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165 Cards in this Set
- Front
- Back
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What does Crtical Thinking incude?
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Looking at situations objectively
Determining pertinent information Recognizing problems or needs Prioritizing those needs Considering various actions & probable outcomes Making informed decisions re: needed actions, based on knowledge, experience, research Evaluating information & making conclusions |
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What is the Nursing Process?
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the process in which nurses utilize critical thinking
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What are the 5 steps to the nursing process?
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A.D.P.I.E
A-assess D-diagnose P-planning (identified goals & desired outcomes, plan intervention) I-implemen E-evaluate |
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What is the nursing process?
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* It is a systematic approach to identification & treatment of clients needs in response to illness
* It is a client-centered,goa-oritented method of providing care. * Provides a framework for nursing practice (develop a plan based on assessment of clients needs) |
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What is The Joint Comissions responsibility?
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they are a voluntary accreditation organization whch evaluates hospitals, HCO, LTC, etc to ensure basic & optmal standards of care are being met.
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What are TJC's requirements for nursing care?
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Care must be documented according to the ursing process
Care must be goal-oriented Multidisciplinary problem list for each client Individualize plan for each pt Document results of care plan, progress towards goals. |
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What is the first step of the nursing process?
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Assessment - Systematic data collection to determine client needs. (current & past hx, meds, functional status, coping patterns, response to therapy, risk for potential problems, desire for higher level of wellness)
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What is a complete physical exam>
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Head to toe
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What is a focused physical exam?
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What they came in for
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What are some ways to assess a pt?
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Client & family hx, current & past, physical exam, observe, reviw records & labs, collaborate w/colleagues
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What is effective communication during assessment?
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verbal & nonverbal empathy, sense of caring, active listening
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What is systematic Observation during assessment?
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Dependent on knowledge base..what causes or contributes to the problem?
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What does accurate interpretation of data during the assessment?
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Accurate & validated sign & symptoms
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What is subjective data?
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What info the client gives you
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What is observable data?
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Observable and measurable data e.g VS
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A nurse who has filled a position on the same unit for 2 years understands the unit's organization and the care of the clients on that nursing unit. Benner defines this nurse as able to anticipate nursing care and to formulate long-range goals; this nurse is given the title:
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Competent Nurse
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An APN is the most independently functioning of all professional nurses. All of the following are examples of a clinically focused APN except:
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Care provider. This position is for staff nurses whereas an APN has far more experience.
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A nurse hears a colleague tell a student nurse that it is best not to touch the clients unless performing a procedure or an assessment. Why is this not the best practice?
A) She does not touch the clients either. B) Touch is a type of verbal communication. C) There is never a problem with using touch. D) Touch forms a connection between nurse and client. |
D) Touch is relational and helps create a connection between the nurse and the client. Touch is best used when there is a caring connection between nurse and client
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The nurse demonstrates the concept of "knowing the client" when he or she:
A) Gathers pertinent data about the client's condition B) Predicts the need for certain interventions based on the disease process C) Encourages the client to depend on the nurse to make important decisions D) Is able to detect changes in the client's condition based on shared information and bonding |
The nurse who knows the client can predict responses, capacity, and endurance because the two have a mutual sense of bonding. Truly knowing the client is much more than gathering data; a relationship is necessary. The nurse must avoid assumptions based on knowledge of the disease process and rely on information revealed by the client. The client should make decisions, and the nurse should work with the client to help so that it is a mutual process.
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number of strategies have the potential for creating work environments that enable nurses to demonstrate more caring behaviors. Some of these include:
A) Increasing working hours B) Raising monetary compensation C) Providing flexibility, autonomy, and improved staffing D) Increasing input from physicians concerning nursing functions |
Strategies to create work environments that allow nurses to demonstrate more caring behaviors include introducing greater flexibility in the work in environment structure, rewarding more experienced nurses in non-monetary ways, improving nurse staffing, and providing nurses with autonomy over their practices.
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The nurse demonstrates caring behavior when he or she:
A) Leaves the light off in the client's room B) Pats the client's arm when approaching the bed C) Asks the client if he or she needs anything while exiting the room D) Traces the intravenous (IV) tubing from the arm to the fluid bag while checking for kinks |
Physical contact is a means of expressing caring. Leaving the lights off interferes with eye contact and clear communication. Caring for the IV shows attention to technology and details rather than to the client. Although asking if the client needs anything is kind, if the nurse does not wait for an answer and is not offering presence, this is not a caring behavior.
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Because clients and nurses may differ in their perceptions of caring, it is important that the nurse:
A) Focus on keeping the relationship on a business level. B) Follow his or her own beliefs about what is appropriate. C) Seek information regarding what is important to the client. D) Allow a more experienced nurse to establish the nurse-client relationship. |
It is important to assess the client's needs and expectations of care. Clients relate to nurses on a personal level. The client's beliefs must be considered. Personnel at all levels of nursing should have effective relationships with clients.
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Which of the following nurses is showing behavior that indicates that the nurse is providing presence in a caring relationship?
A) The clinic nurse who pats the client on the back for reassurance B) The newly licensed nurse who braces the client as he or she gets out of bed C) The home care nurse who focuses attention on the older adult client sharing a story D) The staff nurse who stays with a client who is undergoing an unfamiliar procedure |
Coaching a client through an experience is an example of presence, as is sitting by a client's bedside. The nurse is providing safety while helping the client get out of bed. In option 3, the nurse is listening.
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The nurse can best demonstrate caring to a client who has recently suffered a loss through miscarriage by:
A) Sitting with the client in silence B) Sharing a personal account of a similar loss C) Offering some literature on the grieving process D) Asking the hospital chaplain to visit the client |
Offering self is a powerful demonstration of caring and allows the client to trust and feel the presence of a caring person. Therapeutic communication should focus on the client, not the nurse. Offering literature may be helpful at some point when the client indicates she is ready and asks for information. Chaplain visits may be helpful but do not replace the need for a caring relationship with the nurse.
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Family members make the following comments about the nursing care being received. Which one should be investigated further?
