NCLEX Questions

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EXAM 1 - SBAR

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CH 18 P

21 terms Sha A nurse is providing care for a patient who had a transurethral resection of his prostate this morning. The patient is receiving continuous bladder irrigation, and the urinary catheter is now occluded. The nurse is planning to contact the patient's health care provider and communicate using the SBAR (Situation-Background- Assessment-Recommendation) format. Which statement is a component of communication using SBAR?

• What do you think could be causing this occlusion
• I think that we should manually irrigate his catheter.
• What do you know about this patient and his history?
• Could you please provide some direction for his care?
• "I think that we should manually irrigate his catheter."

Proposing a recommendation is a component of the "R" component of SBAR communication. Asking the health care provider for possible contributing factors to the problem or for general direction may be appropriate in some circumstances, but these are not explicit components of SBAR. The nurse should briefly identify the patient and his circumstances, not ask an open-ended question regarding the health care provider's familiarity.Telehealth devices are commonly used to provide which types of patient care (select all that apply.)?

• Evaluation of weight loss
• Medication administration
• Video assessment of wounds
• Monitoring peak flow meter results
• Real-time blood pressure

A, C, D, E

In which patient care delivery model does the nurse plan and coordinate the aspects of patient care with other disciplines focusing on continuity of care and interprofessional collaboration even if the nurse is absent?

• Team nursing model
• Primary nursing model
• Total patient care
• Case management nursing model
• Primary nursing model

The primary nursing model includes planning the patient's care and coordinating and communicating all aspects of care with other disciplines and those providing care in the nurse's absence. The focus is on continuity of care and interprofessional collaboration. Team nursing uses the RN as the team leader to organize and manage the care for a group of patients with other ancillary workers. The RN has authority and accountability for the quality of care delivered by the team only during the work period. In a total patient care model, the nurse is accountable for the complete care of the patient during the assigned shift. Case management is not a model of care delivery but a collaborative process that involves assessing, planning, facilitating, and advocating for health services with a variety of resources to promote cost-effective outcomes.A nurse is monitoring all of the patients in an outpatient procedure area for complications of administering IV fluids. What type of nursing function is being demonstrated by the nurse?

• Dependent
• Independent
• Autonomous
• Collaborative
• Collaborative

A collaborative nursing function is demonstrated when the nurse monitors patients for complications of acute illness, administers IV fluids and medications per health care provider's orders, and implements nursing interventions such as providing emotional support or teaching about specific procedures. Nursing functions may be dependent, collaborative, or independent. The nurse functions dependently when carrying out medical orders. Physician-initiated nursing functions may include administering medications, performing or assisting with certain medical treatments, and assisting with diagnostic tests and procedures.Independent nursing functions include interventions such as promotion and optimization of health, prevention of illness, and patient advocacy.A group of nurses has a plan to implement evidence- based practice (EBP) for care of patients with pressure ulcers. What will this change in practice encompass (select all that apply.)?

• Consulting with the wound care and ostomy nurse
• Nurses' expertise and bodies of experience and

knowledge

• The preferences of patients and their particular

circumstances

• The traditions that surround pressure ulcer practices

on the unit

• Journal articles that address the care of patients with

pressure ulcers

A, B, C, E

Which interventions are independent nursing actions (select all that apply.)?

• Reinserting an IV
• Assessing lung sounds
• Obtaining informed consent
• Administering IV medications
• Turning a patient every two hours

A, B, E

A nurse with an associate or baccalaureate degree who meets licensing requirements is qualified to practice as

• a nurse practitioner
• a certified specialist
• an entry-level generalist
• an advanced practice nurse
• an entry-level generalist.

Entry-level nurses with an associate or baccalaureate degree are prepared to function as generalists. With experience and continued study, nurses may specialize in an area of practice and may obtain certification in nursing specialties.Certification usually requires clinical experience and successful completion of an examination. A nurse practitioner is an example of an advanced practice nurse. An advanced practice nurse has a minimum of a master's degree with advanced education in pharmacology and physical assessment as well as expertise in a specialized area of practice.The nurse establishes priorities and determines outcomes for an individual patient during which phase of the nursing process?

• Analysis
• Planning
• Evaluation
• Assessment
• Planning

During the planning phase of the nursing process, patient outcomes or goals are developed and nursing interventions are identified to accomplish the outcomes.The assessment phase of the nursing process includes the collection of subjective and objective patient information on which to base the plan of care. The evaluation phase of the nursing process determines if the patient outcomes have been met as a result of nursing interventions. Nursing diagnosis is the act of analyzing the assessment data and making a judgment about the nature of the data.When planning care for a patient, the nurse may use a visual diagram of patient problems and interventions to illustrate the relationships among pertinent clinical data.This format is called a

• concept map
• critical pathway
• clinical pathway
• nursing care plan
• concept map.

A concept map is another method of recording a nursing care plan. In a concept map, the nursing process is recorded in a visual diagram of patient problems and interventions. A clinical (critical) pathway is a prewritten plan that directs the entire interprofessional care team in the daily care goals for select health care problems.

When nurses disagree about the effectiveness of a commonly practiced nursing intervention, the best evidence for determining which intervention to use is

• a systematic review of randomized controlled trails
• a qualitative research study with a large sample size
• a methodical Internet search using key medical terms
• anecdotal evidence retrieved from two or more case

studies

• a systematic review of randomized controlled trials.

Systematic reviews of randomized controlled trials (RCTs) are considered the strongest level of evidence to answer questions about interventions (i.e., cause and effect).When the nurse encourages a patient with heart failure to alternate rest and activity periods to reduce cardiac workload, which phase of the nursing process is being used?

• planning
• diagnosis
• evaluation
• implementation
• Implementation

Carrying out a specific, individualized plan constitutes the implementation phase of the nursing process. The nurse's action of encouragement and instruction to the patient is part of carrying out a plan of action.A patient is being prepared for discharge home after a laparoscopic cholecystectomy. Which team member can be assigned to complete a discharge assessment and provide patient teaching for post-discharge care?

• Registered Nurse (RN)
• Nursing technician (NT)
• Unlicensed assistive personnel (UAP)
• Licensed practical/vocational nurse (LPN/LVN)
• Registered nurse (RN)

Nursing interventions that require independent nursing knowledge, skill, or judgment such as assessment, patient teaching, and evaluation of care cannot be delegated. These interventions are the responsibility of the RN. The scope of practice for LPN/LVNs is determined by each state board of nursing. The RN must know the legal scope of practical/vocational nursing practice and delegates and assigns nursing functions appropriately. In most states LPN/LVNs may administer medications, perform sterile procedures, and provide a wide variety of interventions planned by the RN. UAP are unlicensed individuals who serve in an assistive role to the RN and may include nursing assistants or technicians. The RN may delegate specific activities such as obtaining routine vital signs on stable patients, feeding/assisting patients at mealtimes, ambulating stable patients, and helping patients with bathing and hygiene.