Lesson 03 - Planning and Application of the Nursing Process (SOLVED)

3/25/2020 Lesson 03 - Planning and Application of the Nursing Process: HESI RN FLMIR 1904COHORT * Some questions not yet graded Lesson 03 - Planning and Application of the Nursing Process Due Mar 25 at 11:59pm Points 29 ...

3/25/2020 Lesson 03 - Planning and Application of the Nursing Process: HESI RN FLMIR 1904COHORT * Some questions not yet graded Lesson 03 - Planning and Application of the Nursing Process Due Mar 25 at 11:59pm Points 29 Questions 29 Available Mar 18 at 12am - Mar 25 at 11:59pm 8 days Time Limit None Instructions Attempt History Attempt Time Score LATEST Attempt 1 67 minutes 14.67 out of 29 * Score for this quiz: 14.67 out of 29 * Submitted Mar 25 at 2:17pm This attempt took 67 minutes. This is your Virtual Clinical Excursion. Each VCE is 4 hours and you will be assigned 3 VCE's per 12 hour clinical. This is to be completed on the day of clinical scheduled. This assignment will be reviewed and graded by your clinical instructors. Do not utilize copy and paste from the internet-type the answers in your own words utilizing available resources. Question 1 1 / 1 pts Exercise 1 - Writing Activity This exercise will take approximately 30 minutes to complete. Exercise 1 - Question 1 A nurse is preparing to start her shift on a medical-surgical unit. Which of the following factors concerning the change-of-shift report (hand-off report) will be most important for the nurse to consider? 3/25/2020 Lesson 03 - Planning and Application of the Nursing Process: HESI RN FLMIR 1904COHORT Patient's personality Patient's family support Off-going nurse's opinion about the patient's family background Question 2 1 / 1 pts Exercise 1 - Question 2 Indicate whether the following statement is true or false. Physiologic diagnoses have a higher priority than psychologic diagnoses. True Correct! Correct! Question 3 1 / 1 pts Exercise 1 - Question 3 Indicate whether the following statement is true or false. The Kardex provides a filing system for recording the physician's orders. True Question 4 0 / 1 pts 3/25/2020 Lesson 03 - Planning and Application of the Nursing Process: HESI RN FLMIR 1904COHORT Answer 1: Exercise 1 - Question 4 When providing care to the patient, it is important for the nurse to be able to exercise resilience , which allow the practitioner to shift attention to differing concerns during a period of care. Question 5 1 / 1 pts Answer 1: Exercise 1 - Question 5 The statement that outlines the desired change in the patient's condition or behavior is termed the goal . goal Question 6 1 / 1 pts Exercise 1 - Question 6 You are assigned to provide care to a patient who has recently had abdominal surgery. When you are updating the nursing care plan, which of the following patient outcomes would be appropriate to include? Select all that apply. The nurse will observe the patient's understanding of use of the incentive spirometer. The patient will demonstrate an increased level of comfort. The patient will initiate turning and deep breathing within 2 hours. The patient will be more comfortable. The patient will report lessened pain using the pain scale within 3 hours. Question 7 0 / 1 pts Exercise 1 - Question 7 A review of the care planned for a patient during a given shift reveals the interventions listed below. Which of these interventions is classified as an independent nursing intervention? Select all that apply. Teaching the patient about medication side effects. Referring the patient for home health care. Question 8 Not yet graded / 1 pts 3/25/2020 Lesson 03 - Planning and Application of the Nursing Process: HESI RN FLMIR 1904COHORT Your Answer: Exercise 1 - Question 8 List the seven domains that may be used to classify nursing interventions. Physiologic: Basic Physiologic: complex Behavioral Safety Family Health system Community Physiologic: Basic Physiologic: Complex Behavioral Safety Family Health System Community Question 9 1 / 1 pts Exercise 1 - Question 9 The nurse is assisting a newly graduated nurse in completing a care plan. Which of the nursing interventions planned by the graduate and listed below indicate the need for further instruction? Select all that apply. Monitor blood pressure every 4 hours. Correct! Correct! Call physician for elevated temperature. Assist patient to turn, cough, and deep-breathe every 2 hours. Question 10 1 / 1 pts Answer 1: Exercise 1 - Question 10 A(n) standing order is a preprinted form with orders for routine therapies, monitoring guidelines, and/or diagnostic procedures for specific patients with identified clinical problems. standing order Question 11 Not yet graded / 1 pts Exercise 1 - Question 11 A patient has become disabled as a result of an automobile accident. The case manager has documented concerns about the patient's ability to 3 perform instrumental activities of daily living. Based on your knowledge, what activities are included in this listing? Question 12 Not yet graded / 1 pts Exercise 2 - Virtual Hospital Activity This exercise will take approximately 45 minutes to complete. Sign in to work at Pacific View Regional Hospital on the Medical Surgical Floor for Period of Care 1. (Note: If you are already in the virtual hospital from a previous exercise, click on Leave the Floor and then on Restart the Program to get