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A client is being admitted to the medical floor, and the RN is too busy to do the full assessment. The RN delegates the LPN to care for the client until the RN can see the client. What function is within the scope of practice for the LPN?
- A. The LPN can gather the data.
- B. The LPN can draw conclusions and use judgment to make a diagnosis.
- C. The LPN can establish priorities.
- D. The LPN can manage the client's care.
Correct Answer: A
Rationale: The role of the LPN in the nursing process for assessment is to gather data, perform assessment, and identify the client's strengths. Drawing conclusions and using judgment to make a diagnosis, establishing priorities, and managing the client's care are within the RN scope of practice.
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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.
The nurse is prioritizing the care of a client who has a diagnosis of uncontrolled diabetes and may have the left foot amputated related to a nonhealing ulcer. What need would the nurse place at the lowest level of Maslow's hierarchy while prioritizing this client's care?
- A. Physiologic needs
- B. Safety and security needs
- C. Love and belonging needs
- D. Self-actualization needs
Correct Answer: D
Rationale: Self-actualization needs are the fifth and last level of Maslow's hierarchy. Physiologic needs are the first level, safety and security needs are the second level, and love and belonging needs are the third level.
A nurse and a student are developing a concept care map for a client with multiple sclerosis. Once finished, what important information can the student glean from the concept map?
- A. Ideas about the client's care and how they are linked and interrelated
- B. A prediction of how effective the client's plan of care will be
- C. Trends and patterns in the client's status over time
- D. A determination of whether the desired outcomes are achieved
Correct Answer: A
Rationale: The student can glean important information pertaining to ideas about the client's care and how these ideas are linked and interrelated. A concept map does not predict how effective the client's plan of care will be. That requires the nurse to evaluate the plan's effectiveness. The concept map also does not provide trends and patterns in the client's status over time. That requires the nurse to assess and document those trends. To determine if desired outcomes are achieved, the nurse needs to reassess the client once the plan of care has been implemented.
A client being cared for by the healthcare team has a large open abdominal wound after having a surgical procedure. The wound had to be reopened due to the development of infection and is left to heal with packing and dressing changes twice daily. What would be an appropriate measurable short-term outcome for this client?
- A. The wound will heal before the client is discharged.
- B. The client will be responsible for changing the dressing twice a day.
- C. The client will have no fever and no purulent discharge in 3 days.
- D. Dressing changes will be done twice a day using aseptic technique.
Correct Answer: C
Rationale: The client having no fever or purulent discharge in 3 days is a realistic measurable goal. The wound is large and will not heal within the time frame of discharge. It is unrealistic to have an outcome that the client will be able to change a dressing after a surgical procedure. Dressing changes twice a day is a nursing intervention.
The RN determines the interventions for a client with pneumonia and writes them in the written plan as nursing interventions. What would be an appropriate nursing intervention for this client?
- A. Force fluids.
- B. Offer the client 100 mL of fluid every hour while awake.
- C. Offer fluids prn.
- D. Give adequate amounts of fluid throughout the day.
Correct Answer: B
Rationale: Nursing interventions are specific nursing directions so that all healthcare team members understand exactly what to do for the client. Different people are likely to interpret a vague nursing order such as 'Encourage fluids' differently, resulting in inconsistent care. The other answers are not specific and are open to different interpretations. Forcing a client to do anything is not therapeutic or ethical for nurses.