Nur1025 - T2 - Ch. 18 - Planning Nursing Care

Front 1

C1. A nurse is assigned to a pt who has returned from the recovery room following surgery for a colorectal tumor. After an initial assessment the nurse anticipates the need to monitor the pt's abdominal dressing, intravenous (IV) infusion, and function of drainage tubes. The pt is in pain, reporting 6 on a scale of 0-10, and will not be able to eat or drink until intestinal function returns. The fam has been in the waiting room for an hour, wanting to see the pt. The nurse establishes priorities first for which of the following situations? Select all that apply:
1. The fam comes to visit the pt.
2. The pt expresses concern about pain control
3. The pt's vital signs change, showing a drop in blood pressure.
4. The charge nurse approaches the nurse and requests a report at end of shift.

Back 1

2. 3.

Front 2

C2. A pt signals the nurse by turning on the call light. The nurse enters the room and finds the pt's drainage tube disconnected, 100 mL of fluid in the intravenous (IV) line, and the pt asking to be turned. Which of the following does the nurse perform first?
1. Reconnect the drainage tubing
2. Inspect the condition of the IV dressing
3. Improve the pt's comfort and turn onto her side.
4. Obtain the next IV fluid bag from the med room.

Back 2

1. Reconnect the drainage tubing

Front 3

C3. A nurse assesses a 78-year old pt who weighs 240 pounds and is partially immobilized because of a stroke. The nurse turns the pt and finds that 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 goals are appropriate for the pt? (Select all that apply):
1. Pt will be turned every 2 hours within 24 hours.
2. Pt will have normal bowel function within 72 hours.
3. Pt's skin will remain intact through discharge.
4. Pt's skin condition will improve by discharge

Back 3

2. 3. 4.

Front 4

C4. Setting a time frame for outcomes of care serves which of the following purposes?
1. Indicate which outcome has priority
2. Indicates the time it takes to complete an intervention.
3. Indicates how long a nurse is scheduled to care for a pt.
4. Indicates when the pt is expected to respond in the desired manner

Back 4

4.

Front 5

C5. A pt has been in the hospital for 2 days because of newly diagnosed diabetes. His medical condition is unstable, and the medical staff is having difficulty controlling his blood sugar. The physician expects that the pt will remain hospitalized at least 3 more days. The nurse identifies one nursing Dx as "deficient knowledge regarding insulin administration related to inexperience with disease management." Which of the following pt care goals are long term?
1. Pt will explain relationship of insulin to blood glucose control.
2. Pt will self-administer insulin.
3. Pt will achieve glucose control.
4. Pt wil describe steps for preparing insulin in a syringe.

Back 5

3. Pt will achieve glucose control.

Front 6

C6. A pt has been in the hospital for 2 days because of newly diagnosed diabetes. His medical condition is unstable, and the medical staff is having difficulty controlling his blood sugar. The physician expects that the pt will remain hospitalized at least 3 more days. The nurse identifies one nursing diagnosis as "deficient knowledge regarding insulin administration related to inexperience with disease management." What does the nurse need to determine before setting the goal of "pt will self-administer insulin?" (Select all that apply).
1. Goal within reach of the pt.
2. The nurse's own competency in teaching about insulin.
3. The pt's cognitive function.
4. Availability of family members to assist

Back 6

1, 3, 4.

Front 7

C7. The nurse writes an expected-outcome statement in measurable terms. An example is:
1. Pt will be pain free.
2. Pt will have less pain
3. Pt will take pain medication every 4 hours.
4. Pt will report pain acuity less than 4 on a scale of 0 - 10.

Back 7

4.

Front 8

C8. A pt has the nursing diagnosis of nausea. The nurse develops a care plan with the following interventions. Which are examples of collaborative interventions?
1. Provide frequent mouth care.
2. Maintain intravenous (IV ) infusion at 100 mL/hr.
3. Administer prochlorperazine (Compazine) via rectal suppository.
4. Consult with dietitian on initial foods to offer patient.
5. Control aversive odors or unpleasant visual stimulation that trigger nausea.

Back 8

4.

Front 9

W1. Planning involves.....

Back 9

1. Setting priorities
2. Identifying patient-centered goals & expected outcomes
3. Prescribing individualized nursing interventions

Front 10

W2. Nurses establish priorities in relation to importance and time. Briefly explain the following
a. High priority
b. Intermediate priority
c. Low priority

Back 10

a. If untreated, result in harm to the pt or others
b. Involve nonemergent, nonthreatening pt needs
c. Are not always directly related to a specific illness or prognosis

Front 11

W3. ID some factors within the health care environment that affect the ability to set priorities.

