Nursing Expert Q&A

A staff nurse delegates a task to a nursing assistive personnel (NAP) , knowing that the NAP has never performed the task before. As a result, the patient is injured, and the nurse defensively states that the NAP should have known how to perform such a simple task. Which element of the decision-making process is the nurse lacking?

A) Authority
B) Autonomy
C) Responsibility
D) Accountability

A nurse is working in an intensive care unit (critical care) . Which type of nursing care delivery model will this nurse $\mathbf{most}$ likely use?

A) Team nursing
B) Total patient care
C) Primary nursing
D) Case-management

A nurse is prioritizing care for four patients. Which patient should the nurse see first?

A) A patient needing teaching about medications
B) A patient with a healed abdominal incision
C) A patient with a slight temperature
D) A patient with difficulty breathing

A patient with an indwelling urinary catheter has been given a bed bath by a new nursing assistive personnel. The nurse evaluating the cleanliness of the patient notices crusting at the urinary meatus. Which action should the nurse take next?

A) Ask the nursing assistive personnel to observe while the nurse performs catheter care.
B) Leave the room and ask the nursing assistive personnel to go back and perform proper catheter care.
C) Tell the nursing assistive personnel that catheter care is sloppy.
D) Remove the catheter.

A registered nurse (RN) is the group leader of practical nurses and nursing assistive personnel. Which nursing care model is the RN using?

A) Case management
B) Total patient care
C) Primary nursing
D) Team nursing

A nurse manager conducts rounds on the unit and discovers that expired stock medicine is still in the cabinet despite the e-mail that was sent stating that it had to be discarded. The staff nurse dress code is not being adhered to as requested in the same e-mail. Several staff nurses deny having received the e-mail. Which action should the nurse manager take?

A) Close the staff lounge.
B) Enforce a stricter dress code.
C) Include the findings on each staff member's annual evaluation.
D) Place a hard copy of announcements and unit policies in each staff member's mailbox.

A nurse manager sent one of the staff nurses on the unit to a conference about new, evidence-based wound care techniques. The nurse manager asks the staff nurse to prepare a poster to present at the next unit meeting, which will be mandatory for all nursing staff on the unit. Which type of opportunity is the nurse manager providing for the staff?

A) Staff education
B) Interprofessional collaboration
C) Providing a professional shared governance council
D) Establishing a nursing practice committee

A nurse is providing education to a patient about self-administering subcutaneous injections. The patient demonstrates the self-injection. Which type of indicator did the nurse evaluate?

A) Health status
B) Health behavior
C) Psychological self-control
D) Health service utilization

A goal for a patient with diabetes is to demonstrate effective coping skills. Which patient behavior will indicate to the nurse achievement of this outcome?

A) States feels better after talking with family and friends
B) Consumes high-carbohydrate foods when stressed
C) Dislikes the support group meetings
D) Spends most of the day in bed

The nurse is caring for a patient who has an open wound and is evaluating the progress of wound healing. Which priority action will the nurse take?

A) Ask the nursing assistive personnel if the wound looks better.
B) Document the progress of wound healing as "better" in the chart.
C) Measure the wound and observe for redness, swelling, or drainage.
D) Leave the dressing off the wound for easier access and more frequent assessments.

A new nurse is confused about using evaluative measures when caring for patients and asks the charge nurse for an explanation. Which response by the charge nurse is most accurate?

A) "Evaluative measures are multiple-page documents used to evaluate nurse performance."
B) "Evaluative measures include assessment data used to determine whether patients have met their expected outcomes and goals."
C) "Evaluative measures are used by quality assurance nurses to determine the progress a nurse is making from novice to expert nurse."
D) "Evaluative measures are objective views for completion of nursing interventions."

A nurse is caring for a group of patients. Which evaluative measures will the nurse use to determine a patient's responses to nursing care? (Select all that apply.)

A) Observations of wound healing
B) Daily blood pressure measurements
C) Findings of respiratory rate and depth
D) Completion of nursing interventions
E) Patient's subjective report of feelings about a new diagnosis of cancer

A nurse is modifying a patient's care plan after evaluation of patient care. In which order, starting with the first step, will the nurse perform the tasks?
1) Revise nursing diagnosis.
2) Reassess blood pressure reading.
3) Retake blood pressure after medication.
4) Administer new blood pressure medication.
5) Change goal to blood pressure less than 140/90.

A) 1, 5, 2, 4, 3
B) 2, 1, 5, 4, 3
C) 4, 3, 1, 5, 2
D) 5, 4, 5, 1, 2

The nurse is evaluating whether patient goals and outcomes have been met for a patient with physical mobility problems due to a fractured leg. Which finding indicates the patient has met an expected outcome?

A) The nurse provides assistance while the patient is walking in the hallways.
B) The patient is able to ambulate in the hallway with crutches.
C) The patient will deny pain while walking in the hallway.
D) The patient's level of mobility will improve.

A patient was recently diagnosed with pneumonia. The nurse and the patient have established a goal that the patient will not experience shortness of breath with activity in 3 days with an expected outcome of having no secretions present in the lungs in 48 hours. Which evaluative measure will the nurse use to demonstrate progress toward this goal?

A) No sputum or cough present in 4 days
B) Congestion throughout all lung fields in 2 days
C) Shallow, fast respirations 30 breaths per minute in 1 day
D) Lungs clear to auscultation following use of inhaler

A nurse is evaluating goals and expected outcomes for a confused patient. Which finding indicates positive progress toward resolving the confusion?

A) Patient wanders halls at night.
B) Patient's side rails are up with bed alarm activated.
C) Patient denies pain while ambulating with assistance.
D) Patient correctly states names of family members in the room.

A nurse has instituted a turn schedule for a patient to prevent skin breakdown. Upon evaluation, the nurse finds that the patient has a stage II pressure ulcer on the buttocks. Which action will the nurse take next?

A) Reassess the patient and situation.
B) Revise the turning schedule to increase the frequency.
C) Delegate turning to the nursing assistive personnel.
D) Apply medication to the area of skin that is broken down.

The nurse is evaluating whether a patient's turning schedule was effective in preventing the formation of pressure ulcers. Which finding indicates success of the turning schedule?

A) Staff documentation of turning the patient every 2 hours
B) Presence of redness only on the heels of the patient
C) Patient's eating 100% of all meals
D) Absence of skin breakdown

A nurse determines that the patient's condition has improved and has met expected outcomes. Which step of the nursing process is the nurse exhibiting?

A) Assessment
B) Planning
C) Implementation
D) Evaluation

Which interventions are appropriate for a patient with diabetes and poor wound healing? (Select all that apply.)

A) Perform dressing changes twice a day as ordered.
B) Teach the patient about signs and symptoms of infection.
C) Instruct the family about how to perform dressing changes.
D) Gently refocus patient from discussing body image changes.
E) Administer medications to control the patient's blood sugar as ordered.