Nokea
A client has been admitted to the hospital with a large sacral pressure ulcer. The physician prescribes the wound care protocol to be performed twice a day. What would be a statement on the plan of care that would address the implementation phase of the nursing process for this client?
- A. A 6 cm x 4 cm wound with malodorous, yellow exudate
- B. The client's wound will heal by 1 cm by the end of 5 days.
- C. The client's wound has healed by 0.5 cm on day 3 of wound care.
- D. Turn the client every 2 hours.
Correct Answer: D
Rationale: Turning the client every 2 hours is implementing care to allow the pressure ulcer to heal and prevent another formation of a wound. Recording the description of the wound would occur during the assessment phase of the nursing process. The prediction of how much and how soon the client's wound will heal would be made during the planning phase, while noting the amount the wound has healed on a given day is an example of a statement that would be made during the evaluation phase.
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The nurse understands that critical thinking skills are an integral part of nursing practice. Development of these skills requires what from the nurse?
- A. Intention
- B. Experience
- C. Contemplation
- D. Focus on outcomes
Correct Answer: B
Rationale: Nurses develop critical thinking skills through knowledge, experience, and practice. Intention, contemplation, and a focus on outcomes are characteristics of critical thinking. They are not how the nurse develops critical thinking skills.
Which of the following is the highest level of human need according to Maslow (1968)?
- A. Physiologic
- B. Love and belonging
- C. Esteem and self-esteem
- D. Self-actualization
Correct Answer: D
Rationale: The highest level need is self-actualization. The first level of need is physiological needs. Love and belonging are third-level needs. Esteem and self-esteem are fourth-level needs.
Which phase of the nursing process enables the nurse to compare the actual outcomes with the expected outcomes?
- A. Assessment
- B. Planning
- C. Implementation
- D. Evaluation
Correct Answer: D
Rationale: Evaluation is assessment and review of the quality and suitability of the care given and the client's responses to that care. Assessment is careful observation and evaluation of a client's health status. Planning involves setting priorities, defining expected (desired) outcomes (goals), determining specific nursing interventions, and recording the plan of care. Implementation means carrying out the written plan of care; performing interventions; monitoring the client's status; and assessing and reassessing the client before, during, and after treatments.
The LPN is collecting data so that the RN may develop the plan of care for the client. What is the importance of accurate gathering of baseline data?
- A. The physician will be able to make a diagnosis.
- B. It serves as a comparison for future signs and symptoms
- C. The RN will be able to make the assignments based on the baseline data.
- D. The RN will know what type of medication the client will receive.
Correct Answer: B
Rationale: The client database includes all the information obtained from the medical and nursing history, physical examination, and diagnostic studies. Baseline data serve as a comparison for future signs and symptoms and provide a reference for determining if a client's health is improving. The physician does not use the care plan for the diagnosis.
Which of the following is a true statement about critical thinking in nursing?
- A. It involves purposeful, outcome-directed thinking.
- B. It shows trends and patterns in client status.
- C. It makes judgments based on conjecture.
- D. It supplies validation for reimbursement.
Correct Answer: A
Rationale: In nursing, critical thinking involves purposeful, outcome-directed thinking. Critical thinking makes judgments based on evidence rather than conjecture. Providing a foundation for evaluation and quality improvement and showing trends and patterns in client status are functions served by documentation.