1.An example of an intervention independently initiated by the nurse is a.starting a teaching plan for the...
Question:
1.An example of an intervention independently initiated by the nurse is
a.starting a teaching plan for the patient who will go home tomorrow.
b.instituting diet restrictions with subsequent progression of diet as tolerated.
c.sending an abnormal appearing urine sample to the lab for routine urinalysis.
d.writing an order for aspirin for a headache.
2.A nursing intervention directs the patient to be turned every 2 hours to prevent skin breakdown from immobility. SELECTEDANSWERsessment findings on new reddened areas on the lateral aspects of the right knee and ankle are obtained. What is the most appropriate way for thesefindings to be used when the care plan is evaluated?
a.The information will be added to the relevant area of the electronic medical record.
b.The nursing diagnosis will be changed from an actual problem to a potential problem.
c.The new intervention of calling the physician will be added to the care plan.
d.The intervention will change to have the patient turned every hour.
3.In the assessment phase of the nursing process, there are several ways to collect data. Which statements reflect the need for more training? (Select all that apply.)
a.The patient is talking in full sentences with visitors and appears to be breathing without distress.
b.Bowel sounds are hypoactive in all four quadrants; no pain with palpation.
c.Mrs. Collins, are you experiencing any pain right now?
d.According to the chart, the patient slept well last night as a result of the pain medicine administered at 2100.
e.The abdominal wound is slightly red at the approximated edges, no edema noted.