Fundamentals of Nursing

A patient has labored breathing, a respiratory rate of 28 per minute, and lung sounds that reveal wheezing bilaterally. The nurse starts an ordered intravenous infusion to administer medication that will relax the patient’s airways. When the nurse asks how the patient feels, he responds by saying, “I feel as if I can breathe better.” The nurse auscultates the patient’s lungs and notes decreased wheezing with a respiratory rate of 22 per minute. Which of the following evaluative measures may not reflect change in a patient’s condition?

• Counting respirations per minute

• Asking the patient to describe how his breathing feels

• Observing breathing pattern

• Auscultating lung sounds

A nurse has been caring for a patient over 2 consecutive days. During that time the patient had an intravenous (IV) catheter in the right forearm. At the end of shift on the second day the nurse inspects the catheter site, observes for redness, and asks whether the patient feels tenderness when the site is palpated. The nurse reviews the medical record from 24 hours ago and finds the catheter site was without redness or tenderness. Which of the activities below reflect the nurse’s ability to perform patient evaluation? (Select all that apply.)

• Comparing patient response with previous response

• Examining results of clinical data

• Recognizing error

• Self-reflection

• Checking medical record for when IV was inserted

A nurse asks how a patient’s condition from a serious infection changed since yesterday while receiving a hand-off report. The 280nurse leaving the shift reports the patient has two priority nursing diagnoses—fluid imbalance and fever. The receiving nurse begins to provide care by measuring the patient’s body temperature, inspecting the condition of the skin, reviewing the intake and output record, and checking the summary notes describing the patient’s progress since the day before. The nurse asks a technician to measure intake and output during the shift. What critical thinking indicators reflect the nurse’s ability to perform evaluation? (Select all that apply.)

• Checking the summary notes

• Asking the leaving RN about the patient’s condition

• Assigning the technician to measure intake and output

• Comparing current outcomes with those set for the patient’s goals

• Reflecting on patient’s progress

A nurse in the recovery room is monitoring a patient who had a left knee replacement. The patient arrived in recovery 15 minutes ago. The nurse observes the patient to be restless, turning frequently, and groaning; the patient’s heart rate is 92 compared with 76 preoperatively. Blood pressure is stable since admission to the recovery room. The nurse reviews the medical orders for analgesic therapy. The nurse notes that the postop dose of an ordered analgesic has not yet been given. What is most likely to cause the nurse to reflect on the patient’s situation?

• The patient is recovering normally

• The symptoms reflecting restlessness

• The patient’s blood pressure trend

• The delay in administration of the analgesic

A nurse enters a patient’s room and begins a conversation. During this time the nurse evaluates how a patient is tolerating a new diet plan. The nurse decides to also evaluate the patient’s expectations of care. Which of the following is appropriate for evaluating a patient’s expectations of care?

• On a scale of 0 to 10 rate your level of nausea

• The nurse weighs the patient

• The nurse asks, “Did you believe that you received the information you needed to follow your diet?”

• The nurse states, “Tell me four different foods included in your diet.”

Which of the following is the proper sequence for a four-point crutch gait?

• 1

• 2

• 3

• 4

Tags

NGSS.MS-PS2-1

The nurse is caring for an older adult in a long-term care setting. The nurse reviews the medical record to find that the patient has progressive loss of total bone mass. The patient’s history and tendency to take smaller steps with feet kept closer together will most likely result in which of the following?

• Increase the patient’s risk for falls and injuries

• Result in less stress on the patient’s joints

• Decrease the amount of work required for patient movement

• Allow for mobility in spite of the aging effects on the patient’s joints

Place in the correct order the steps needed (below) to transfer a patient with sufficient lower body strength to a chair.

Tags

NGSS.HS-ETS1-3

Before transferring a patient from the bed to a stretcher, which assessment data does the nurse need to gather? (Select all that apply.)

• Patient’s weight

• Patient’s activity tolerance

• Patient’s level of mobility

• Recent laboratory values

• Nutritional intake

What is the primary purpose of the nursing process in patient care?

• To diagnose diseases

• To provide a systematic approach to patient care

• To prescribe medication

• To perform surgical procedures