A) "The nurses showed us how to keep Mother's arm propped on a pillow." B) "Our nurses don't seem too optimistic about the outcome of Dad's stroke." C) "The night nurse tells us to wait and ask the doctor the questions we have." D) "The nurses have written down the turn schedule and taped it above the bed." |
A caring nurse should show interest in answering questions and giving clear explanations. The comment in option 3 indicates that the nurse is shirking responsibility. Teaching the family is important and gives the family the feeling of being useful. Keeping the family informed and included in care is a sign of good nursing. Honesty is a quality of caring. False reassurance is dishonest and is not helpful.
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A client needs a liver transplant but has been out of work for several months and does not have insurance or enough cash. A discussion about the ethics of this situation would predominantly involve which principle?
A) Justice B) Ethics of care C) Accountability D) Respect for autonomy |
Justice is fairness, and in health care, the focus of justice is the fair distribution of resources. It is illegal in the United States to buy or sell organs, and recipients are ranked according to need. Ethics of care is not related to deciding if an individual is eligible for organ transplant. Accountability refers to the ability to answer for one's actions, and this is not part of the equation in determining eligibility for organ donation. Autonomy is the ability to operate independently. Clients have the ability to determine their course of treatment. Those in need of organs have the autonomy to decide if they want an organ transplant, but recipients in the United States are chosen according to need.
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A child's immunization may cause discomfort during administration, but the benefits of protection from disease outweigh the temporary discomforts. Which principle applies to this situation?
A) Beneficence B) Fidelity C) Nonmaleficence D) Respect for autonomy |
In the orientation phase of the helping relationship, the nurse and client meet and get to know each other. The nurse reviews the history to identify possible health concerns before meeting the client. The nurse and client also work together to solve problems and accomplish goals. Therapeutic communication skills are used during the working phase to facilitate successful interactions.
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If a nurse assesses a client for pain and then offers a plan to manage the pain, which principle encourages the nurse to monitor the client's response to the pain management plan?
A) Fidelity B) Beneficence C) Nonmaleficence D) Respect for autonomy |
Fidelity means keeping the promises that are made. If the nurse offers to manage pain, then the nurse needs to follow through and ensure that the pain is controlled. Beneficence means taking positive actions to help others. Nonmaleficence means doing no harm. Respect for autonomy refers to the commitment to include clients in decisions regarding all aspects of their care.
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Nurses agree to be advocates for their clients. The practice of advocacy calls for the nurse to do which of the following?
A) Seek out the nursing supervisor in conflicting situations. B) Work to understand the law as it applies to the client's clinical condition. C) Assess the client's point of view and prepare to articulate this point of view. D) Document all clinical changes in the medical record in a timely manner |
As an advocate, the nurse needs to understand the client's point of view and then be prepared to verbalize that point of view to others involved in the client's care. Understanding the law, seeking advice from a manager, and providing careful documentation can all help in advocacy, but they are not advocacy.
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When many people share the same values, it may be possible to identify a philosophy of utilitarianism. Which of the following statements is a principle of utilitarianism?
A) The value of something is determined by its usefulness to society. B) The value of people is determined solely by leaders of the Unitarian Church. C) The best way to determine the solution to an ethical dilemma is to refer the case to the attending physician. D) The decision to perform a liver transplant must be based on the morality of the life that the client has led so far. |
A utilitarian system of ethics proposes that the value of something is determined by its usefulness. The other answers are incorrect.
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The ethics of care suggests that ethical dilemmas can best be solved by attention to which of the following?
A) Clients B) Relationships C) Ethical principles D) Code of ethics for nurses |
The ethics of care promotes a philosophy that focuses on understanding relationships, especially personal narratives. The other answers are incorrect.
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In most ethical dilemmas, the solution to the dilemma requires negotiation among members of the health care team. Why is the nurse's point of view valuable?
A) The principle of autonomy guides all participants to respect their own self-worth. B) Nurses have a legal license that encourages their presence during ethical discussions. C) Nurses develop a relationship with the client that is unique among all professional health care providers. D) The nurse's code of ethics recommends that a nurse be present at any ethical discussion about client care. |
Nurses generally interact with clients over longer intervals of time than care providers in other disciplines. Because nurses are often involved in personal care, clients and families reveal information not always shared with physicians or others. The other options are incorrect.
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Ethical dilemmas often involve a conflict of opinion. Once the nurse has determined that the dilemma is ethical, which of the following would be a critical first step in negotiating the difference of opinion?
A) Consult a professional ethicist to ensure that the steps of the process occur in full. B) Gather all relevant information regarding the clinical, social, and spiritual aspects of the dilemma. C) List the ethical principles that inform the dilemma so that those negotiating can agree on the language of the discussion. D) Ensure that the attending physician has written an order for an ethics consultation to support the ethics process. |
The process of resolving ethical dilemmas is similar to the nursing process. The first step is gathering all relevant information. Then the group will proceed through assessment, planning, implementation and evaluation.
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Which of the following sets forth ethical principles for professional nursing practice in a clinical setting?
A) Good Samaritan laws for civil guidelines B) Standards of care from experts in the practice field C) Nurse Practice Act (NPA) written by state legislatures D) Code of Ethics of the American Nurses Association (ANA) |
The Code of Ethics is a set of ethical principles embodying the professional guidelines established by the ANA to maintain the highest standards for the nurse's conduct in practice. The NPA gives a broad overview of what are the appropriate and inappropriate roles of the registered nurse. Standards of care written by field experts are guidelines that direct the usual pathway of client management under certain circumstances. Good Samaritan laws are laws that prevent an individual from suing another person who tries in "good faith" to assist that individual in an accident.
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Which of the following statements concerning ethical issues is correct?
A) Nonmaleficence is avoiding doing harm or hurting someone at all costs. B) Beneficence is working to do good or acting in a positive manner for another. C) Justice is following through on a promise that is stated or implied. D) Fidelity refers to fairness, such as equal distribution or random distribution of resources without regard to individual’s perceived value. |
Beneficence involves looking at all aspects of care or management and working toward the "good" outcomes. Justice is related to fairness, and fidelity is related to telling the truth and keeping one's promises. Nonmaleficence is avoiding causing harm or hurt, but it is tempered by the potential benefits that may be gained from short-term harm (for example, a bone marrow transplant causes suffering but offers a chance at a cure).
