Nokea
The nurse is caring for a critically ill patient in the intensive care unit and plans an every-2-hour turning schedule to prevent skin breakdown. Which type of nursing function is demonstrated with this turning schedule?
- A. Dependent
- B. Cooperative
- C. Independent
- D. Collaborative
Correct Answer: D
Rationale: When implementing collaborative nursing actions, the nurse is responsible primarily for monitoring for complications of acute illness or providing care to prevent or treat complications. Independent nursing actions are focused on health promotion, illness prevention, and patient advocacy. A dependent action would require a physician order to implement. Cooperative nursing functions are not described as one of the formal nursing functions.
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Which of the following refers to a situation that results in unintended harm to the patient and is related to the care or services provided rather than the patient's medical condition?
- A. Negligence
- B. Adverse event
- C. Incident report
- D. Nonmaleficence
Correct Answer: B
Rationale: An adverse event is an event that results in unintended harm to the patient and is related to the care or services provided to the patient rather than to the patient's underlying medical condition.
The nurse is caring for a patient who has left-sided paralysis as the result of a stroke and assesses a pressure injury on the patient's left hip. Which of the following is the most appropriate nursing diagnosis for this patient?
- A. Impaired physical mobility related to decrease in muscle control (left-sided paralysis)
- B. Risk for impaired tissue integrity as evidenced by insufficient knowledge about protecting tissue integrity
- C. Impaired skin integrity related to pressure over bony prominence (impaired circulation)
- D. Ineffective peripheral tissue perfusion related to sedentary lifestyle
Correct Answer: C
Rationale: The patient's major problem is the impaired skin integrity as demonstrated by the presence of a pressure injury. The nurse is able to treat the cause of impaired circulation and pressure over bony prominence by frequently repositioning the patient. Although left-sided weakness is a problem for the patient, the nurse cannot treat the weakness. The 'risk for' diagnosis is not appropriate for this patient, who already has impaired tissue integrity. The patient does have ineffective peripheral tissue perfusion, but the impaired skin integrity diagnosis indicates more clearly what the health problem is.
Which of the following represents a nursing activity that is carried out during the evaluation phase of the nursing process?
- A. Determining if interventions have been effective in meeting patient outcomes.
- B. Documenting the nursing care plan in the progress notes in the medical record.
- C. Deciding whether the patient's health problems have been completely resolved.
- D. Asking the patient to evaluate whether the nursing care provided was satisfactory.
Correct Answer: A
Rationale: Evaluation consists of determining whether the desired patient outcomes have been met and whether the nursing interventions were appropriate. The other responses do not describe the evaluation phase.
Which of these tasks is appropriate for the registered nurse to delegate to an unregulated care provider?
- A. Perform a sterile dressing change for an infected wound.
- B. Complete the patients' initial bath.
- C. Teach a patient about the effects of prescribed medications.
- D. Document patient teaching about a routine surgical procedure.
Correct Answer: B
Rationale: Unregulated care providers are able to provide personal care to patients. Patient teaching and the initial assessment and development of the plan of care are nursing actions that require RN-level education and scope of practice when working with patients that are not stable.
The nurse is caring for a patient with a new diagnosis of pneumonia and explains to the patient that together they will plan the patient's care and set goals for discharge. The patient asks: 'How is that different from what the doctor does?' Which response by the nurse is most appropriate?
- A. The role of the nurse is to administer medications and other treatments prescribed by your doctor.
- B. The nurse's job is to help the doctor by collecting data and communicating when there are problems.
- C. Nurses perform many of the procedures done by physicians, but nurses are here in the hospital for a longer time than doctors.
- D. In addition to caring for you while you are sick, the nurses will assist you to develop an individualized plan to maintain your health.
Correct Answer: D
Rationale: This response is consistent with the Canadian Nurses Association (CNA) definition of nursing. Registered nurses are self-regulated health care professionals who work autonomously and in collaboration with others. RNs enable individuals, families, groups, communities and populations to achieve their optimal level of health. RNs coordinate health care, deliver direct services, and support patients in their self-care decisions and actions in situations of health, illness, injury, and disability in all stages of life. The other responses describe some of the dependent and collaborative functions of the nursing role but do not accurately describe the nurse's role in the health care system.