The nurse has observed an increase in the occurrence of pressure injuries among patients in the Intensive Care Unit (ICU). After documenting these findings, the nurse collaborated with the manager to create and implement a new policy that emphasizes the consistent use of a pressure injury risk assessment scale.

Which term best characterizes the nurse’s actions?

Quality Improvement.

Collaboration.

Case Management.

Advocacy.

Answer and Explanation

The Correct Answer is A

Choice A rationale
The nurse’s actions are an example of Quality Improvement. Quality Improvement involves systematic actions that lead to measurable improvement in health care services and the health status of targeted patient groups. In this case, the nurse identified a problem (increase in pressure injuries), collected data (documented findings), and implemented a change (new policy for consistent use of a pressure injury risk assessment scale) to improve patient outcomes.
Choice B rationale
While collaboration was part of the process (the nurse collaborated with the manager), the overall actions taken represent a Quality Improvement process.
Choice C rationale
Case Management typically involves coordinating the care and services of select patient populations, such as those with chronic illnesses or complex health needs. It does not directly apply to this scenario.
Choice D rationale
Advocacy involves supporting or promoting the interests of others, such as patients or colleagues. Although the nurse’s actions could be seen as advocating for the patients’ well- being, the term that best characterizes these actions is Quality Improvement.

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Correct Answer is D

Explanation

Choice A rationale
Performing an opening move is an initial step in the negotiation process where each party presents their initial demands or offers. This is not the step the nurse manager is using in this scenario.
Choice B rationale
Continuing the negotiation involves ongoing discussions and adjustments to reach a mutually beneficial agreement. This is not the step the nurse manager is using in this scenario.
Choice C rationale
Clarifying the problem involves understanding and defining the issues at hand. While this is an important step in the negotiation process, it is not the step the nurse manager is using in this scenario.
Choice D rationale
Setting ground rules involves establishing the guidelines for how the negotiation will be conducted. In this scenario, the nurse manager is setting ground rules by inviting the staff to each take a turn speaking and requesting that everyone listen respectfully and refrain from making personal or professional comments about one another.

A. Application of anti-embolism stockings. B. Use of the incentive spirometer. C. Assessment of the chest tube and pleur-evac. D. Repositioning the patient in bed.

Correct Answer is C

Explanation

Choice A rationale
While the application of anti-embolism stockings can be beneficial in preventing deep vein thrombosis in postoperative patients, it is not the most prioritized nursing intervention in the immediate postoperative period for a patient who has undergone a left pneumonectomy. The immediate postoperative period after a pneumonectomy is critical for monitoring and managing potential complications such as respiratory distress, hemorrhage, and bronchopleural fistula.
Choice B rationale
The use of the incentive spirometer is an important nursing intervention for postoperative patients to promote lung expansion and prevent atelectasis. However, in the immediate postoperative period following a pneumonectomy, the priority is to monitor for complications and ensure the stability of the patient.
Choice C rationale
Assessment of the chest tube and pleur-evac is the most prioritized nursing intervention in the immediate postoperative period for a patient who has undergone a left pneumonectomy. After a pneumonectomy, a chest tube is placed to drain air, blood, and fluid from the pleural space to allow the remaining lung to re-expand. It is crucial to monitor the chest tube system for proper functioning and to assess for complications such as excessive bleeding, infection, or pneumothorax.
Choice D rationale
Repositioning the patient in bed is a standard nursing intervention in postoperative care to enhance comfort, promote lung expansion, and prevent complications such as pressure ulcers and deep vein thrombosis. However, it is not the most prioritized intervention in the immediate postoperative period following a pneumonectomy, where monitoring for respiratory complications and ensuring the stability of the patient are paramount.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

A patient diagnosed with lung carcinoma is scheduled for a left pneumonectomy. Which nursing intervention should be prioritized in the immediate postoperative period?

Correct Answer is C

Explanation

A nurse is preparing to discharge a patient who is post-operative following a laryngectomy. The nurse should recognize which of the following discharge teaching as the highest priority?

In the context of developing a care plan for a patient on a ventilator to prevent ventilator-associated pneumonia, which interventions should be included? Select all that apply.

A 65-year-old client with a history of diabetes mellitus was admitted to the hospital for a scheduled knee replacement surgery. During the postoperative period, the client developed a surgical site infection that required prolonged antibiotic therapy and wound care. This event is categorized as:

A patient with lung cancer confides in the nurse, expressing fear about the disease and guilt for smoking in the past. Which response from the nurse would be most appropriate?

A nurse is caring for a postoperative client experiencing shallow respirations and refusing to cough or get out of bed to the chair. The nurse should educate the client about the increased risk of which complication?

Several staff nurses express concern over their confidence levels and performance to the nurse in charge of performance improvement after responding to a "code.”. The best way for the nurse in charge to evaluate and improve performance is to implement which of the following?

A patient reports that they avoid being around sick people, however, they have experienced repeated colds over the past several weeks. A nurse should respond to the patient’s concern by providing which of the following teaching?

A nurse is caring for a client diagnosed with adult respiratory distress syndrome (ARDS) and being treated with positive end expiratory pressure (PEEP). How does PEEP benefit the client?