Nokea
A nurse is catheterizing a patient. What action illustrates respect for the patients privacy?
- A. explaining the procedure to the family
- B. leaving the patients pajamas on
- C. closing the door to the room
- D. asking another nurse if he wants to watch
Correct Answer: C
Rationale: Closing the door to the room ensures privacy by limiting exposure to others, a key aspect of respecting patient dignity during invasive procedures.
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What is one advantage of having a standard classification of nursing interventions?
- A. to standardize nomenclature (names or terms)
- B. to legitimize the use of the nursing process
- C. to classify indicators of patient outcomes
- D. to facilitate documentation of expected goals
Correct Answer: A
Rationale: A standard classification of nursing interventions standardizes nomenclature, ensuring consistent terminology across healthcare settings, which improves communication and documentation.
What activity is carried out during the implementing step of the nursing process?
- A. Assessments are made to identify human responses to health problems.
- B. Mutual goals are established and desired patient outcomes are determined.
- C. Planned nursing actions (interventions) are carried out.
- D. Desired outcomes are evaluated and, if necessary, the plan is modified.
Correct Answer: C
Rationale: The implementing step involves carrying out planned nursing interventions to address the patient's needs, as outlined in the nursing care plan.
A nurse is preparing to insert an intravenous line and begin administering intravenous fluids. The patient has visitors in the room. What should the nurse do?
- A. Ask the visitors to leave the room.
- B. Ask the patient if visitors should remain in the room.
- C. Tell the patient to ask the visitors to leave the room.
- D. Wait until the visitors leave to begin the procedure.
Correct Answer: B
Rationale: The nurse should ask the patient if visitors should remain, respecting patient autonomy and privacy preferences during the procedure.
Which of the following examples of nursing actions involve direct care of the patient? Select all that apply.
- A. A nurse counsels a young family who is interested in natural family planning.
- B. A nurse massages the back of a patient while performing a skin assessment.
- C. A nurse arranges for a consultation for a patient who has no health insurance.
- D. A nurse helps a patient in hospice fill out a living will form.
- E. A nurse arranges for physical therapy for a patient who had a stroke.
- F. A nurse comforts a distraught patient whose baby was stillborn.
Correct Answer: A,B,D,F
Rationale: Direct care involves hands-on or face-to-face interaction with the patient. Counseling (A), massaging (B), assisting with a living will (D), and comforting (F) involve direct patient interaction, whereas arranging consultations (C) and physical therapy (E) are indirect care activities.
A student is ambulating a patient for the first time after surgery. What would the student do to anticipate and plan for an unexpected outcome?
- A. Take the patients vital signs after ambulation.
- B. Ask the patients wife to assist with ambulation.
- C. Delay ambulation until the following shift.
- D. Ask another student to help with ambulation.
Correct Answer: D
Rationale: Asking another student to help anticipates potential complications (e.g., falls) by ensuring additional support is available during ambulation.