Galen Trujillo NUR 155 Exam 1

What should be taken into consideration by RN when deciding on interventions to include in pt’s plan of care? Select all

Which statement illustrates a characteristic of goals within the care planning process?

Which nursing intervention is most important to complete before giving medication to a patient?

Which clinical patient scenario is associated with the most critical need for the nurse to obtain vital signs?

What is the primary purpose of the nursing diagnosis?

Which statement best describes the relationship of medical diagnoses and nursing diagnoses?

Which factors should be taken into consideration before and during a patient interview? (Select all that apply)

When initiating a physical examination, which action should the nurse take first?

A pt reports feeling tired and complains of not sleeping at night. What action should nurse perform first?

When should administered medications be documented?

Which nursing action is critical before delegating interventions to another healthcare member?

Of the following assessment findings, which cues indicate to RN that a pt has a surgical site infection? Select all

Which sequence best identifies the order in which the nurse should complete an abdominal assessment?

A patient comes to the ER complaining of nausea and vomiting. What should the nurse ask the pt about first?

Which resource is most helpful when prioritizing identified nursing diagnoses?

Which activity by the nurse best demonstrates part of the working phase of a patient interview? (Select all that apply.)

RN is providing pt education on infection prevention. Which definition of infection does the RN use as a teaching point?

Which statements regarding temperature and heat production in the body are accurate? (Select all that apply)

What action should the nurse take: the pt met their short term goal of voiding 1 hour post-surgery

A patient develops food poisoning from contaminated food. What is the means of transmission for the infectious organism?

Which attributes are important in nursing documentation? (Select all that apply.)

An alert, oriented pt is admitted with chest pain. From whom should the nurse collect primary data on this pt?

If a pt is exhibiting signs and symptoms of each of these nursing diagnoses, which should the RN address first?

What should be the primary focus for nursing interventions?

Which interventions can the nurse initiate independently while providing patient care? (Select all that apply.)

What cues would the RN appropriately cluster as supporting data for a pt with extreme anxiety? (Select all that apply)

What is the purpose of the nursing process?

Which action by the RN would be most important in developing a pt-centered plan of care for an alert, oriented adult?

If the RN discovers that a pt's elbow is swollen & painful during physical examination, which action should the RN take

RN is preparing to auscultate a pt’s chest. In which area should the RN listen to evaluate the patient’s aortic valve?

On what premise is a nursing diagnosis identified for a pt? (select all that apply)

Which action by the nurse is most appropriate during the orientation phase of the patient interview?

What is a purpose of a hand-off report?

Which actions does the RN need to take before determining the types of nursing diagnoses for pt? (Select all that apply)

Which ? by the RN best represents an appropriate approach to the review of systems aspect of the assessment process?

What is the primary difference between a NANDA-I risk nursing diagnosis and a problem-focused nursing diagnosis?

A new pt is admitted to a unit with C Diff. Which type of precautions does the RN know is appropriate for pt?

Which cue by a patient can be validated by laboratory and diagnostic test results?

Objective data can be gathered from the pt during which aspects of the physical assessment process? (Select all )

The nurse understands that which statement is correct regarding respiratory rates?

Which assessment finding would be most important to document in a pt w/ known liver disease who has a distended abdomen?

Which actions are part of the evaluation step in the nursing process? (Select all that apply.)

Which action by a patient marks the beginning of the physical assessment process?

Which action would the nurse undertake first when beginning to formulate a patient’s plan of care?

Vital signs for the patient indicate hypotension and tachycardia. Which data would support this evaluation?

1.Which are reasons that accurate documentation in the medical record is important? (Select all that apply.)

Which entry in a pt EHR best indicates the need for a nurse to gather secondary rather than primary subjective data

What should the nurse consider before implementation of all nursing interventions? (Select all that apply.)

What is the most important reason for nurses to use a standardized taxonomy, such as the NANDA-I?

Of the following hospitalized patients, who is most at risk for acquiring a health care–associated infection?

Which nursing goal is written correctly for a pt with the nursing diagnosis Risk for Infection after abdominal surgery?

Which situation indicates the greatest need for collaborative interventions provided by several healthcare team members?

What action is needed to have a new nursing diagnosis considered for inclusion in the NANDA-I?

What is the most significant problem that may result from improperly written NANDA-I nursing diagnostic statements?

A pt’s sister comes to visit and asks to read the patient’s medical records. What is the best response by the nurse?

What situations would necessitate modification of a patient’s plan of care? (Select all that apply.)

Which action by the nurse would be most effective in determining whether a patient has muscle hypertonicity?