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To distinguish an ethical problem from other types of problems encountered, the nurse should be aware that an ethical problem is one for which:
A) The nurse has the same values as the client. B) The answer is not determined by logical deduction. C) The answer is easily decided but is not the popular one in today's society. D) Professional literature review provides the answer based on scientific principles that indicate which of the two choices available is correct. |
Characteristics of an ethical problem include lack of a logical conclusion, lack of scientific support for either choice or support for both choices, differences in valuing by staff and client that might result in harm or less than the best options, and an answer that involves several areas of human concern.
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After researching the scientific literature and confirming that an issue is an ethical dilemma, which of the following should a nurse do next?
A) Verbalize the problem. B) Seek the support of the family. C) Perform a values clarification. D) Negotiate options or outcomes. |
In the sequence of steps to resolve an ethical dilemma, once the dilemma is identified, the nurse should look to see what issues contribute to the dilemma. The nurse's examination of his or her own values helps to remove the hidden bias in the situation and allows the situation to be viewed in a more neutral manner. Verbalization of the problem follows values clarification and is not the next step after identification of the dilemma. Once the nurse identifies his or her own bias, then the nurse can be confident of using a neutral approach to solving the dilemma. Negotiation of options is the next to the last step in the process. Family input should be a small part of the second step during the information-gathering process, so that all relevant facts can be reviewed together. Not involving the family or getting their input early in the process can result in a lack of satisfaction with the solution to the problem, and it may not be in the client's best interests.
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Which of the following represents utilitarian allocation of scarce resources?
A) Application of the nonmaleficence principle to everyone B) Distribution of goods based on the amount of influence the person has C) Distribution of resources to achieve the greater good of the larger group D) Democratic choice of who gets what when there is not enough to go around |
Utilitarian decision making is based on the theory that the action should be determined by the outcome. Therefore, the greater good is achieved by basing decisions on what is more important for the majority rather than focusing on the smaller group that does not benefit. Distribution based on who has the greatest influence is not decision making focused on the greater good. The influential group may have little or nothing to contribute in either a positive or a negative way. When resources are scarce, someone is always left out or receives minimal benefits from the resource. In cases in which equal distribution is not a choice, utilitarianism focuses on the options that achieve the greatest good for the greatest number
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The distribution of nurses to areas of greatest need when there is a nursing shortage represents the application of which principle or theory?
A) Justice B) Beneficence C) Utilitarianism D) Deontological theory |
Justice is defined as fairness in the distribution of resources. However, guidelines have been formulated for establishing a hierarchy of needs, such as with organ transplantation. Moving nurses to areas of greatest need when shortages occur on the floors is thus a fair (just) allocation of resources.
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When a nurse stops to help in an emergency at the scene of an accident, if the injured party files suit and the insurance of the nurse's employing institution does not cover the nurse, the nurse would probably be covered by:
A) The nurse's automobile insurance B) The nurse's homeowner's insurance C) The Patient Care Partnership, which may grant immunity from suit if the injured party consents D) The Good Samaritan laws, which grant immunity from suit if there is no gross negligence |
Good Samaritan laws grant immunity from lawsuits if the nurse follows the standards of care that a nurse of his or her experience would prudently have followed. The other answers are incorrect.
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The legal definition of death that facilitates organ donation is cessation of:
A) Pulse B) Respirations C) Functions of the entire brain D) Circulatory and respiratory functions |
The whole-brain standard of death requires irreversible cessation of all functions of the entire brain, including the brainstem. This definition allows for the recovery of organs for transplantation. Individuals who are not donors typically are pronounced dead when there is a total cessation of circulatory and respiratory functions. The absence of pulse and respirations must occur together to meet the legal definition of death.
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The nurse notes that an advance directive is in the client's medical record. Which of the following statements represents the best description of guidelines a nurse would follow in this case?
A) A durable power of attorney for health care is invoked only when the client has a terminal condition or is in a persistent vegetative state. B) A living will allows an appointed person to make health care decisions when the client is in an incapacitated state. C) A living will is invoked only when the client has a terminal condition or is in a persistent vegetative state. D) The client cannot make changes in the advance directive once the client is admitted into the hospital. |
A living will directs the client’s healthcare in the event of a terminal illness or condition. A durable power of attorney is invoked when the client is no longer able to make decisions on his or her own behalf. The client may change an advance directive at any time.
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The nurse should understand law primarily because the nurse:
A) Wants to avoid lawsuits B) Can be an advocate for clients C) Is mandated to review law to keep licensure D) Can protect the hospital from minor lawsuits |
B. As an advocate for the client, the nurse must make sure that "safe, effective care" is given in conformity with the Nurse Practice Act (NPA). The client is the primary recipient of care and is the most important party in health care relationships. Self, hospital, and physicians are secondary to the outcomes of client care. Nurses should focus on giving correct care to avoid lawsuits. Legal review is a good practice to follow but is not mandated for licensure. The nurse's first responsibility is to the client. Giving proper care will protect an employer from many lawsuits.
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Nurses are bound by a variety of laws. Which of the following descriptions of types of law is correct?
A) Statutory law is created by elected legislatures, such as the state legislature that defines the Nurse Practice Act (NPA). B) Regulatory law provides for prevention of harm to the public and punishment when those laws are broken. C) Common law protects the rights of the individual within society to fair and equal treatment. D) Criminal law creates boards that pass rules and regulations to control society. |
A) Statutory law is created by legislatures. These bodies enact statutes such as the NPA, which defines the role of the nurse and expectations of the nurse's performance of his or her duties and explains what is contraindicated as guidelines for the breach of those regulations. Regulatory law or administrative law is created by an administrative body such as the Board of Nursing, which passes rules and regulations. Common law is created by judicial decisions in court based on individual cases that are decided. Criminal law prevents harm to society and provides punishment for crimes.
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Which of the following regulates hospitals to ensure safety in the provision of services, establishes criteria that must be met for a hospital to receive funding from the government, and provides for penalties if guidelines are not followed?
A) Board of Nursing Examiners (BNE) B) Nurse Practice Act (NPA) C) American Nurses Association (ANA) D) Americans With Disabilities Act (ADA) |
D) If a hospital fails to follow ADA guidelines for meeting the special needs of persons with disabilities, the facility loses funding and become ineligible to receive low-income loans or reimbursement of expenses. ADA protects the civil rights of disabled people. Its provisions apply to both hospital clients and hospital staff.
