Nokea
A patient who was previously awake and alert suddenly becomes unconscious. The nursing plan of care includes an order to increase oral intake. Why would the nurse review the plan of care?
- A. to implement evidence-based practice
- B. to ensure the order follows hospital policy
- C. to be sure interventions are individualized
- D. to be sure the intervention is safe
Correct Answer: D
Rationale: The nurse reviews the plan to ensure the intervention (increasing oral intake) is safe, as an unconscious patient cannot safely consume oral intake, risking aspiration.
You may also like to solve these questions
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.
The researchers developing classifications for interventions are also committed to developing a classification of which of the following?
- A. diagnoses
- B. outcomes
- C. goals
- D. data clusters
Correct Answer: B
Rationale: Researchers focus on classifying outcomes alongside interventions to measure the effectiveness of nursing actions and ensure patient-centered care.
Which of the following statements accurately describe a recommended guideline for implementation? Select all that apply.
- A. When implementing nursing care, remember to act independently, regardless of the wishes of the patient/family.
- B. Before implementing any nursing action, reassess the patient to determine whether the action is still needed.
- C. Assume that the nursing intervention selected is the best of all possible alternatives.
- D. Consult colleagues and the nursing and related literature to see if other approaches might be more successful.
- E. Reduce your repertoire of skilled nursing interventions to ensure a greater likelihood of success.
- F. Check to make sure that the nursing interventions selected are consistent with standards of care.
Correct Answer: B,D,F
Rationale: Recommended guidelines include reassessing the patient (B), consulting colleagues and literature for better approaches (D), and ensuring interventions align with standards of care (F). Acting independently without patient input (A), assuming interventions are the best (C), or reducing skills (E) are not recommended.
The staff in a long-term care facility often plays loud rock music on the radio and designs childrens games as exercise. What is the staff doing in this situation?
- A. considering the hearing level of older adults
- B. failing to consider visual deficits that occur with aging
- C. ignoring the developmental needs of older adults
- D. meeting needs for sensory input and exercise
Correct Answer: C
Rationale: Playing loud rock music and using children's games ignores the developmental needs of older adults, as these activities may not align with their preferences or cognitive and physical capabilities.
What is the unique focus of nursing implementation?
- A. patient response to health and illness
- B. patient response to nursing diagnosis
- C. patient compliance with treatment regimen
- D. patient interview and physical assessment
Correct Answer: A
Rationale: The unique focus of nursing implementation is addressing the patient's response to health and illness, as it involves carrying out interventions to promote health, prevent illness, or manage health problems.