed). Philadelphia, PA: F.A. Davis. Pg. 56-62
Which type of nursing diagnosis is used when there is a potential for a client problem to develop?
Actual nursing diagnosis
Risk nursing diagnosis
Wellness nursing diagnosis
Syndrome nursing diagnosis
Student feedback: Review the variety of diagnoses types in Treas, pages 59-60.
Rationale/ Feedback: A risk nursing diagnosis describes a problem that is likely to develop in a vulnerable client if the nurse and the client does not intervene. An actual nursing diagnosis the problem exists at the time of the assessment. A wellness nursing diagnosis identifies a health status but not a health problem. Syndrome nursing diagnosis represents a collection of nursing diagnoses that usually occur together.
Reference: Treas, L., Wilkinson, J., Barnett, K. & Smith, M. (2018). Basic nursing: Thinking, doing, and caring (2nd ed). Philadelphia, PA: F.A. Davis. Pg. 59-60
Which components are necessary for an actual nursing diagnosis statement? Select all that apply.
Diagnosis
Interventions
Symptom
Outcomes
Etiology
Student Feedback: Review the basic three-part statement (PES format) in Treas, pages 68-71.
Rationale: The nursing diagnosis identified and approved by NANDA-I, includes a related to factor (etiology) and includes the defining characteristics (symptoms/as evidenced by).
Reference: Treas, L., Wilkinson, J., Barnett, K. & Smith, M. (2018). Basic nursing: Thinking, doing, and caring (2nd ed). Philadelphia, PA: F.A. Davis. Pg. 68-71
Which component of a 3- part NANDA-I nursing diagnosis statement identifies the cause of the client problem?
Etiology
Definition
Symptom
Intervention
Student Feedback: Review the three part nursing diagnostic statement in Treas , pgaes 68-71.
Rationale: The etiology is the cause or the contributing factor believed to be at the root of the problem. The definition explains what the nursing diagnosis means. The
symptom is the evidence the problem exists. The nursing interventions are individualized actions needed to achieve the desired outcome.
Reference: Treas, L., Wilkinson, J., Barnett, K. & Smith, M. (2018). Basic nursing: Thinking, doing, and caring (2nd ed). Philadelphia, PA: F.A. Davis. Pg. 68-71
An RN has developed a plan of care for a client. Which nursing diagnostic statement requires revision?
Fear related to spouse’s death as evidenced by client stating, “I don’t know how I will go on”.
Impaired comfort related to prolonged hospital stay as evidenced by irritability and asking to go home.
Dysfunctional gastrointestinal motility related to absence of bowel sounds as evidenced by immobility.
Impaired bed mobility related to weakness as evidenced by client’s inability to change position in bed.
Student Feedback: Review the PES format in Treas, page 68-71.
Rationale: A nursing diagnosis statement contains a nursing diagnosis, physiologic factor (related factor) and subjective/objective data (as evidence by).
Reference: Treas, L., Wilkinson, J., Barnett, K. & Smith, M. (2018). Basic nursing: Thinking, doing, and caring (2nd ed). Philadelphia, PA: F.A. Davis. Pg. 68-71
Which statement by the student nurse indicates additional teaching about patient outcomes is necessary?
“The outcome includes a time estimate for attainment.”
“Outcomes must be realistic, measurable and culturally appropriate.”
“The outcome identifies what the nurse will do for the patient.”
“Outcomes are used to modify the plan based on patient response.”
Student feedback: Review components of goal statement in Treas, pages 84-85.
Rationale: Outcomes are patient-centered, must be observable, measurable, realistic, and culturally appropriate. The expected outcome also serves as a guide for selecting nursing interventions as well as a basis for evaluating and modifying the plan of care.
Reference: Treas, L., Wilkinson, J., Barnett, K. & Smith, M. (2018). Basic nursing: Thinking, doing, and caring (2nd ed). Philadelphia, PA: F.A. Davis. Pg. 84-85
Which patient outcome is correctly written?
Patient will list dangers of smoking and will stop smoking.
Patient will have clear lung sounds in bilateral upper and lower lobes within 3 days.
Patient will understand how to bathe her baby before being discharged home.
Patient will be offered 60 mL of fluid every 2 hours while awake.
Student Feedback: Review components of goal statement in Treas, pages 84-85.
Rationale: Outcomes are client-centered, must be observable, measurable, realistic, and culturally appropriate. The expected outcome also serves as a guide for selecting nursing interventions as well as a basis for evaluating and modifying the plan of care.
Reference: Treas, L., Wilkinson, J., Barnett, K. & Smith, M. (2018). Basic nursing: Thinking, doing, and caring (2nd ed). Philadelphia, PA: F.A. Davis. Pg. 84-86
Which is a characteristic of nursing interventions?
Interventions are based on the nursing workload.
Interventions identify a priority problem for the patient.
Interventions are consistent with standards of care.
Interventions always require a medical order.
Student Feedback: Review the nursing intervention information as apart of the nursing process in Treas, pages 94-95
Rationale: Nursing interventions are actions that are consistent with standards of care and will assist the client to achieve the expected outcome.