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A client who is confused is left alone in bed with the side rails down and the bed in a high position, and the client falls and breaks a hip. In legal terms, what has occurred?
A) Assault B) Battery C) Negligence D) Civil tort |
C) Knowing what to do to prevent injury is a part of the standard of care that nurses must follow. Negligence is conduct that falls below the standard of care that protects others against unreasonable risk of harm. Assault is the threat to engage in harmful or offensive contact. Battery is the actual unlawful touching of another, whether threat of harm is included or not. Intentional touching without permission or consent is not lawful. A civil tort is a civil wrong committed against a person or property. An example of a tort involving property would be to lose the client's dentures by misplacing them.
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When the nurse signs a form as a witness, the nurse's signature shows that the client:
A) Is fully informed and is aware of all consequences of signing B) Was awake and fully alert and not medicated with narcotics at the time of signing C) Was free to sign without pressure D) Has signed that form and the witness saw it being done |
D) The nurse's signature as a witness indicates only that the person signing the form was indeed the person whose name was on the form. The witness does not have to know if the client was fully informed or not. The witnessing agent is indicating no judgment about the level of cognitive function of the client by signing as witness. The nurse should assess for coercion, but the signature of the witness is not an acknowledgement of having performed such an assessment. If the witness feels that someone is forcing a client to sign, however, then the witness may refuse to sign and the contract is then void (unless a different witness signs).
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Which of the following statements is correct?
A) Consent for medical treatment can be given by a minor with a sexually transmitted disease (STD). B) A second-trimester abortion can be performed without state involvement. C) Student nurses cannot be sued for malpractice while in a nursing clinical class. D) Nurses who get sick and leave during a shift are not abandoning their clients if they call their supervisor and leave a message about their emergency illness. |
Anyone, at any age, can be treated for an STD without parental permission. The client is "advised" to contact sexual partners but is not required to give their names. A first-trimester abortion can be given without state regulation because of the low risks of mortality. Student nurses are liable for their performance based on their level of knowledge at the time of providing care. Abandonment rules do apply if the nurse leaves without waiting for a replacement to arrive and/or talking directly to the supervisor
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A nurse works on a cardiac unit. The nurse is taking care of a client who recently underwent coronary bypass surgery. Which of the following represent legal sources of standards of care nurses use to deliver safe health care? (Select all that apply.)
A) Information provided by the head nurse B) Regulations identified in the Joint Commission manual C) Policies and procedures of the employing hospital D) Nurse Practice Act of the state in which the nurse is working E) American Nurses Association standards of nursing practice |
All except the information provided by the head nurse provide legal guidelines for minimum acceptable nursing care.
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A nurse is sued for failure to monitor a client appropriately. Which statements are correct about professional negligence lawsuits? (Select all that apply.)
A) The nurse is the plaintiff. B) The person filing the lawsuit has the burden of proof. C) The defendant must prove injury, damage, or loss. D) The plaintiff must prove that a breach in the prevailing standard of care caused an injury. |
B, D) The plaintiff (the person filing the suit) has the burden of proof and must prove that a breach in the prevailing standards of care caused an injury. The nurse would be a defendant in this case. The plaintiff, not the defendant, must prove injury, damage, or loss.
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During the change-of-shift report the night nurse states that a client mentioned having a bad experience with surgery in the past. The nurse was called away and was unable to continue the conversation with the client. The nurse tells the day shift nurse about the comment and notes that the client appears anxious. When the day shift nurse visits the client to clarify the client's bad experience with surgery, the nurse is exhibiting which aspect of critical thinking?
A) Integrity B) Discipline C) Confidence D) Perseverance |
B) Discipline includes completing the task at hand, including assessments (which were not completed on the previous shift). Integrity includes recognizing when one's opinions conflict with those of others and finding a mutually satisfying solution. Confidence is demonstrated in one's presentation and belief in one's knowledge and abilities. Perseverance helps the critical thinker to find effective solutions to client care problems, especially when they have been previously unresolved.
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During the day the nurse spends time instructing a client in how to self-administer insulin. After discussing the technique and demonstrating an injection, the nurse asks the client to try it. After the client makes two attempts it is clear that the client does not understand how to prepare the correct dose. The nurse discusses the situation with the charge nurse and asks for suggestions. This is an example of:
A) Reflection B) Risk taking C) Problem solving D) Client assessment |
This is an example of problem solving because the nurse is taking a problem to a supervisor for help in finding a different approach. Reflection is the process of purposefully thinking back and recalling a situation to discover its purpose or meaning. Risk taking involves trying a different approach. Client assessment is the first step in the process of instruction.
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A nurse refers to a client's postsurgical written plan of care, noting that the client has a drainage device collecting wound drainage. The surgeon is to be notified when drainage in the device exceeds 100 ml for the day. The nurse carefully notes the amount of drainage currently in the device. This is an example of:
A) Planning B) Evaluation C) Assessment D) Intervention |
Assessment is the process of observing and collecting data. Planning is the step in which the diagnosis is analyzed for problem resolution. Intervention consists of the steps actually taken after planning. Evaluation measures the effectiveness of the plan.
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The nurse asks a client how she feels about impending surgery for breast cancer. Before initiating the discussion the nurse reviewed information about loss and grief in addition to therapeutic communication principles. The critical thinking component involved in the nurse's review of the literature is:
A) Experience B) Problem solving C) Knowledge application D) Clinical decision making |
The nurse sought appropriate information to be able to communicate more knowledgeably with the client. Experience is acquired through clinical learning situations. Problem solving is a series of steps to resolve a problem. Clinical decision making is a process in which critical thinking steps are followed for problem resolution
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Which of the following is the most accurate information to give a nurse during change-of-shift reporting?
A) Client refuses to take medications. B) Client reports sharp pain in left anterior knee. C) Client encouraged to consume more fluids. D) Client expressed concern about pending surgery. |
The information in option 2 represents objective data that the nurse can use as part of baseline information. "Encouraged" and "more" are vague terms. "Concern" is also vague; relating the exact concern would be more accurate. Option 1 may be true, but accurate data would also report why the client refused medication.
