Nokea
Which of these nursing actions for the patient with heart failure is appropriate for the nurse to delegate to experienced unregulated care providers?
- A. Assess for shortness of breath or fatigue after ambulation.
- B. Instruct the patient about the need to alternate activity and rest.
- C. Obtain the patient's blood pressure and pulse rate after ambulation.
- D. Determine whether the patient is ready to increase the activity level.
Correct Answer: C
Rationale: Unregulated care provider education varies according to the type of worker, however, unregulated care providers are able to measure vital signs. Assessment and patient teaching require RN education and scope of practice and cannot be delegated.
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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.
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 would the nurse perform during the assessment phase of the nursing process?
- A. Obtains data with which to diagnose patient problems.
- B. Uses patient data to develop priority nursing diagnoses.
- C. Teaches interventions to relieve patient health problems.
- D. Assists the patient to identify realistic outcomes to health problems.
Correct Answer: A
Rationale: During the assessment phase, the nurse gathers information about the patient. The other responses are examples of the intervention, diagnosis, and planning phases of the nursing process.
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 been admitted to the hospital for surgery and tells the nurse, 'I do not feel right about leaving my children with my neighbour.' Which action should the nurse take next?
- A. Reassure the patient that these feelings are common for parents.
- B. Have the patient call the children to ensure that they are doing well.
- C. Call the neighbour to determine whether adequate childcare is being provided.
- D. Gather more data about the patient's feelings about the childcare arrangements.
Correct Answer: D
Rationale: Since a complete assessment is necessary in order to identify a problem and choose an appropriate intervention, the nurse's first action should be to obtain more information. The other actions may be appropriate, but more assessment is needed before the best intervention can be chosen.