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A nurse assesses the vital signs of a patient who is one day postsurgery in which a colostomy was performed. The nurse then uses the data to update the patient plan of care. What are these actions considered?
- A. initial planning
- B. comprehensive planning
- C. on-going planning
- D. discharge planning
Correct Answer: C
Rationale: Updating the care plan based on new assessments, such as post-surgery vital signs, is considered ongoing planning (C).
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In which of the following patients has the order of priorities for nursing diagnoses changed? Select all that apply.
- A. a patient in a long-term care facility who had a stroke
- B. a patient who is recovering from a broken leg
- C. a patient who insists on using the bathroom instead of a bedpan
- D. a patient who appears confused after taking pain medication
- E. a pregnant patient whose contractions are progressing as anticipated
- F. a patient who has wounds that require stitches as well as a concussion
Correct Answer: A,C,D,F
Rationale: Patients with a stroke (A), insistence on bathroom use (C), confusion after medication (D), and wounds plus concussion (F) may have shifting priorities due to acute or changing conditions.
What is true of nursing responsibilities with regard to a physician-initiated intervention (physicians order)?
- A. Nurses do not carry out physician-initiated interventions.
- B. Nurses do carry out interventions in response to a physicians order.
- C. Nurses are responsible for reminding physicians to implement orders.
- D. Nurses are not legally responsible for these interventions.
Correct Answer: B
Rationale: Nurses are responsible for carrying out physician-initiated interventions (B) as part of their role.
A nurse has developed a plan of care with nursing interventions designed to meet specific patient outcomes. The outcomes are not met by the time specified in the plan. What should the nurse do now in terms of evaluation?
- A. Continue to follow the written plan of care.
- B. Make recommendations for revising the plan of care.
- C. Ask another healthcare professional to design a plan of care.
- D. State goal will be met at a later date.
Correct Answer: B
Rationale: If outcomes are not met, the nurse should recommend revising the plan of care (B) based on evaluation.
A nurse is developing outcomes for a specific problem statement. What is one of the most important considerations the nurse should have?
- A. that the written outcomes are designed to meet nursing goals
- B. to encourage the patient and family to be involved
- C. to discourage additions by other healthcare providers
- D. why the nurse believes the outcome is important
Correct Answer: B
Rationale: Involving the patient and family (B) is crucial for developing patient-centered outcomes.
What name is given to tools that are used to communicate a standardized interdisciplinary plan of care for patients within a case management healthcare delivery system?
- A. Kardex care plans
- B. computerized plans of care
- C. clinical pathways
- D. student care plans
Correct Answer: C
Rationale: Clinical pathways (C) are tools used to communicate standardized interdisciplinary care plans.