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 B

Explanation

Choice A rationale
This response is not appropriate as it does not address the patient’s emotional state and may come across as dismissive or coercive. It is important to approach a tearful and refusing patient with empathy and understanding, acknowledging their feelings and concerns.
Choice B rationale
This response is the most appropriate as it acknowledges the patient’s emotional state and opens up a dialogue for the patient to express their worries or concerns. By asking the patient what is worrying them, the nurse shows empathy and provides an opportunity for the patient to voice their fears or concerns, which can be the first step towards resolving the issue.
Choice C rationale
This response is not appropriate as it does not address the patient’s emotional state and may come across as dismissive or coercive. It is important to approach a tearful and refusing patient with empathy and understanding, acknowledging their feelings and concerns.
Choice D rationale
This response is not appropriate as it may come across as dismissive or insensitive. It is important to approach a tearful and refusing patient with empathy and understanding, acknowledging their feelings and concerns.

A. Use of Passy Muir speaking valve. B. Phone number of healthcare provider to report complications. C. Emergency personal identification that patient is unable to speak. D. Ability to perform tracheostomy care.

Correct Answer is D

Explanation

Choice A rationale
The use of a Passy Muir speaking valve can be important for communication, but it is not the highest priority for discharge teaching.
Choice B rationale
Having the phone number of the healthcare provider to report complications is important, but it is not the highest priority. The patient needs to know how to prevent and recognize complications first.
Choice C rationale
While having emergency personal identification that the patient is unable to speak is important, it is not the highest priority. The patient’s immediate post-operative needs should be addressed first.
Choice D rationale
The ability to perform tracheostomy care is the highest priority for discharge teaching. This is a new and critical skill that the patient must learn to prevent complications, maintain the airway, and manage their own care at home.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a patient who is tearful while refusing care and medications. Which of the following is the most appropriate response by the nurse?

Correct Answer is B

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?

Correct Answer is D

Explanation

A nurse is caring for a client diagnosed with chronic obstructive pulmonary disease (COPD) who is being evaluated for a lung transplant. What findings should a nurse expect when performing an initial physical assessment on a client diagnosed with COPD? 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 clinic nurse is preparing a lesson for nursing students on the care of patients with viral pharyngitis. What information should be included in the lesson? (Select all that apply)

A nurse is developing a plan of care for a patient on a ventilator, to prevent ventilator-associated pneumonia. The nurse recognizes that which of the following interventions should be included? Select all that apply.

A nurse on a quality control committee is evaluating the effectiveness of recently implemented measures aimed at reducing medication errors. Which methods should the nurse use to evaluate the success of the changes?

A nurse is analyzing arterial blood gas results for a client diagnosed with chronic obstructive pulmonary disease (COPD). What abnormal finding should the nurse anticipate?

A nurse is part of a Continuous Quality Improvement (CQI) committee tasked with developing a program to decrease medication administration errors following a sentinel event. Which strategy should the committee consider implementing first?

A nurse is caring for a client who has a tracheostomy. Based on the Nurses Notes and Diagnostic Results, which of the following is a manifestation in the client?