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50 Cards in this Set
- Front
- Back
Nursing process?
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problem solving tool to assess patients
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Nursing activity during assessment phase?
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determining if effectiveness of interventions was successful
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Complete diagnosis statement?
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a problems with its etiology and S/S
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Info the nurse needs to collect assessing the health status of a community
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life expectancy of individuals
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82 year old Asian… lives in the U.S. for 50 years. speaks English, lives in Asian neighborhood… ask about?
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ask about special culture beliefs and practice
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Planning health care for a community with lots of asian immigrants…most important intervention?
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T.B. screening
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When performing a culture assessment, first action is to?
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ask the patient about any affiliations with a culture group
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Pt diff breathing, admitted, best approach for a nurse to use?
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Several short sessions with patient for discovery
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The nurse reports a general survey… 68 year old male asian, wife and two daughters… no eye contact with the nurse. No apparent disabilities, include what findings?
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Nutritional status
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Health hx and physical for right sided rib fractures… pertinent negative finding?
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denies pain upon palpation over the site
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Preparing for a focused abdominal assessment for high pitched bowel sounds?
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stethoscope
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Planning for a physical exam of an alert 80 year old patient exam should include?
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organize the assessment to avoid position changes
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Assessing the circulation to the lower leg with recent knee surgery…action taken first?
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visualize the color of the foot first
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43 year old type II diabetes after admitted to hospital with foot wound… adult learning strategy should be used by the nurse?
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teach correct method for cleaning and dressing the wound
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Nursing diagnosis of inadequate health issues with a diabetic pt?
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Pt says dietary intake does not seem to impact his energy level or overall health
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Pt teaching plan includes this goal… 2gm sodium restrict diet…how do we evaluate if the patient understands the plan?
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Check sodium content in the patient's menu over the last three days. "have to evaluate how he follows the diet and responded to your teaching, you can't watch him all day."
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22 yr old pt smokes a pack a day, pt sts i enjoy smoking and I'm not quitting… how do we fix?
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ineffective health care maintenance related to health care maintenance
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Pt has type II with severe hyperglycemia what is best way to teach when pt leaves hospital?
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symptoms indicating pt should contact the health care provider
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AA0*4 85 yr old multiple meds cardiac and resp/// no caregiver around enough... what diagnosis is most important?
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drug drug interaction injury
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developing a plan of care with an older adult with an acute illness, nurse should?
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consider pre admission functionality before
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78 yr old pt, multiple health problems, increasingly weak, 11 pound weight loss…nurse should initially?
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ask about dietary intake
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planning discharge for an alert 70 year old foot infection, most important for nurse to?
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refer to social services for better treatment of foot
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which of these pts assigned to the nurse will need planning for long term nursing management?
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56 year old with bilateral knee surgeries and weighs 400 lbs
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Pt in an MVC, nurse is a case manger… nurse's responsibilities in this role are to?
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coordinate the services the pt receives in the hospital and at home
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Which pts being discharged from the acute care nurse will get Medicare benefits for at home care?
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65 year old with spinal cord injury who needs help eating
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After the charge nurse is done orientating what action by a new nurse shows she needs remediation?
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new nurse massages an active ulcer wound leg
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Pt with fibromyalgia had back pain and stiffness… nurse suggests what tx?
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acupuncture
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Which therapies should nurse suggest for elevated triyclicerides level?
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fish oil
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Pt who has nausea with chemo, what alternative measures can a nurse suggest?
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acupuncture
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Frequent URI's nurse can suggest what alternative med?
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echincea
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Pt has a chronic infection and doesn't want to use antibiotics? Nurse should?
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Nurse should explain how they interact
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Multiple abrasions after an MVC, 180/98… nurse should?
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recheck BP before patient is discharged
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Overweight pt, enjoys active life, knees start to get arthritic… nurse should tell him after the bad news?
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encourage pt to see how weight loss will improve his knees
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Diabetic pt hospitalized tells the nurse he can control his BGl at home alone, when he gets sick it goes up…. nurse should explain this is because?
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stressors release hormones and increase BGL
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Nurse takes health hx for four patients… which info regarding then patient's sleep is most important to take?
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42 BMI with snoring at night
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Pt received a new c pap a week ago… severe day time sleepiness still apparent… nurse should?
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Are you using the C pap every night?
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A patient who uses a patch for chronic cancer pain…. rapid onset of pain 9/10…. I want something quicker…. Pain is what?
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break thru pain
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A pt with chronic cancer pain is receiving morphine and tofranil….. Best indicator that the tofranil is effective?
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Pain is manageable and I can accomplish goals during the day
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Pt receives MS cotton every 12 hours, pt experiences a break thru 9/10… Nurse should administer?
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Imm release morphine 30mg orally
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Pt second degree burns,,,, getting morphine thru a pump for a week, pt complains of pain at night frequently….. Nurse should?
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separate tx for the pain
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Pt receiving epidural morphine.. pt may be having a side effect. It is?
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Pt hasn't voided for 10 hours
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Which therapy should the nurse use first with cancer pain 8/10 and deep and aching?
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Dilaudid
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Diabetic pt chronic burning leg pain even when taking oxycodone…. what med is the best adjunct to decrease the pt's pain?
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elavil
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Meds are prescribed by HCP for patients using MS cotton but still has on going pain… nurse should question which med?
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Talwan
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post op pat morphine from a pump…. report to HCP what finding?
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10 breaths per minute
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Pt using patch and imm release morphine… new onset of dizziness and AMS, nurse should?
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remove the patch
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Meds are ordered… 86 year old osteoarthritis in his hip. what med should be used first?
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Tylenol orally
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Select all that apply? Nurse should take actions to watch acute stressors on a patient?
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elevated bgl, epigastric pain, pt wants to eat more
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Pt uses multiple herbal products… knee replacement surgery. nurse informs pt herbs that should be discontinued 2-3 weeks prior? Select all that apply?
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garlic, ginger, ginko, feverview
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HCP plans to titrate a pt controlled analgesic pain pump for post op? Nusre should? Select all that apply?
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improvement of post op activities and therapeutic range/adverse effects
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