Nure 131- Unexpected Outcomes

Patient develops chest pain/discomfort during exercise. Which intervention is not related?

Patient needs bronchodilator more than every 4 hours. Which intervention does not apply?

Patient starts to fall while ambulating with nurse or other caregiver. Which intervention does not apply?

IV site shows symptoms of infiltration or phlebitis. Which intervention does not apply?

Patient experiences systemic effects from drops. Which intervention does not apply?

Patient’s hearing acuity does not improve. Which related intervention does not apply?

Patient complains of sinus headache. Sinuses remain congested. Which intervention applies?

Patient experiences cardiac dysrhythmias especially if receiving beta-adrenergic meds. Which intervention doesn’t apply?

Patient does not understand what surgery will be performed. Which Intervention is correct?

Patient unable to explain info about drug or doesn’t take as prescribed. Which intervention applies?

Localized areas of tenderness occur on feet w/ calluses or corns at point of friction. Which intervention doesn’t apply?

Patient is unable to comprehend or is unwilling to follow directions. Which is not a related intervention?

Patient sustains injury or is agitated & places others at risk or injury. Which intervention does not apply?

Patient displays behaviors that increase risk or injury to self or others. Which intervention does not apply?

Patient complains of severe incisional pain. Which interventions are related?

Patient develops adverse reaction to medication. Which related intervention does not apply?

Ear canal remains inflamed, swollen, tender to palpation. Drainage is present. Which intervention does not apply?

Patient complains of pain/burning at insertion site or site is red/swollen/leaking. Which intervention doesn’t apply?

Areas of excessive dryness, rashes, irritation, or pressure injury appear on skin. Which intervention does not apply?

Patient sustained injury on transfer. Which related intervention does not apply?

Patient experiences cardiac dysrhythmias especially if receiving beta-adrenergics. Which intervention does not apply?

Patient reports rectal pain during insertion. Which related intervention does not apply?

Cuticles & surrounding tissues are inflamed & tender to touch. Which intervention does not apply?

Patient wanders away from health care agency. Which intervention applies?

Patient is unable to self- administer medications. Which intervention would apply to this unexpected outcome?

Joint contractures develop or worsen. Which related intervention does not apply?

Patient exhibits signs of hypovolemia related to internal or incisional hemorrhage. Which intervention does not apply?

Patient is unable to discuss drug therapy correctly. Which intervention does not apply?

Cheilosis- dry and cracked lips. Which intervention applies?

Patient identifies incorrect procedure, site, date, or time of surgery. This is related to which Intervention?

Patient reports allergy to latex. All but which intervention is correct?

Patient refuses medication. Which intervention does not apply?

Patient displays signs of allergic reaction to medication. Which intervention does not apply?

Patient/family caregiver unable to identify fall risks or fall prevention strategies. Which intervention relates?

Patient sustains an injury. Which intervention does not apply?

Patient becomes excessively tired & unable to cooperate or participate in bathing. Which intervention doesn’t apply?

Patient incorrectly performs one of the postoperative exercises. Which Interventions are correct?

Raised, reddened, or hard zone forms around ID test site. Which intervention does not apply?

Gum margins are retracted from teeth w/areas of inflammation & some bleeding by gums. Which intervention doesn’t apply?

Patient’s respiration’s are rapid and shallow; breath sounds indicate wheezing. Which intervention does not apply?

Patient is unable to stand for time required to transfer to chair. Which related intervention pertains to this situation

Patient is unable to explain drug info or steps for taking eyedrops or cannot use dropper. Which intervention applies?

Patient complains of severe incisional pain. What related intervention does not apply in the PACU?

IV medication is incompatible with IV fluids. Which intervention does not apply?

Ulcerations involving toes or feet may remain. Which intervention does not apply?

Skin site inflamed w/blistering & oozing from legions indicating subacute inflammation. Which intervention doesn’t apply

Patient complains of pain/burning at injection site, potential injury to nerve/vessels. Which intervention doesn’t apply

Patient experiences impaired skin integrity. Which intervention does not apply?

