1. A nurse enters the room of a 32-year-old pt newly diagnosed with cancer at the beginning of the 0700 evening/night shift. The nurse noted in the pt's
... [Show More] nursing history that this is her first hospitalization. She is scheduled for surgery in the morning to remove a tumor and has questions about what to expect after surgery. She is observed talking with her mother and is crying. The pt says, "This is so unfair." An order has been written for an enema to be given this evening in preparation for the surgery. The nurse establishes priorities for which of the following situations first?
1. Giving the enema on time
2. Talking with the pt about her past experiences with illness
3. Talking with the pt about her concerns and acknowledging her sense of unfairness
4. Beginning instruction on postoperative procedures
1. Answer: 3. The patient is obviously emotionally upset. Her concerns, whether they be about surgery or cancer or both, need to be addressed first for her to be able to be instructed and to be comfortable for the enema. Talking with the patient about her past experiences may be appropriate in the long term, but is less important than the other three priorities.
2. A 62-year-old pt had a portion of the large colon removed and a colostomy created for drainage of stool. The nurse has had repeated problems with the pt's colostomy bag not adhering to the skin and thus leaking. The nurse wants to consult with the wound care nurse specialist. Which of the following should the nurse do? (Select all that apply.)
1. Assess condition of skin before making the call
2. Rely on the nurse specialist to know the type of surgery the pt likely had
3. Explain the pt's response emotionally to the repeated leaking of stool
4. Describe the type of bag being used and how long it lasts before leaking
5. Order extra colostomy bags currently being used
2. Answer: 1, 3, 4. The nurse should have as much information available before making the call to the nurse specialist. It is also important for the nurse to interpret and explain the problem. In addition it is important to explain the patient's perspective. Assuming the nurse specialist knows the extent of the surgery is not appropriate.
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3. It is time for a nurse hand-off between the night nurse and nurse starting the day shift. The night nurse checks the most recent laboratory results for the pt and then begins to discuss the pt's plan of care to the day nurse using the standard checklist for reporting essential information. The pt has been seriously ill, and his wife is at the bedside. The nurse asks the wife to leave the room for just a few minutes. The night nurse completes the summary of care before the day nurse is able to ask a question. Which of the following activities are strategies for an effective hand-off? (Select all that apply.)
1. Using a standardized checklist for essential information
2. Asking the wife to briefly leave the room
3. Completing the hand-off without inviting questions
4. Doing prework such as checking laboratory results before giving a report
5. Including the wife in the hand-off discussion
3. Answer: 1, 4. Using standardized forms or checklists and doing thorough pre work enhances the nurse's ability to communicate the plan of care effectively during a handoff. The other two options are barriers to an effective hand-off.
4. A nurse assesses a 78-year-old pt who is 108.9 kg (240 lbs) and partially immobilized b/c of a stroke. The nurse turns the pt and finds the skin over the sacrum is very red and the pt does not feel sensation in the area. The pt has had fecal incontinence on and off for the last 2 days. The nurse identifies the nursing diagnosis of Risk for Impaired Skin Integrity. Which of the following outcomes is appropriate for the pt?
1. Pt will be turned every 2 hrs within 24 hrs.
2. Pt will have normal bowel function w/i 72 hrs
3. Pt's skin integrity will remain intact thru discharge.
4. Erythema of skin will be mild to none w/i 48 hrs
4. Answer: 4. The statement "Patient will be turned every 2 hours within 24 hours" is an intervention. The statements "Patient will have normal bowel function within 72 hours" and "Patient's skin integrity will remain intact through discharge" are goals.
5. Which factors does a nurse consider in setting priorities for a pt's nursing diagnoses? (Select all that apply.)
1. Numbered order of diagnosis on the basis of severity
2. Notion of urgency for nursing action
3. Symptom pattern recognition suggesting a problem
4. Mutually agreed on priorities set with pt
5. Time when a specific diagnosis was identified
5. Answer: 2, 3, 4. All factors are considered in setting priorities for a patient's nursing diagnoses or collaborative problems. The numbered order of diagnosis based on severity is inappropriate as a numbering system holds little meaning when a patient's condition changes.
6. A home health nurse visits a 42-year-old woman with diabetes who has a recurrent foot ulcer. The ulcer has prevented the woman from working for over 2 weeks. The pt has had diabetes for 10 years. The ulcer has not been healing; it has drainage with a foul-smelling odor. As the nurse examines the pt, she learns that the pt is not following the ordered diabetic diet. Which of the following is considered a low-priority goal for this pt?
1. Achieving wound healing of the foot ulcer
2. Enhancing pt knowledge about the effects of diabetes
3. Providing a dietitian consultation for diet retraining
4. Improving pt adherence to diabetic diet
6. Answer: 2. The high priority for this patient is wound healing. If the ulcer is left untreated it will cause more serious harm; an infection is likely and it could spread. Providing a diet consult is an intervention. Improving patient adherence to her diet is an intermediate outcome. Adherence to the diet is important but not life threatening when unmet. Since the patient has had diabetes for 10 years, enhancing knowledge is important because of her poor adherence but a lower priority than the others.
7. The nurse writes an expected outcome statement in measurable terms. An example is:
1. Pt will have normal stool evacuation.
2. Pt will have fewer bowel movements.
3. Pt will take stool softener every 4 hours.
4. Pt will report stool soft/formed with each defecation.
7. Answer: 4. Stool that is soft and formed at each defecation is measurable upon observation. "Patient will have normal stool evacuation" is a goal. "Patient will take fewer bowel movements" is not specific enough for measuring improvement. "Patient will take stool softener every 4 hours" is an intervention.
8. A pt has the nursing diagnosis of Nausea. The nurse develops a care plan with the following interventions. Which are examples of collaborative interventions? (Select all that apply.)
1. Providing mouth care every 4 hours
2. Maintaining intravenous (IV) infusion at 100 mL/hr
3. Administering prochlorperazine (Compazine) via rectal suppository
4. Consulting with dietitian on initial foods to offer pt
5. Controlling aversive odors or unpleasant visual stimulation that triggers nausea
8. Answer: 2, 4. The options "Provide mouth care every 4 hours" and "Control aversive odors or unpleasant visual stimulation that triggers nausea" are independent nursing interventions. The option "Administer prochlorperazine (Compazine) via rectal suppository" is a dependent intervention. [Show Less]