Which of the following groups of terms best describes a nurse-initiated intervention?
A) Dependent, physician-ordered, recovery
B) Autonomous, clinical judgment, client outcomes
C) Medical diagnosis, medication administration
D) Other health care providers, skill acquisition
Ans: B
A nursing intervention is any treatment, based on clinical judgment and knowledge, that a nurse performs to enhance client outcomes. Nurse-initiated interventions are autonomous (independently performed).
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The nurse is reviewing the results of a literature search and wants to determine the strength of the evidence. In which order, from strongest to weakest, should the nurse analyze this data?
1. Single, well-conducted clinical trials 2. Single descriptive or qualitative study 3. Expert opinion of authorities or committees 4. Single correlational study or observational studies 5. Systematic reviews of randomized and nonrandomized trials 6. Systematic review of descriptive studies including qualitative 7. Systematic review of correlational studies or observational studies
Which of the following factors are considered to be absolute contraindications to use of throm-bolytic therapy? Select all that apply
a. Cerebrovascular accident (CVA) within previous 3 months b. Aneurysm c. Intracranial neoplasm d. Platelet count under 100,000 mm3 e. Age greater than 65 years f. History of mitral valve prolapse
When changing the client's sterile dressings on the second postoperative day, the nurse notes that the suture line is red and slightly inflamed. The nurse recognizes these findings are:
A) abnormal and need to be reported to the charge nurse. B) signs of infection and need to be reported to the physician. C) normal signs of the inflammatory response. D) abnormal and need to be documented.
The emergency department (ED) triage nurse is assessing four victims involved in a motor vehicle collision. Which patient has the highest priority for treatment?
a. A patient with no pedal pulses. b. A patient with an open femur fracture. c. A patient with bleeding facial lacerations. d. A patient with paradoxic chest movements.