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On entering a client's room during change-of-shift rounds, the nurse notices that the client and spouse have their backs turned to each other, and both have their arms folded across their chests. The best action for the nurse to take at this time is to:
A) Introduce himself or herself and begin discharge teaching. B) Proceed with the tasks the nurse was intending to perform. C) Say nothing and leave quickly, closing the door behind. D) Ask the client and spouse if they need some time alone right now. |
The situation suggests that the nurse entered during a stressful time. Offering privacy would be appropriate. Because the situation indicates tension between the couple, this is not the time to initiate teaching.
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The nurse is assessing the urinary history of a middle-aged married woman. The nurse asks her if she gets up at night. She replies, "Yes." What other question should the nurse ask?
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Perhaps it is the client's husband who is getting up in the middle of the night because of a prostate problem, and this is why she is awakened. The nurse should not assume nocturia without further assessment questions.
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A client with diabetes mellitus who takes daily insulin injections is scheduled for surgery the next day. The client is to take nothing by mouth (NPO status) after midnight. The nurse questions whether insulin should be given the morning of surgery. This is an example of:
A) Problem solving B) Previous experience C) Clinical practice guideline D) Scientifically based clinical judgment |
The nurse is demonstrating awareness of the effect of insulin, which is to lower blood glucose level. Because the client will be NPO status for a long period of time, no calories will be consumed. Giving the usual injection of insulin could cause the client to experience hypoglycemia.
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The client is a 65-year-old overweight woman with multiple medical diagnoses, including diabetes mellitus type 2, hypertension, and residual right-sided weakness resulting from a previous cerebrovascular accident. What tool should be used to plan her care?
A) Care plan B) Care map C) Concept map D) Critical thinking |
A concept map is a visual representation of client problems and interventions that shows their relationships to each other and allows easy synthesis of data about the client
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A client newly admitted to the hospital begins to have chest pain. Before calling the physician, the nurse should gather what additional data? (Select all that apply.)
A) Pain intensity B) Location of pain C) Character of pain D) Radiation of pain E) Meaning of pain to the client F) Family history of myocardial infarctions |
A, B, C, D, E) The nurse should gather the data the physician will need to determine whether the chest pain represents a myocardial infarction. Family history is important in comprehensive pain assessment; however, taking time to obtain this information is inappropriate in this critical situation.
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A technique that encourages further elaboration, for example "go on & say more" is know as what?
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Back Channeling
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Information that is descriptive, concise, & complete with inferences or assumptions is known as?
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Assessment data
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Organization of data to classify and focus on the correct problem is known as what?
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Data Clustering
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The purpose of assessment is to:
A) Make a diagnostic conclusion. B) Delegate nursing responsibility. C) Teach the client about his or her health. D) Establish a database concerning the client |
D) The purpose of assessment is to establish a database about the client's perceived needs, health problems, and responses to these problems. The data also reveal related experiences, health practices, goals, values, and expectations. The other options are not purposes of assessment.
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Assessment data must be descriptive, concise, and complete. In performing an assessment the nurse should not:
A) Include subjective data from the client. B) Perform a thorough physical examination. C) Use interpersonal and cognitive skills. D) Include inferences or interpretative statements not supported with data. |
D) The nurse should not generalize or form judgments not supported by the collected data. Inferences and interpretive statements must be supported by data. Assessments do include conducting a thorough physical examination, using interpersonal and cognitive skills, and obtaining subjective data from the client.
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The nurse asks a client, "Ms. Neil, describe for me your typical diet over a 24-hour day. What foods do you prefer? Have you noticed a change in your weight recently?" This series of questions would likely occur during which phase of a client interview?
A) Working B) Orientation C) Termination |
A
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During data clustering, a nurse:
A) Provides documentation of nursing care B) Reviews data with other health care providers C) Makes inferences about patterns of information D) Organizes cues into patterns that lead to identification of nursing diagnoses |
D) During data clustering, the nurse organizes cues into patterns that indicate individualized nursing diagnoses and identify collaborative problems. The other options are incorrect.
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Which of the following is subjective information to be entered in the client's medical record?
A) Skin warm and dry. B) Pain intensity 8 out of 10. C) Breath sounds clear to auscultation. D) Amber urine in sufficient quantities. |
B) Pain is purely a subjective phenomenon. Although the pain intensity rating is an objective number, it depends on the client's report. The other options are objective data.
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Which of the following is objective information to be recorded in the client's medical record?
A) Anxious over upcoming test. B) Increasing stress over past 2 months. C) Performs breast self-examination monthly. D) Expelled 1 tablespoon of yellow sputum. |
D) Objective data are measurable data. Options 1, 2, and 3 describe data that cannot be measured by the nurse but depend on the client's reports; thus they are subjective data.
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The nurse asks the client whether the client has any allergies. This is an example of:
A) Health history data B) Biographical information C) History of present illness D) Environmental history data |
A) Known allergies are a part of historical data. Biographical data include age, address, occupation, work status, marital status, course of health care, and insurance. The history of the present illness includes when the symptoms began, whether they began suddenly or gradually, whether they come and go, and other information about the illness. The environmental history includes data about the client's home and working environments.
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What techniques encourage a client to tell his or her full story? (Select all that apply.)
A) Active listening B) Back channeling C) Use of open-ended questions D) Use of closed-ended questions |
Options 1, 2, and 3 encourage clients to tell their full stories. Closed-ended questions allow clients to answer with one or two words, which makes it more difficult to obtain all the information required for a full story. The other options give clients the opportunity to tell their stories and feel supported. Active listening helps them feel that they, and their stories, are important.
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The nurse gathered the following assessment data. Which of these cues form a pattern? (Select all that apply.)
A) Client is restless. B) Respirations are 24/min and irregular. C) Client states feeling short of breath. D) Fluid intake for 8 hours is 800 ml. E) Client has drainage from surgical wound. F) Client reports loss of appetite for over 2 weeks. |
The data in items 1, 2, and 3—rapid irregular breathing, complaints of shortness of breath, and restlessness—form a pattern indicating that the client may be experiencing hypoxia, because all are signs and symptoms characteristic of this condition. The other information, although important, is not related to hypoxia.
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The nurse asks the client's spouse, "Mrs. Smith, your husband told me that for the past week he has not been eating the meals you prepare. Do you agree?" This is an example of __________________ of assessment data.
