the nurse performs short assessment of a neonatal who is displaying s/s jaundice. Nurse observes the infants skin color and orders a test for bilirubin levels to report to the primary care provider. what type of assessment is this?
the nurse is admitting 35 yo pregnant woman to the hospital for treatment of preeclampsia. the Patient asks the nurse: "why are you doing a history and physical exam when the doctor just did one?" which statement best explains the primary reason a nursing assessment is performed? select all that apply
when you receive the shift report, you learn that your patient has no special skin care needs. you are surprised during the bath to observe reddened areas over bony prominences. what type of action is appropriate?
5 human needs
5 human needs
student nurse attempts to perform a nursing history for the first time. the student nurse asks the instructor how anyone ever learns all the questions the nurse must ask to get good baseline data. what would be the instructors best reply?
nurse collects S/O data when conducting patient assessments. which patient conditions are examples of subjective data? select all that apply
a) patient tells the nurse that she is feeling nauseous
b) Pt ankles are swollen
c) Pt tells the nurse that she is nervous about her test results
d) Pt complains of having a rash on her arm that is itchy
e) Pt rates his pain as a 7 on a scale of 1 to 10
f) Pt vomits after eating super
a, c, d, e
when Nx enters the Pt room to begin nursing history, the Pt's wife is there. what should the nurse do?
Ns is surprised to detect an elevated temperature (102F) in Pt scheduled for surgery. the Pt has been afebrile and shows no other signs of being febrile. what is the first thing the Ns should do?
a student Ns tells the instructor that the Pt is fine and has "no complaints." what would the instructors best response be?
which steps are related to nursing Dx?
a) use interview to collect data
b) analyze data collected
c) develop care plan
d) points out the Pt's strengths
e) assess the Pt's mental status
f) identify community resources to help family cope
b, d, f
Ns caring for an older Pt who presents with labored respirations, productive cough, and fever. what would be appropriate nursing Dx for this Pt? select all that apply
a) bronchial pneumonia
b) impaired gas exchange
c) ineffective airway clearance
d) potential complication: sepsis
e) infection related to pneumonia
f) risk for septic shock
b, c, f,
1) no problem
2) possible problem
3) actual or potential nursing Dx
4) clinical problem other than nursing Dx
patient outcome requires medical assessment
when initial Ns assessment reveals Pt has zero bowel movements over duration of 2 days, the student Ns writes "constipation" in Dx label. The instructor will most likely say
Ns makes clinical judgement that an AfAm male Pt in a stressful job is more vulnerable to develop hypertension than White male Pts in the same situation. the Ns has formulated what type of nursing diagnosis?
when helping a Pt turn in bed, the nurse notices that his heels are reddened and plans to place him on precautions for skin breakdown. this is an example of what type of planning?
Ns is prioritizing the following Pt diagnoses according to Moslow's hierarchy of human need:
(1) Disturbed body image
(2) Ineffective airway clearance
(3) spiritual distress
(4) impaired social interaction
Rn is using CareMaps methodology for choosing interventions for a Pt who is receiving chemotherapy for breats cancer. which nursing actions are characteristics of this systems being used when planning care? select all that apply.
a) Rn uses minimal practice standard and is able to alter care to meet the Pt's individual needs
b) Rn uses binary decision tree for stepwise assessment intervention
c) Rn is able to measure the cause-and-effect relationship between pathway and patients
d) Rn uses broad, research-based practice recommendations that may or may not have been tested in clinical practice
e) Rn uses preprinted provider orders used to expedite the order process after a practice standard has been validated through research
Rn in stroke unit prepares clinical outcome for a 32 yo marathon runner with paresis on Rt side of her body
Rn is caring for an elderly male patient who is receiving fluids for dehydration. which outcome for this patient is correctly written?
Rn is collecting more Pt data to confirm Dx emphysema for 68 yo male Pt. what type of of Dx does this intervention seek to confirm?
school Rn notices female student may have eating disorder AEB weight loss. how should she proceed?
school Rn is performing assessment of student who states: "im too tired to keep my head up in class." the student has a low-grade fever. the nurse would interpret these findings as indicating which stage of infection?
in addition to standard precautions, the nurse would initiate droplet precautions for which Pts? select all that apply
a, b, f
in addition to standard precautions, the nurse would initiate airborne precautions for which Pts? select all that apply
b, c, d
in addition to standard precautions, the nurse would initiate contact precautions for which disease?
mumps, rubella, & diphtheria have what Transmission-based Precautions?
measles, TB, & varicella have what transmission-based precautions?