Back 11

1. Model for delivering care
2. Organization of the nursing unit
3. Staffing levels
4. Interruptions from other care providers
5. Available resources
6. Policies and procedures
7. Supply access

Front 12

W4. What's the term for "a broad statement that describes a desired change in a pt's condition or behavior."

Back 12

Goal

Front 13

W5. What's the term for "Specific and measurable behavior or response that reflects a pt's highest possible level of wellness."

Back 13

Pt-centered goal.

Front 14

W6. What the term for "objective behavior that you expect the pt will achieve in a short time."

Back 14

Short-term goal

Front 15

W7. The term for "Specific and measurable behavior or response that reflects a patient's highest possible level of wellness."

Back 15

Long term goal

Front 16

W8. A measurable criterion to evaluate goal achievement

Back 16

Expected outcome

Front 17

W9. An individual, family, or community state, behavior, or perception that is measurable in response to a nursing intervention.

Back 17

Nursing-sensitive pt outcome

Front 18

W10* There are 7 guidelines to follow when writing goals and expected outcomes. What are the 7?

Back 18

1. Pt centered
2. Singular goal/outcome
3. Observable
4. Measurable
5. Time limited
6. Mutual
7. Realistic

Front 19

W10. Patient-centered ?

Back 19

Outcomes and goals reflect the pt's behavior and responses expected as a result of nursing interventions.

Front 20

W11. Singular goal or outcome?

Back 20

Precise in evaluation a pt response to a nursing action; addresses only one behavior or response per goal.

Front 21

W12. Observable?

Back 21

When writing an observable goal or outcome, the nurse should be able to observe if a change takes place in a pt's status.

Front 22

W13. Measurable?

Back 22

Terms describing quality, quantity, frequency, length, or weight allow the nurse to evaluate outcomes precisely.

Front 23

W14. Time limited?

Back 23

Outcome written so it indicates when the nurse expects the response to occur.

Front 24

W15. Mutual

Back 24

A mutual goal or outcome is one in which the pt and nurse agree on the direction and time limits of care.

Front 25

W16. Realistic

Back 25

Goal/outcome is one that a pt is able to achieve.

Front 26

W17-19.* What are the 3 categories of interventions:

Back 26

Independent NI.
Dependent NI
Collaborative NI

Front 27

W17. Independent Nursing Intervention

Back 27

Nurse-initiated interventions, not requiring direction or an order from another health care prof

Front 28

W18. Dependent Nursing intervention

Back 28

Phys-initiated interventions that require an order from a physician or other health care professional.

Front 29

W19. Collaborative interventions.

Back 29

Interdependent nursing interventions that require the combined knowledge, skill, and expertise of multiple care professionals.

Front 30

W20. ID the six factors the nurse uses to select nursing interventions for a specific pt.

Back 30

1. Characteristics of the nursing Dx
2. Goals and expected outcomes
3. Evidence-based interventions
4. Feasibility of interventions
5. Acceptability to the pt
6. Your own competency

Front 31

W21. Define the purposes of the nursing care plan.

Back 31

Should direct clinical nursing care and decrease the risk of incomplete, incorrect, or inaccurate care. Identifies and coordinates resources for delivering care. Lists the interventions needed to achieve the goals of care.

Front 32

W22. Student care plans.

Back 32

Useful for learning problem-solving techniques, nursing process, skills of written communication, and organizational skills needed for nursing care.

Front 33

W23. Interdisciplinary care plans.

Back 33

Designed to improve the coordination of all pt therapies and communication among all disciplines.

Front 34

W24. Explain the process of "nursing handoffs" as a practice of communication information at the end of the shift.

Back 34

...nurses collaborate and share information that ensures the continuity of care for a pt and prevents errors or delay in providing nursing interventions.

Front 35

W25. Critical pathways are:

Back 35

Pt care management plans that provide multidisciplinary health care team with activities and tasks to be put into practice sequentially. Their main purpose is to deliver timely care at each phase of the care process for a specific type of pt.

Front 36

W26. Consultation is a process in which?

Back 36

...the nurse seeks the expertise of a specialist to identify ways to handle problems in pt management or the planning and implementation of therapies.

Front 37

W27. List the 6 steps of the nurse's role when seeking consultation.