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Validation
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A review of systems (ROS) is based on information obtained from the client during the interview. This information is an example of ______________ data
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Subjective
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A nursing diagnosis is:
A) The diagnosis and treatment of human responses to health and illness B) The advancement of the development, testing, and refinement of a common nursing language C) A clinical judgment about individual, family, or community responses to actual and potential health problems or life processes D) The identification of a disease condition based on a specific evaluation of physical signs, symptoms, the client's medical history, and the results of diagnostic tests |
A nursing diagnosis is a clinical judgment about individual, family, or community responses to actual and potential health problems or life processes. It is not a disease condition or medical diagnosis, or the diagnosis and treatment of human responses to health and illness. Nursing diagnoses are not a development or refinement in nursing language.
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The nurse reviews data regarding a client's pain symptoms, comparing the defining characteristics for Acute pain with those for Chronic pain. In the end the nurse selects Acute pain as the correct diagnosis. This is an example of avoiding which type of error?
A) Error in data clustering B) Error in data collection C) Error in data interpretation D) Error in making a diagnostic statement |
When a nurse compares collected assessment data with defining characteristics for two diagnoses, the selection of the correct diagnosis is an example of avoiding an error in making a diagnostic statement. There is no indication the data clustering or interpretation were incorrect.
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One of the purposes of the use of standard formal nursing diagnostic statements is to:
A) Evaluate nursing care. B) Gather information on client data. C) Help nurses to focus on the role of nursing in client care. D) Facilitate understanding of client problems by different health care providers |
The use of standard formal nursing diagnostic statements provides a precise definition that gives all members of the health care team a common language for understanding the client's needs. The other options are not part of the reason for the development of nursing diagnostic statements.
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The nursing diagnosis Hypothermia is an example of which of the following?
A) Risk nursing diagnosis B) Actual nursing diagnosis C) Potential nursing diagnosis D) Wellness nursing diagnosis |
B)
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"Unhappy and worried about health" is not a scientifically-based nursing diagnosis, and it can lead to error in:
A) Data collection B) Date clustering C) Diagnostic label D) Medical diagnosis |
The diagnostic label is the name of the nursing diagnosis as approved by the North American Nursing Diagnosis Association (NANDA) International. The question does not discuss data collection, medical diagnosis, or data clustering.
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When developing a nursing care plan for a client with a fractured right tibia, the nurse includes in the plan of care independent nursing interventions, including which of the following?
A) Apply a cold pack to the tibia. B) Elevate the leg 5 inches above the heart. C) Perform range-of-motion movement with right leg every 4 hours. D) Administer aspirin 325 mg every 4 hours as needed |
Elevation of the leg does not need a physician's order. Applying a cold pack and administering medication do require a physician's order. Range-of-motion movement of the fractured tibia is inappropriate.
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Which of the following nursing interventions is written correctly?
A) Change dressing once a shift. B) Perform neurovascular checks. C) Elevate head of bed 30 degrees before meals. D) Apply continuous passive motion machine during day. |
Option 3 is specific—it indicates what to do and when.
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When calling a nurse consultant about a difficult client-centered problem, which of the following should the primary nurse report?
A) Client's concern about the current treatment B) Length of time current treatment has been in place C) Spouse's reaction to the client's current treatment D) Physician's reluctance to change the current treatment plan |
Reporting the length of time the current treatment has been used gives the consulting nurse facts that will influence formulation of a new plan. The other options are subjective and emotional issues or conclusions about the current treatment plan and may bias the nurse consultant's decision regarding a new treatment plan.
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The primary nurse asked a clinical nurse specialist (CNS) to consult on a difficult nursing problem. The primary nurse is obligated to do which of the following?
A) Implement the specialist's recommendations. B) Discuss and review advised strategies with the CNS. C) Report the recommendations to the primary physician. D) Clarify the suggestions with the client and family members. |
Because the primary nurse requested the consultation, it is important that the primary nurse and the CNS communicate and discuss recommendations. The primary nurse can then accept or reject the CNS's recommendations. A consultation requires review of the recommendations but not immediate implementation. Reporting the recommendations to the physician would be appropriate after the nurse first talks with the CNS about recommended changes in the plan of care and the rationale. Only then should the primary nurse call the physician. The client and family do not have the knowledge to determine whether new strategies are appropriate or not. It is better to wait until the new plan of care is agreed upon by the primary nurse and physician before talking with the client and/or family.
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Which of the following are defining characteristics for the nursing diagnosis of Impaired urinary elimination? (Select all that apply.)
A) Nocturia B) Frequency C) Urinary retention D) Inadequate urinary output E) Receipt of intravenous fluids F) Sensation of bladder fullness |
A, B, C) The defining characteristics for Impaired urinary elimination according to NANDA include nocturia, frequency, and urinary retention. The other options are not defining characteristics from NANDA.
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During the planning phase of the nursing process, the nurse along with the client decides which of the following? (Select all that apply.)
A) Interventions B) Nursing diagnosis C) Expected outcomes D) Client-centered goals E) Nurse-centered priorities |
C, D) Expected outcomes and goals are the main components of the planning phase of the nursing process. The nurse determines these from the assessment. The client should be the focus of the planning stage. Interventions are initially determined by the nurse.
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A nurse is assigned to a client 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 client's abdominal dressing, intravenous infusion, and drainage tubes. The client is in pain and will not be able to eat or drink until intestinal function returns. The nurse will have to establish priorities of care in which of the following situations?
A) The family comes to visit the client. B) The client expresses concern about pain control. C) The client's vital signs change showing a drop in blood pressure. D) The charge nurse approaches the assigned nurse and requests a report at the end of the shift. |
A drop in blood pressure indicates a possible emergency situation, including bleeding at the surgical site. Concern about pain control, including a thorough assessment focusing the client's pain, would be the second priority. The end-of-shift report and the family's visit are lesser priorities.
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A postsurgical client calls for a nurse and asks to be repositioned. The nurse finds that the client's drainage tube is disconnected and the intravenous (IV) line has 100 ml of fluid remaining. Which of the following should be performed first?