to the sign-in window.) From the Patient List, select Patricia Newman (Room 406). Click on Get Report. Click on Go to Nurses' Station. Click on Chart and select the chart for Room 406. Click on and review the Nursing Admission and History and Physical. Exercise 2 - Question 1 What is Patricia Newman's chief complaint at the time of admission? Question 13 0.6 / 1 pts Exercise 2 - Question 2 According to Patricia Newman's past medical history, she has a history of several medical disorders. Listed below are her primary medical diagnoses. Prioritize these disorders in order of importance for this hospital admission. (A) Tobacco use (B) Emphysema (C) Pneumonia (D) Osteoporosis (E) Hypertension 1st C 2nd B 3rd E 4th D Correct! Correct! Correct! Correct! Correct! Correct! ou Answered ou Answered 3/25/2020 Lesson 03 - Planning and Application of the Nursing Process: HESI RN FLMIR 1904COHORT Question 14 1 / 1 pts Exercise 2 - Question 3 During the nursing admission, Patricia Newman described her health as "not very good." This is an example of: subjective data. objective data. back channeling. defining characteristics. Correct! Correct! Question 15 1 / 1 pts Click on Return to Nurses' Station. Click on 406 at the bottom of the screen. Review the Initial Observations. Exercise 2 - Question 4 Based on your knowledge of Patricia Newman's condition and review of the Initial Observations, which of the following tasks should the nurse 3/25/2020 Lesson 03 - Planning and Application of the Nursing Process: HESI RN FLMIR 1904COHORT perform first after entering the room? Assess patient's vital signs. Correct! Correct! Check patient's arm band for identification. Assess patient's neurologic status. Determine patient's chief concern at this time. Question 16 Not yet graded / 1 pts Your Answer: Click on Patient Care and then on Nurse-Client Interactions. Select and view the video titled 0730: Prioritizing Interventions. (Note: Check the virtual clock to see whether enough time has elapsed. You can use the fast-forward feature to advance the time by 2-minute intervals if the video is not yet available. Then click again on Patient Care and on Nurse-Client Interactions to refresh the screen.) Exercise 2 - Question 5 Based on the video, what has been identified as the priority intervention by the nurse? Administering the oxygen, because her O2 sat was 85%. Administration of oxygen has been identified as a priority. Question 17 Not yet graded / 1 pts 3/25/2020 Lesson 03 - Planning and Application of the Nursing Process: HESI RN FLMIR 1904COHORT Your Answer: Exercise 2 - Question 6 Based on the video, what concern does Patricia Newman have? Is this concern shared by the nurse? She is concerned that she has a fever, and the nurse asurres her that she does. The nurses concern is the patients O2 she then addresses her SOB and explains her O2 sat is 85% and gives her oxygen, and informed her that she is going to give her some tylenol for the fever. Patricia Newman reports feeling feverish. Yes, the nurse agrees and plans to administer Tylenol. Question 18 Not yet graded / 1 pts Your Answer: Exercise 2 - Question 7 Critique the nurse-patient interaction in the video. What strengths does the nurse display in her interaction with Patricia Newman? The nurse displayed good therapeutic communication with the patient during the introduction and when she explained what she would be doing. Mrs. Newman seemed very comfortable with Suzanne and was at ease telling her how she was feeling. The nurse takes time to introduce herself to the patient and explains why she is present. There is an effort to speak in a tone of voice easily heard by Patricia Newman. The nurse also maintains eye contact. 3/25/2020 Lesson 03 - Planning and Application of the Nursing Process: HESI RN FLMIR 1904COHORT Question 19 0 / 1 pts Exercise 2 - Question 8 What action should the nurse take after receiving report? Discuss the plan of care for the day with the patient. Validate patient's pulmonary status by conducting a physical examination. ou Answered ou Answered orrect Answer orrect Answer Begin instruction on breathing exercises. Call the physician to review data from the report. Question 20 Not yet graded / 1 pts Your Answer: Exercise 2 - Question 9 During the physical assessment, you are able to review Patricia Newman's cardiovascular and respiratory status. What other sources of data might you use to support your findings? EKG ABG's Sputum culture chest x-ray Labs-CBC 3/25/2020 Lesson 03 - Planning and Application of the Nursing Process: HESI RN FLMIR 1904COHORT Electronic Patient Record (EPR) Other staff members Significant others Laboratory and diagnostic test results Question 21 0.5 / 1 pts Exercise 2 - Question 10 After gathering data from the physical assessment to further define potential problem areas, the following issues are identified. Prioritize the potential problems in order of importance. (A) Nutritional intake (B) Oxygenation (C) Health promotion habits (D) Reduced energy level 1st B 2nd D Correct Answer Correct Answer A 3rd A Correct Answer Correct Answer D Correct! Correct! ou Answered ou Answered ou Answered ou Answered 3/25/2020 Lesson 03 - Planning and Application of the Nursing Process: HESI RN FLMIR 1904COHORT 4th Correct! Correct! C Question 22 0.57 / 1 pts Correct! Correct! Correct! Correct! ou