Planning Nursing Care Assignment Essay

Planning Nursing Care Assignment

1. A nurse is assigned to a patient who has returned from
the recovery room following surgery for a colorectal tumor.
After an initial assessment the nurse anticipates the need to
monitor the patient’s abdominal dressing, intravenous (IV)
infusion, and function of drainage tubes. The patient is in pain,

reporting 6 on a scale of 0 to 10, and will not be able to eat or
drink until intestinal function returns. The family has been
in the waiting room for an hour, wanting to see the patient.
The nurse establishes priorities first for which of the following
situations? (Select all that apply.)
1. The family comes to visit the patient.
2. The patient expresses concern about pain control.
3. The patient’s vital signs change, showing a drop in blood
pressure.
4. The charge nurse approaches the nurse and requests a
report at end of shift.
2. A patient signals the nurse by turning on the call light. The
nurse enters the room and finds the patient’s drainage tube
disconnected, 100 mL of fluid in the intravenous (IV) line, and
the patient asking to be turned. Which of the following does
the nurse perform first?
1. Reconnect the drainage tubing
2. Inspect the condition of the IV dressing
3. Improve the patient’s comfort and turn onto her side.
4. Obtain the next IV fluid bag from the medication room
3. A nurse assesses a 78-year-old patient who weighs 240 pounds
(108.9 kg) and is partially immobilized because of a stroke.
The nurse turns the patient and finds that the skin over
the sacrum is very red and the patient does not feel sensation
in the area. The patient has had fecal incontinence on and
off for the last 2 days. The nurse identifies the nursing
diagnosis of risk for impaired skin integrity. Which of the following goals are appropriate for the patient? (Select all
that apply.)
1. Patient will be turned every 2 hours within 24 hours.
2. Patient will have normal bowel function within 72 hours.
3. Patient’s skin will remain intact through discharge.
4. Patient’s skin condition will improve by discharge.
4. Setting a time frame for outcomes of care serves which of the
following purposes?
1. Indicates which outcome has priority
2. Indicates the time it takes to complete an intervention
3. Indicates how long a nurse is scheduled to care for a
patient
4. Indicates when the patient is expected to respond in the
desired manner
5. A patient has been in the hospital for 2 days because of newly
diagnosed diabetes. His medical condition is unstable, and the
medical staff is having difficulty controlling his blood sugar.
The physician expects that the patient will remain hospitalized
at least 3 more days. The nurse identifies one nursing diagnosis
as deficient knowledge regarding insulin administration related
to inexperience with disease management. Which of the following patient care goals are long term?
1. Patient will explain relationship of insulin to blood glucose
control.
2. Patient will self-administer insulin.
3. Patient will achieve glucose control.
4. Patient will describe steps for preparing insulin in a
syringe.

Planning Nursing Care Assignment Essay

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