Reference: Treas, L., Wilkinson, J., Barnett, K. & Smith, M. (2018). Basic nursing: Thinking, doing, and caring (2nd ed). Philadelphia, PA: F.A. Davis. Pg. 94-95
The RN develops a plan of care and includes which of the following as a dependent intervention?
Reposition every 2 hours
Educate client
Administer medication
Perform range of motion
Student feedback: Review what determines if an intervention is dependent or independent action by the nurse on Treas, page 94.
Rationale: Dependent interventions require a provider order, and the order is carried out by the nurse. Independent nursing interventions do not require a health care provider order.
Reference: Treas, L., Wilkinson, J., Barnett, K. & Smith, M. (2018). Basic nursing: Thinking, doing, and caring (2nd ed). Philadelphia, PA: F.A. Davis. Pg. 94
After the interventions are completed, it is essential for the RN to complete which actions as part of the nursing process? Select all that apply.
Encourage the client to continue interventions.
Evaluate the effectiveness of the interventions.
Document that the interventions were completed.
Develop new interventions for the client.
Delegate at least some interventions.
Rationale: After completing interventions, the RN needs to evaluate the effectiveness of the interventions in meeting the outcome. Also documentation is considered a last step in implementation and is appropriate.
Reference: Treas, L., Wilkinson, J., Barnett, K. & Smith, M. (2018). Basic nursing: Thinking, doing, and caring (2nd ed). Philadelphia, PA: F.A. Davis. Pg. 115-121
Which action puts the RN at risk for legal liability when supervising health care staff?
Collaborating with team members to plan care and share decision making.
Educating the nursing assistive personnel (NAP) to provide client teaching.
Delegating tasks to staff based on job description and experience with task.
Completing hourly rounds to ensure delegated tasks were completed.
Student Feedback: Review the five rights of delegation for the RN in Treas, page 114.
Rationale: The 5 rights of delegation include right task, circumstance, person, communication, and supervision. The nursing assistive personnel (NAP) may not provide client teaching. It is out of their scope of practice.
Reference: Treas, L., Wilkinson, J., Barnett, K. & Smith, M. (2018). Basic nursing: Thinking, doing, and caring (2nd ed). Philadelphia, PA: F.A. Davis. Pg. 114
Which activity can be delegated to the nursing assistive personal (NAP) by the RN?
Complete vital signs for a client prior to the RN’s medication administration.
Assess the condition of the client’s abdominal dressing.
Determine if the client requires a laxative for constipation.
Assist the client to take medications if the RN brings to the bedside.
Student Feedback: Review the five rights of delegation for the RN in Treas, pages 113 & 114.
Rationale: The RN may not delegate assessments to the NAP but may delegate tasks if the NAP is qualified to complete the task.
Reference: Treas, L., Wilkinson, J., Barnett, K. & Smith, M. (2018). Basic nursing: Thinking, doing, and caring (2nd ed). Philadelphia, PA: F.A. Davis. Pg. 113, 114
The RN is caring for clients with the following NANDA-I nursing diagnoses. According to Maslow’s Hierarchy, which diagnoses relate to physiological needs? Select all that apply.
Risk for shock
Social isolation
Readiness for enhanced hope
Constipation
Impaired gas exchange
Student feedback: Review the human needs common in physiological and safety levels of Maslow’s Hierarchy in Treas, page 63.
Rationale: According to Maslow’s hierarchy, physiological needs are the highest priority, followed by safety, love and belonging, esteem and self-actualization.
Rationale: Treas, L., Wilkinson, J., Barnett, K. & Smith, M. (2018). Basic nursing: Thinking, doing, and caring (2nd ed). Philadelphia, PA: F.A. Davis. Pg. 63
Which outcome statement, written by the student RN, requires additional teaching?
The client will demonstrate how to correctly administer an insulin injection during this visit.
The client will increase understanding of their disease process by the end of this visit.
The client will ambulate to the nurse’s station and back with a steady gait by the end of the week.
The client will have clear lung sounds over upper and lower lobes by the end of this week.
Student Feedback: Review components of goal/outcome statement in Treas for measurability in Treas, pages 84-85.
Rationale: Outcomes must be client specific, measurable and have a time frame for completion.
Reference: Treas, L., Wilkinson, J., Barnett, K. & Smith, M. (2018). Basic nursing: Thinking, doing, and caring (2nd ed). Philadelphia, PA: F.A. Davis. Pg. 84-85
The RN has developed a plan of care for a client with Impaired skin integrity and the nursing assistive personnel (NAP) has turned and positioned the client every 2 hours. Which is the priority activity for the RN during the evaluation phase of the nursing process?
Evaluate the client for other problems.
Evaluate the client’s skin surfaces.
Evaluate the NAP’s repositioning skill.
Evaluate the client’s ability to position self.
Student Feedback: Review evaluation step of the nursing process in Treas, page 115.
Reference: Treas, L., Wilkinson, J., Barnett, K. & Smith, M. (2018). Basic nursing: Thinking, doing, and caring (2nd ed). Philadelphia, PA: F.A. Davis. Pg. 115
Rationale: In the evaluation phase of the nursing process the RN determines whether the interventions were effective in meeting the planned outcome. The plan can be modified if the interventions were not effective or more interventions can be added to the plan if supplementation is needed to achieve the outcome.
Quiz Score: 98.75 out of 100
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