Patient Care Delivery System

Although the nursing process is presented as an orderly progression of steps, in reality there is great interaction and overlapping among the five steps. This characteristics of the nursing process is described as:

• systematic

• dynamic

• interpersonal

• outcome oriented

One hour after receiving pain medication, a postoperative client reports intense pain. What is the nurse's most appropriate first action?

• Discuss the frequency of pain medication orders with the client.

• Assess the client to determine the cause of the pain

• Consult with the healthcare provider for additional pain orders

• Assist the client to reposition and splint the incision site

The nurse knows which intervention is a dependent intervention?

• Obtaining a client's BP

• Massaging a client's back

• Administering medications to a client

• Assessing a client's lung sounds

The nurse repositions a client who has difficulty breathing. Which nursing action, when performed following the intervention, demonstrates evaluation?

• Instructing the client the importance of mobility

• Arranging the pillows behind the client's back

• Checking the client's respiratory status

• Changing the rate of flow for the oxygen delivery system

A patient complains about feeling nauseated after lunch. This is an example of what type of data?

• subjective

• objective

• sign and symptoms

• overt

When you receive shift report, you learn that your patient has no special skin care needs. You are surprised during the bath to observe reddened areas over bony prominences. You should:

• Correct the initial assessment form

• Redo the initial assessment and document current findings

• Conduct and document an emergency assessment

• Perform and document a focused assessment on skin integrity

When you enter the patient’s room to begin your nursing history, the patient’s wife is there. You should:

• Introduce yourself to both and thank the wife for being present.

• Introduce yourself to both and ask the wife if she wants to remain.

• Introduce yourself to both and ask the wife to leave.

• Introduce yourself and ask the patient if he would like the wife to remain

Altered health maintenance is an example of:

• Collaborative problem

• Interdisciplinary problem

• medical problem

• nursing problem

Niccon is a college student who wants to lose 20 pounds. She meets with the student health nurse and develops a plan to increase her activity level and decrease the consumption of wrong types of food and calories. The nurse plans to evaluate her weight loss monthly. When Niccon arrives for her first “weigh-in”, the nurse discovers that instead of the projected weight loss of 5 pounds, Niccon has only lost 1 pound. Which is the best nursing response?

• Congratulate Niccon and continue the plan of care.

• Terminate the plan of care since it is not working.

• Try giving Niccon more time to reach the targeted outcome.

• Modify the plan of care after discussing possible reasons for Niccon’s partial success.

As a student nurse you observed that your patient is experiencing irritability and disoriented during your interview . This is an example of what type of data?

• subjective

• objective

• sign and symptoms

• none of the above