A) Reconnect the drainage tube. B) Inspect the condition of the IV dressing. C) Improve the client's comfort and turn her to her side. D) Go to the medication room and obtain the next IV fluid bag. |
The nurse should reconnect the drainage tube first to ensure that the wound is properly draining. The client should then be turned (with care taken to ensure that the tubing remains connected), followed by replacing the IV fluid bag, checking the IV site, and restarting the IV fluid. With 100 ml left, the nurse has a bit of time to replace the IV bag before it runs dry, so caring for the client's wound and comfort should come first.
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A nurse has set a time limit for expected outcomes. What is the purpose of establishing such a time frame?
A) Indicate which outcome has priority. B) Indicate the time it takes to complete an intervention. C) Indicate how long the nurse is scheduled to care for the client. D) Indicate when the client is expected to respond in the desired manner. |
D) The time limit sets measurable points to evaluate the client's response and movement toward meeting the outcome goals. The other options are incorrect
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A client-centered goal is a specific and measurable behavior or response that reflects:
A) The physician's goal for the specific client B) The client's desire for specified health care interventions C) The client's response compared to that of another client with a similar problem D) The client's highest possible level of wellness and independence in function |
D) A client-centered goal is a specific and measurable behavior or response that reflects a client's highest possible level of wellness and independence in function. The other options do not meet the definition of a client-centered goal.
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The nurse prepares a client for a lumbar puncture. Before the start of the procedure the nurse is sure to:
A) Have the client void. B) Place the client in Sims' position. C) Premedicate the client with analgesics. D) Insert a peripheral intravenous (IV) catheter. |
The nurse takes care of physical needs (voiding) that could interrupt the procedure and possibly increase the risk of complications. The client assumes the fetal position or sits upright with arms over a bedside table. Because lidocaine is used in lumbar puncture, analgesics are not essential. Peripheral IV catheters are not required for this procedure.
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The nurse anticipates that a right-handed client with a fractured right arm will require assistance with activities of daily living. What skill is the nurse demonstrating?
A) Cognitive skill B) Behavioral skill C) Interpersonal skill D) Psychomotor skill |
The nurse is using sound judgment and clinical decisions to provide individualization of care. A decision is made without direct interaction with the client but is based on knowledge about the client. No psychomotor skill is involved in this decision-making process. There is no such thing as a behavioral skill
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A nurse provides counseling to a family in spiritual distress caused by the recent, but expected, death of a family member when the nurse implements which of the following interventions?
A) Praying with the family B) Reminiscing with the family C) Arranging for the chaplain to visit the family D) Obtaining a consult with a psychiatric clinical nurse specialist |
Reminiscing is an active intervention that allows family members to remember the deceased in a positive way. One expects spiritual distress in the acute stage of loss. Praying with the family and arranging for a chaplain's visit may be appropriate interventions, but they are not counseling.
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The nurse requests a stimulant laxative for a client who is receiving an opioid around the clock. What is the nurse demonstrating?
A) Concern for safety B) Promotion of client health C) Colleague health education D) Control of adverse reactions |
The nurse is demonstrating knowledge of opioid side effects and being proactive by asking for an intervention that will most likely prevent the side effect of constipation associated with opioids. The intervention does not promote health; it is aimed at preventing a side effect of an opioid. Safety is not an issue. Requesting a laxative does not provide education.
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Which of the following characteristics of a goal is missing from the statement "Client will ambulate daily"?
A) Observable B) Measurable C) Client centered D) Singular goal or outcome |
B) Goals must be measurable, such as "Client will ambulate 15 feet daily." The other characteristics are met in this goal statement.
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When determining a client's ability to perform instrumental activities of daily living, which of the following skills does the nurse assess? (Select all that apply.)
A) Ability to cook meals B) Ability to feed oneself C) Ability to write checks D) Ability to bathe oneself E) Ability to take medications |
A, C, E) The correct options are skills that allow the client to live independently in society. They may or may not be performed on a daily basis. The other options are activities of daily living.
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Which of the following are nurse-provided indirect care activities? (Select all that apply.)
A) Delegating B) Documenting C) Evaluating new products D) Administering medications E) Providing client counseling |
The correct options do not involve direct interaction with the client or family. The other options do require such direct interaction.
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The unit policy and procedure manual states that, for all clients admitted to the cardiac unit, if the client experiences chest pain, 1/150 grain nitroglycerin should be administered sublingually and an electrocardiogram should be obtained immediately. This is an example of a(n) _____________.
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Protocol. (que words procedure & manual states)
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What can cause error in R/T portion of a NANDA statement?
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NANDA needs to be
EX: What is a better way to write Acute Pain R/T physician ordering inadequate pain meds... - R/T tissue trauma, inflammation |
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What are the parts to a diagnostic statement>
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NANDA
R/T -etiology/cause of problem, should be pathology or condition not medical dx or judgement about pt S/T medical dx (optional) AEB (as evidence by)- major defining characteristics & s/sx that validate nursing dx. |
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Why do we use the nursing process?
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To provide a systematic approach & better quality care
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Organized collected data in a ligical manner is described as what
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data clustering
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Who do you want to gather your information from?
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The patient preferably and if not available the family is ok.
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When doing an assessment would you conduct an assessment or interview first?
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Interview so you know what to focus your assessment on.
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In Maslow's hierarchy of needs what comes first?
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Physiological needs
Ex. breathing, food, shelter, clothing, sleep Then, safety & security, love & belonging, self-esteem, self-actualization |
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What does ABC stand for
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Airway, breathing, circulation.
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Anything that deals with collecting more data is what?
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assessment
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What does RUMBA refer to in outcome statements?
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R -realistic
U -understandable to client M -measurable B -believable A -achievable |
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When is it ok to delegate a task?
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Whe the pt is stable
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Where does most excretion of medications take place
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kidneys
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What are drug classifications?
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Drugs are classified according to their characterisitics, use on body systems, or desired effects. Some may have more than 1 classification.
For example. aspirin may classified as analgesic, antipyretic, or anti-inflammatory. **A perscriber can choose a med based on client characteristics, cost, dosing frequency, or prescriber experience w/medication |
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What is a drugs chemical name?
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it is th echemical composition and molecular structure.
Example: 2-p-isobutylphenylpropionic acid |
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What is a drugs generic (nonproprietary) name?