Patient is unable to explain drug information. Which intervention does not apply?

Patient complains of burning or pain or experiences local side effects. Which intervention does not apply?

Patient avoids moving. Which intervention does not apply?

Patient’s symptoms are unrelieved. Which intervention applies to this unexpected outcome?

Air bubbles remain in syringe. Which related intervention applies to this situation?

Medication does not infuse over established time frame. Which intervention does not apply?

Mucosa becomes inflamed from repeated chemo/radiation and a lesion develops. Which intervention does not apply?

Patient suffers traumatic injury. Which intervention does not apply?

Secretions or crusts remain on mucosa , tongue, or gums. Which intervention applies?

Patient develops adverse or allergic reaction to medication. Which intervention does not apply?

Patient has paroxysms of coughing. Aerosolized particles irritate posterior pharynx. Which intervention doesn’t apply?

Patient complains of pain/burning at injection site indicating injury to nerve/vessel. Which intervention doesn’t apply?

Informed consent has not been signed & witnessed. Surgeon did not provide info. Which intervention applies?

Patient becomes more confused or agitated. Which intervention does not apply?

Mucosa is dry & inflamed. Tongue has thick coating. Which intervention does not apply?

Patient has abnormal vital sign response or decrease in O2 saturation requiring termination of exercise. Which is wrong?

Patient found after falling. Which intervention is not related?

When using cane or walker, patient bends over and doesn’t stand straight. Which intervention applies to this situation?

Patient complains of localized pain, numbness, tingling, or burning at injection site. Which intervention doesn’t apply?

Patient exhibits adverse effects (side effect, toxic effect, allergic reaction) which intervention does not apply?

Patient is unable to ambulate because of fear of falling, discomfort, or weakness. Which intervention does not belong?

Patient experiences decreased heart rate during rectal suppository insertion. Which intervention does not apply?

Patient aspirates oral secretions. Which intervention does not apply?

Patient exhibits adverse effects. (Side effect, toxic effect, allergic reaction). Which intervention does not apply?

Patient exhibits respiratory depression. Which Related Intervention does not apply?

Incorrect dose of medication is prepared. Which related intervention does not apply?

Localized inflammation or bleeding of gums or mucosa is present. Which intervention does not apply?

Lips are cracked or inflamed. When intervention applies?

Nasal mucosa remains inflamed and tender, with discharge from nares. Which related intervention applies?

Patient reports localized pruritus and burning. Which related intervention does not apply?

Patient has adverse reaction with signs of urticaria, pruritus, wheezing, & dyspnea. Which intervention doesn’t apply?

Patient has neurovascular injury. (Cyanosis, pain, numbness, etc) which intervention does not relate?

CSQI becomes dislodged. Which intervention does not apply to this unexpected outcome?

Vital signs above or below baseline or expected range. Related interventions include all but which?

During injection blood is aspirates. Which intervention does not apply?

Patient seems unusually restless or complains of discomfort. Which intervention does not apply?

Patient shows adverse reaction&signs of urticaria, eczema, pruritus, wheezing & dyspnea.Which intervention doesn’t apply

Patient aspirates secretions. Which intervention does not apply?

Patient is unable to give consent, and family member is unavailable. All but which Interventions apply?

Skin shows localized areas of erythema and breakdown. Which intervention is not related?

Patient does not receive medication because of blocked enteral tube. Which intervention does not apply?

Patients breathing pattern: respirations rapid & shallow; breath sounds wheezing. Which intervention doesn’t apply?

Hypertrophy of skin develops from repeated subcutaneous injection. Which intervention does not apply?

Patient signs of aspiration, including resp. distress changes in VS or O2 saturation. Which intervention doesn’t apply

Patient displays adverse reaction with signs of urticaria, wheezing, & dyspnea. Which intervention does not apply?

Patient did not remain NPO. Patient may not have understood or forgot. Which related intervention applies?

IV site shows signs of infiltration or phlebitis

Patient is unable to breathe easily in nasal passages, mucosa swollen & congested. Which intervention doesn’t apply?