Rn finished w/ Pt care. How would the Rn dof PPE when leaving the room?
Rn starting w/ Pt care. How would the Rn don PPE when entering the room?
when do RN use sterilization to break cycle of infection?
when do RN use disposable gloves to break cycle of infection?
when do RN use dry dressing to break cycle of infection?
when do RN use pesticides that will eliminate vectors to break cycle of infection?
when do RN use proper disposal of sharps to break cycle of infection?
when do RN use immunizations and screenings of staff to break cycle of infection?
RN cares for Pt in long-term care facility knows there are factors that place certain Pts at a higher risk for falls. select all that apply?
a) >60 yo
b) already fallen x2
c) taking antibiotics
d) experiences postural hypotension
e) experiencing nausea from chemotherapy
f) 70 yo Pt recently transferred to LTC facility
b, d, f
Pt uses furniture as ambulatory aid and forgets their own limitations. according to Morse Fall Risk Assessment, how would this person score?
Pt in acute care on IV has history of falling x2. according to Morse Falls Risk Assessment, how would this patient score?
Pt has fallen twice and forgets limitations. Morse Fall Risk Assessment says?
Pt uses cane to walk and reports feeling weak. according to Morse Fall Risk Assessment, the Pt would score?
Rn will prepare exercise routine for Pt w/ COPD. select all that apply
a) avoid sudden changes in position, which may lead to dizziness
b) restrict fluids until after workout
c) push further beyond fatigue
e) modify routine if weak or ill
f) avoid workouts in very hot or very cold temperatures
Rn is providing ROMs when Pt says "i am too tired to move on." select all that apply
a) stop ROMs
b) decrease reps
c) re-evaluate plan of care
d) encourage Pt to finish set and then rest
e) assess the Pt for other symptoms
a, c, e
Pt on bed rest upon recovering after spinal cord injury. Which position will prevent footdrop?
Pt spinal cord injury in short-term rehab. which position is indicated?
Rn planning hygiene for Pt on her unit. what is the most important consideration when planning a Pt's personal hygiene?
Rn performing skin assessment on Pts must pay careful attention. which guidelines should nurse follow?
a) compare bilateral parts for symmetry
b) proceed head-to-toe in a systematic manner
c) use standard terminology when documenting
d) do NOT allow data from the nursing history to direct the assessment
e) perform the appropriate skin assessment when risk factors are identified
a, c, e
which is not a part of assessment for hygiene?
Dx for hygiene is NOT correct?
subjective: xerostomia; objective: halitosis
true or false?
subjective: family reports change in interaction; objective: impaired social functioning
T or F?
using principles of standard precaution, the nurse would wear gloves in what nursing interventions?
Rn is preparing to take vital sign in an alert client admitted to hospital w/ dehydration secondary to vomiting and diarrhea. what is the best method used to assess the client's temperature?
two Pts on your floor have HAIs. one has MRSA and the other has C. Difficile. what isolation precaution will you institute?
Rn is concerned about a patient's ability to withstand exposure to pathogens. what blood component should the nurse monitor?
which nursing action protects the Pt from infection at the portal of entry?
blood and tissue are examples of
which one is NOT an example of portals of exit/entry?
nurse in MedSurge is preparing hygiene Plan for elderly Pt who has self-care deficits. which one is INCORRECT?
Rn explaining to the Pt that
poor oral care leads to colonization of oropharyngeal secretions by respiratory pathogens would fall under what face of the nursing process?
"Pt states mouth feel refreshed," in regards to documentation, would go under what phase of the nursing process?
which one is not a valid implementation for oral hygiene
when would you perform an initial assessment?
when would you use Quick priority assessments?
when would you use the problem focused assessment? select all that apply
a) new patient
b) beginning of shift
c) nurse-initiated intervention
d) home visit
e) emergency room
b, c, d
what time of assessment would you use during a home visit? select all that apply?
RN ambulates 48 yo female Pt for first time post-op for knee replacement. shortly after beginning to walk, the Pt tells the Rn that she feels dizzy and weak like she might fall. Select the first step in the Nursing Priority for this Pt?
49 yo male Pt injured spinal cord in motorcycle accident is receiving rehab in short-term setting. the Rn cares for him correctly by NOT placing him in which position?