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Which nursing intervention is complete and correct?
- A. May 10: Unlicensed assistive personnel will ambulate patient. A. Nurse
- B. Day nurse will cleanse wound and change dressings every day. May 10 A. Nurse
- C. Unlicensed assistive personnel will serve 8 oz glass of juice at each meal 5/10.
- D. P.M. nurse will ensure that heel protectors are in place before bedtime.
Correct Answer: B
Rationale: Nursing orders must be signed, dated, and have specific designation as to who will perform intervention and specifics about time or frequency of the intervention.
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What expected outcome exemplifies accepted criteria?"
- A. Nurse will assess vital signs every day
- B. Resident will observe safety guidelines while smoking
- C. Resident will take part in one activity daily for the next 90 days
- D. Nurse will monitor O2 saturation to maintain at greater than 90%
Correct Answer: C
Rationale: Expected outcomes must be patient-centered, measurable, and refer to a time frame.
The human responses to health conditions/life processes that exist in an individual family or community are known as a(n) ____ patient problem.
Correct Answer: actual
Rationale: An actual patient problem is described as the human responses to health conditions/life processes that exist in an individual, family, or community.
NANDA International meets to reorganize diagnosis labels and language every 2 ____
Correct Answer: years
Rationale: NANDA International meets every two years to revise language, form, and diagnosis labels.
What subjective data does the nurse record following a head-to-toe examination?
- A. Rash on back
- B. Prolonged nausea
- C. Blood pressure of 190/100
- D. White blood cell count of 19000
Correct Answer: B
Rationale: Another term for subjective data is symptoms, which cannot be observed or measured. This data must come from the patient.
What organized approach might the nurse use when performing a complete physical examination?
- A. Maslow's hierarchy of needs
- B. A head-to-toe assessment
- C. Subjective data collection
- D. Objective data collection
Correct Answer: B
Rationale: A head-to-toe format provides a systematic approach.