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name given byt the United States Adopted Name Council
Ex: ibuprofen |
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What is a drugs trade (proprietary) name?
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the drug has a registered trade mark: use of the name is restricted by the drugs owner.
Ex: Advil |
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What is Pharmacological classification?
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grouped by the physiologic activity and mechanisms of action.
Ex: beta blockers, ACE inhibitors, Cephalosporins |
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What is Therapeutic classification?
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Grouped by similar therapeutic indications
Ex: Anti-coagulants, anti-anxiety, anti-hypertensives |
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What is Chemical classifications?
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Grouped by chemical structure, regardless of differences in pharmacologic activity.
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What does pharmacokinetics mean?
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sudy of how meds enter thebody, are absorbed, distributed into cells, tissues, organs, & alter physiological fxns.
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What is absorption?
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The rate at which drug leaves the site of administration
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What is distribution?
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how the drug is transported where it is needed
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What is Metabolism of a drug?
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How the drug is broken down usually in the liver
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What is the excretion of a drug?
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leftover drug is excreted from the body usually by the kidneys.
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What does bioequivelent mean?
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2 meds have the same amount of drug available or has same availability by different routes.
Ex: Cirpo has same bioavailability by IV or oral route |
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What route is absorbed in the stomach or small intestines, & has first pass effect?
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Oral Route -includes sublingual & buccal
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What is the first pass effect?
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When drugs have to pass through the portal circulation before going into the bloodstream. Some of the drug is metabolized prior to distribution. Dosage would need to be higher than a parenteral route
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Which route of administration is the fastest, includes IV, IM, subctaneous, intradermal, intraspinal?
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Parenteral route
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What route of administration has a slow rate of absorption and includes eyes, skin, ears?
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topical routes
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The rate of distrubtions depends on what?
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vascularity of various tissues & organs
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What is onset of a medication?
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Time it takes for a medication to produce a response
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What is a medications peak?
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time in which a medication reaches its highest effective concentration. (if too high may have toxic effects)
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What is a medications duration?
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Time medication concentration is sufficient to produce therapeutic response
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What is serum half-life
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Time for drug concentration to be halved. Time for 1/2 of original or remaining amount of drug to be eliminated from the body. Duration usually has about 5 half lives.
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What does half life determine?
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how often a drug must be given & how long therapeutic or adverse effects will last.
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What is a medications trough level?
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minimum serum concentration (checked before next scheduled dose)
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What is pharmacodynamics>
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The study of what the drug does to the body.
-drug action -therapeutic effect |
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What is teh therapeutic effect?
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expected or predictable desired response
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What is a side effect?
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predictable, often unavoidale secondary effect
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What is adverse effect?
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severe, unexpected, undesirable effect
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What is toxic effect
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medication accumulates in the blood stream and becomes toxic
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What is a idiosyncratic reaction?
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Over or under reaction to a medication or peculiar response. opposite of what its supposed to do
Ex: sleeping pill & pt gets hypper |
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What is an allergic reaction?
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unpredictable hypersensitivity response to a medicatiom. may be mild or severe
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WHat does contraindicated mean?
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don't give together
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What does caution mean?
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be careful giving together
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What is synergistic effect?
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When 2 medications work together to create an effect greater than individually.
Ex: diuretic & vasodilator to control high blood pressure |
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What is an antagonistic effect?
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second drug diminishes or cancel effect of first drug?
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What is incompatibility?
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2 drugs cannot be given together.
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What is acute therapy?
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treat a short-term or critical problem
Ex: infection |
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What is maintenance therapy?
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Treatment of a long term or chronic disease. It prevents disease progression, slows complications
Ex:hypertension, diabetes, birth control |
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What is palliative therapy?
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therapy that makes the client more comfortable . Does not cure but improves the quality of life (in terminally ill)
Ex: pain meds, oxygen, radiation to shrink tumor |
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What is supportive therapy?
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Helps client fxn better
Ex: hydration, blood products |
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What is prophylactic drug therapy?
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It is preventative measure based on scientific data.
Ex: antibiotics before surgery to reduce the chance of infection |
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What is supplemental drug therapy?
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Vitamins, herbals, iron
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What is a drugs therapeutic index?
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the ration b/w a drugs therapeutic benefits and its toxic effects. Drugs are goo dunless you get too much.
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What ia Tolerance to a drug?
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A decreasing response to repetitive drug doses. Req's higher dose to achieve therapeutic effect
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What is a intolerance to a drug?
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inability to absorb or metabolize a drug
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What are warnings & precautions?
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list of conditions or types of clients that need close observation while on a specific drug.
Ex: persons w/liver impairment |
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What are interactions
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list of other drugs or foods that may alter the effect of the drug;
Ex: delayed aborption of tetracycline if given with antacid |
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What are contraindications?
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Conditions for which a drug should not be given
Ex: elderly person with kidney damage would not be able to take penicillin` |
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What are cumulative effects?
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occurs when a drug is metabolized or excreted more slowly than the rate at which it is being administered. May cause toxicity
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What is dependence of a drug?
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a physiologic or psychological need for a drug. Pt will have withdrawal symptoms if drug is abruptly discontinued.
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What is addiction to a drug?
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Pt consistently uses more drug than what is ordered, display drug-seeking behaivor, hoards medication, lies or steals to get it.
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What can you do to reduce the risk of medical errors?
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3 check, 6 rights
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What needs to be done to ensure safe medication administration?
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-wash hands prior to preparing & administeeign meds
-3 checks, 6 rights -check 2 forms of identification -verify allergies -assess client condition prior to giving meds: labs, VS, LOC, any SE -know action, indications, dosage, potential SE, & nursing implications |
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What are the 6 right of medication administration?
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-right dose
-right time -right patient -right route -right documentation -right drug also -right to refuse -right knowledge |
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What are the 3 checks?
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check MAR (med record) against physicians orders
-check meds against MAR while preparing. Check expiration date -check meds against MAR in client room. (confirm pt ID & allergies, review meds with client as you are giving) |
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What is the nurses role in med administration?
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-more than just memorization of names of drugs
-must understand their actions, dose, potential SE, monitoring -comprehend and apply knowledge of drugs to a variety of clinical situations -monitorignt the pt for therapeutic effects is an essential part of nursing |