Answered ou Answered ou Answered ou Answered Correct! Correct! Exercise 2 - Question 11 Data clusters are sets of signs or symptoms that are grouped together logically. Match each sign or symptom with its appropriate data cluster category. (A) Respiratory/oxygenation (B) Reduced energy level PaO2 below normal A Dyspnea on exertion A Productive cough B Correct Oxygen saturation 92% B Correct Answer Feels "too tired to do much" B 3/25/2020 Lesson 03 - Planning and Application of the Nursing Process: HESI RN FLMIR 1904COHORT Requires frequent rest periods ou Answered ou Answered A Correct Answer Correct Answer B Correct! Correct! Respirations labored A Question 23 0.5 / 1 pts Exercise 2 - Question 12 As you identify clusters of data, you begin to recognize patterns or trends. Data often contain defining characteristics, or criteria, for nursing diagnoses. Listed below are three nursing diagnoses with defining characteristics. Which of the diagnoses would likely apply to Patricia Newman? Select all that apply. Impaired Gas Exchange: Tachycardia, hypoxia, abnormal arterial blood gases, abnormal rate and depth of breathing, hypoxemia Ineffective Breathing Pattern: Pursed-lip breathing, dyspnea, use of accessory muscles to breathe, respiratory rate higher than 24 per minute, altered chest excursion Ineffective Airway Clearance: Diminished breath sounds, dyspnea, adventitious breath sounds, ineffective cough, sputum production, changes in respiratory rate 3/25/2020 Lesson 03 - Planning and Application of the Nursing Process: HESI RN FLMIR 1904COHORT Question 24 1 / 1 pts Answer 1: Select and view the videos titled 0740: Evaluation: Response to Care and 0750: Evaluation: Patient Teaching. (Note: Check the virtual clock to see whether enough time has elapsed. You can use the fast-forward feature to advance the time by 2- minute intervals if the video is not yet available. Then click again on Patient Care and on Nurse-Client Interactions to refresh the screen.) Exercise 2 - Question 13 Consultation is a strategy to seek the expertise of a specialist, Question 25 1 / 1 pts Answer 1: Exercise 2 - Question 14 Consultation with other health care providers increases the nurse’s Question 26 Not yet graded / 1 pts Exercise 2 - Question 15 Your Answer: The plan of care often requires input from a variety of disciplines. Consider Patricia Newman's needs. Which members of the healthcare team could provide useful input into the plan of care? Respiratory therapist Social worker PT OT Nutritionist Respiratory therapy Discharge planning Social services Occupational therapy Home health care Dietitian Question 27 0.83 / 1 pts Click on Chart and then on 406. Click on and review the Physician's Orders, Physician's Notes, and Consultations. Exercise 2 - Question 16 A series of interventions are indicated to assist Patricia Newman in managing her impaired gas exchange problems. Match each intervention with its correct type. (Hint: Refer to your textbook if you need help identifying types of interventions.) 3/25/2020 Lesson 03 - Planning and Application of the Nursing Process: HESI RN FLMIR 1904COHORT (A) Nurse-initiated (B) Physician-initiated (C) Collaborativeou Answe Administer oxygen at 2 L per nasal cannula. Correct Instruct patient on how to perform pursed-lip breathing. Position patient with head of bed elevated to 45 degrees. Administer bronchodilator by a metered-dose inhaler (MDI). Have the patient perform cascade coughing every 1 hour. Arrange for home oxygen therapy. Question 28 0.67 / 1 pts Exercise 2 - Question 17 A nurse caring for Patricia Newman performs the following activities. Which of these activities are examples of indirect care measures? Select all that apply. Adjusts the oxygen flow meter to ensure that it runs correctly and checks condition of the tubing Coaches Patricia Newman on the technique for performing a cascade cough Documents the character of Patricia Newman's cough and ability to expectorate mucus Administers intravenous (IV) fluid infusion Question 29 Not yet graded / 1 pts Your Answer: Exercise 2 - Question 18 For each of the expected outcomes listed below, write an evaluation measure. Patient's lungs will clear without crackles within 48 hours Patient's fluid intake will be 3 L every 24 hours Patient will perform pursed-lip breathing correctly within 24 hours Patient will experience less dyspnea while ambulating within 2 days 1. Patient's lungs will clear without crackles within 48 hours: Assess the patient’s lungs bilaterally. 1. Patient's fluid intake will be 3 L every 24 hours: Assess patient’s fluid intake and output. 1. Patient will perform pursed-lip breathing correctly within 24 hours: Assess how patient demonstrates pursed-lip breathing on his or her own. 1. Patient will experience less dyspnea while ambulating within 2 days: Assess patient’s breathing while he or she is ambulating. Patient's lungs will clear without crackles within 48 hours: Auscultation of lung sounds Patient's fluid intake will be 3 L every 24 hours: Measurement of patient's fluid intake Patient will perform pursed-lip breathing correctly within 24 hours: Observation of patient performing pursed-lip breathing Patient will experience less dyspnea while ambulating within 2 days: Asking patient whether she feels less dyspneic or breathless after ambulation