A nurse admits a patient to the unit after completing a comprehensive interview and physical examination. To develop a nursing diagnosis, the nurse must now:
a. Analyze the assessment data
b. Consult standards of care
c. Decide which interventions are appropriate
d. Ask for the client's perceptions of her health problem
A
The basis of the nursing diagnosis is the assessment data. Standards of care are referred to when establishing nursing interventions. Customizing interventions personalizes nursing care. Asking the patient about her perceptions is a method to validate whether the nurse has chosen the correct nursing diagnosis and would probably have been done during the comprehensive assessment.
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A nurse is frustrated about the lack of staffing for the shift. When one of the patients fell and broke a hip, the nurse documented the incident in the patient's chart. Which entry is the best way that the nurse should document what happened?
a. "Patient stated that fell while going to the bathroom. Physician notified." b. "Nobody available to answer call bell; patient got up on own and fell." c. "Patient fell because of unsafe staffing levels on unit." d. "Patient waited as long as possible but nobody there to help and fell."
Order: Lasix 20 mg IVP Available: Lasix 40 mg/4 mL
a. 1 mL b. 3 mL c. 2 mL d. 1.5 mL
The nurse asks you to discontinue a peripheral IV. This task is not in your job description. What should you do?
a. Politely refuse. b. Report the nurse to the director of nursing. c. Discontinue the IV only if a nurse can su-pervise you. d. Ask another nursing assistant to help you.
Caring _____ a basic human need that must be fulfilled if an individual is to meet his or her full potential
a. is b. is not