Which nursing documentation demonstrates the integration of patient-centered care?

Steady gait observed when ambulating.

Social worker paged for consultation.

Nursing literature reviewed for best practice approaches.

Discussed dietary preferences with client.

Answer and Explanation

The Correct Answer is D

Patient-centered care involves actively involving the patient in their care and considering their preferences, values, and goals. By discussing dietary preferences with the client, the nurse is demonstrating a patient-centered approach. This documentation indicates that the nurse took the time to engage in a conversation with the client to understand their dietary preferences,

which can help tailor the care plan to meet the client's individual needs and preferences. "Steady gait observed when ambulating" focuses on the nurse's observation and assessment but does not specifically involve the patient's preferences or goals.

"Social worker paged for consultation" indicates collaboration with another healthcare professional but does not necessarily reflect the patient's active involvement or preferences. "Nursing literature reviewed for best practice approaches" highlights evidence-based practice but does not directly involve the patient's preferences or engagement in decision-making.

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Correct Answer is ["C","D","E"]

Explanation

Crackles and wheezing indicate the presence of excessive mucus or secretions in the airways, which may require suctioning to clear the airway and improve breathing.

The presence of serosanguineous drainage on the tracheostomy dressing may indicate increased mucus production or bleeding, suggesting the need for suctioning to remove secretions or assess for any bleeding complications.

Regular suctioning is necessary to maintain a patent airway for patients with a tracheostomy. If suctioning was performed more than 4 hours ago, it may be time for another suctioning session to prevent the accumulation of secretions and maintain airway clearance. While a fever may indicate an underlying infection or inflammation, it does not specifically indicate the need for suctioning. The decision to suction should be based on the patient's respiratory assessment and the presence of respiratory symptoms.

While patient requests and preferences are important, the need for suctioning should be determined based on clinical indicators and assessment findings rather than solely relying on patient requests.

A. Check the patency of the NG tube. B. Place the patient in a recumbent position. C. Encourage the patient to deep breathe and consciously relax. D. Assess the patient's vital signs and circulatory status.

Correct Answer is D

Explanation

The development of nausea and increased upper abdominal bowel sounds after 24 hours of NG decompression in a patient with gastric outlet obstruction raises concerns for possible complications or changes in the patient's condition. Assessing the patient's vital signs, including blood pressure, heart rate, respiratory rate, and oxygen saturation, can provide important information about their circulatory status and overall stability.

While checking the patency of the NG tube is important, it is not the best immediate action in this situation. The nurse should first assess the patient's vital signs to ensure their stability before proceeding with further interventions.

Placing the patient in a recumbent position (lying down) or encouraging deep breathing and conscious relaxation may not address the underlying issue and could potentially exacerbate the symptoms. It is essential to assess the patient's vital signs and circulatory status to determine the appropriate course of action.

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Which nursing documentation demonstrates the integration of patient-centered care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which condition or changes indicate to the nurse that a patient with a tracheostomy requires suctioning? Select all that apply.

Correct Answer is ["C","D","E"]

Explanation

A patient with a gastric outlet obstruction has been treated with NG decompression. After the first 24 hours, the patient develops nausea and increased upper abdominal bowel sounds. What is the best action by the nurse?

Correct Answer is D

Explanation

You're providing discharge instructions to a patient who will be taking a loop diuretic at home. Which statement by the patient demonstrates they did NOT understand the teaching material and requires that you reinforce some of the teaching points?

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Select Dropdowns: Aminoglycosides work by binding to the dropdown which prevents dropdown

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The nurse determines that teaching for the patient with peptic ulcer disease has been effective when the patient makes which statement?

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