Nokea
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.
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Which of the following includes the components required for a complete nursing diagnosis statement?
- A. A problem and the suggested patient goals or outcomes.
- B. A problem, its cause, and objective data that support the problem
- C. A problem with all its possible causes and the planned interventions
- D. A problem with its etiology and the signs and symptoms of the problem
Correct Answer: D
Rationale: The PES format is used when writing nursing diagnoses. The subjective, as well as objective, data should be included in the defining characteristics. Interventions and outcomes are not included in the nursing diagnosis statement.
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.
Which of the following is an example of a correctly written nursing diagnosis statement?
- A. Altered tissue perfusion related to heart failure
- B. Risk for impaired tissue integrity related to sacral redness
- C. Ineffective coping related to insufficient sense of control
- D. Altered urinary elimination related to urinary tract infection
Correct Answer: C
Rationale: This diagnosis statement includes a NANDA nursing diagnosis and an etiology that describes a patient's response to a health problem that can be treated by nursing. The use of a medical diagnosis (as in the responses beginning 'Altered tissue perfusion' and 'Altered urinary elimination') is not appropriate. The response beginning 'Risk for impaired tissue integrity' uses the defining characteristics as the etiology.
Which of the following best explains the nurse's primary use of the nursing process when providing care to patients?
- A. To explain nursing interventions to other health care professionals
- B. As a problem-solving tool to identify and treat patients' health care needs
- C. As a scientific-based process of diagnosing the patient's health care problems
- D. To establish nursing theory that incorporates the biopsychosocial nature of humans
Correct Answer: B
Rationale: The nursing process is an assertive problem-solving approach to the identification and treatment of patients' problems. Diagnosis is only one phase of the nursing process. The primary use of the nursing process is in patient care, not to establish nursing theory or explain nursing interventions to other health care professionals.
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.