Back 37

1. ID the general problem area.
2. Direct the consultation to the right prof.
3. Provide the consultant with the relevant information about the problem area.
4. Do not prejudice or influence the consultants
5. Be available to discuss the findings and recommendations
6. Incorporate the recommendations into the plan of care

Front 38

W28. The following statement appears on the nursing care plan for an immunosuppressed pt: "The pt will remain free from infection throughout hospitalization." This statement is an example of a:
1. LT goal
2. ST goal
3. Nursing Dx
4. Expected outcome

Back 38

2. An objective behavior or response that you expect a pt to achieve in a short time, usually less than 1 week.

Front 39

W29. The following statements appear on a nursing care plan for a pt after a mastectomy: "Incision site approximated; absence of drainage or prolonged erythema at incision site; and pt remains afebrile." These statements are examples of:
a. LT goals
b. ST goals
c. Nursing Dx
d. Expected outcomes

Back 39

4. The measurable change in a pt's condition that you expect to occur in response to the nursing care.

Front 40

W30. The planning step of the nursing process includes which of the following activities?
a. Assessing and diagnosing
b. Evaluating goal achievement
c. Setting goals and selecting interventions
d. Performing nursing actions and documenting them

Back 40

C. The nurse sets pt-centered goals and expected outcomes and plans nursing interventions.

Front 41

C9. A 72-year old pt has come to the health clinic with Sx of a productive cough, fever, increased respiratory rate, and shortness of breath. His respiratory distress increases when he walks. He lives alone and did not come to the clinic until his neighbor insisted. He reports not getting his pneumonia vaccine this year. Blood tests show the pt's oxygen saturation to be lower than normal. The physician diagnoses the patient as having pneumonia. Identifyy the priority level with the nursing diagnoses listed for this patient - LT, ST, or Intermediate.

1. Impaired gas exchange ____
2. Risk for activity intolerance _____
3. Ineffective self-health management _____

Back 41

1. LT
2. ST
3. Intermediate

Front 42

C10. An 82-year old pt who resides in a nursing home has the following three nursing diagnoses: "risk for fall, impaired physical mobility related to pain, and wandering related to cognitive impairment." The nursing staff identified several goals of care. Match the goals on the left with the appropriate outcome statements on the right. (just review answers)

1. Pt will ambulate independently in 3 days. ____
2. Pt will be injury free for 1 month. ____
3. Pt will be less agitated. _____
4. Pt will achieve pain relief. ____

Back 42

1. Pt will walk correctly using a walker.
2. Pt will exit a low bed without falling.
3. Pt will follow a set care routine.
4. Pt will express fewer nonverbal signs of discomfort

Front 43

C11. A nurse is preparing for change-of-shift rounds with the nurse who is assuming care for his patients. Which of the following statements or actions by the nurse are characteristics of ineffective handoff communication?

1. Pt is anxious about his pain after surgery; you need to review the info I gave him about how to use a pt-controlled analgesia (PCA) pump this evening.
2. The nurse refers to the electronic care plan in the EHR to review interventions for the pt's care.
3. During walking rounds the nurse talks about the problem the pt care technicians created by not ambulating the pt.
4. The nurse gives her pt a pain med before report so there is likely to be no interruption during rounding.

Back 43

3.

Front 44

C12. Which of the following outcome statements for the goal, "Pt will achieve a gain of 10 lbs in body weight in a month" are worded incorrectly? (Select all that apply).
1. Pt will eat at least three fourths of each meal by 1 week.
2. Pt will verbalize relief of nausea and have no episodes of vomiting in 1 week.
3. Pt will eat foods with high-calorie content by 1 week.
4. Give pt liquid supplements 3 times a day.

Back 44

2. 4.

Front 45

C13. A nurse from home health is talking with a nurse who works on an acute medical division within a hospital. The home health nurse is making a consultation. Which of the following statements describes the unique difference between a nursing care plan from a hospital versus one for home care?

1. The goals of care will always be more long term.
2. Th pt and family need to be able to independently provide most of the health care.
3. The pt's goals need to be mutually set with family members who will care for him or her.
4. The expected outcomes need to address what can be influenced by interventions.

Back 45

2.

Front 46

C14. Which outcome allows you to measure a pt's response to care more precisely?
1. The pt's wound will appear normal within 3 days.
2. The pt's wound will have less drainage within 72 hours.
3. The pt's wound will reduce in size to less than 4 cm by day 4.
4. The pt's wound will heal without redness or drainage by day 4.

Back 46

3.

Front 47

C15. A nurse identifies several interventions to resolve the pt's nursing Dx of "impaired skin integrity." Which of the following are written in error? (Select all that apply)
1. Turn the pt regularly from side to back to side.
2. Provide perineal care, using Dove soap and water, every shift and after each episode of urinary incontinence.
3. Apply a pressure-relief device to bed.
4. Apply transparent dressing to sacral pressure ulcer.

Back 47

1. 3.