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A medical nurse has obtained a new patients health history and completed the admission assessment. The nurse has followed this by documenting the results and creating a care plan for the patient. Which of the following is most important rationale for documenting the patients care?
- A. It provides continuity of care.
- B. It creates a teaching log for the family.
- C. It verifies appropriate staffing levels.
- D. It keeps the patient fully informed.
Correct Answer: A
Rationale: This record provides a means of communication among members of the health care team and facilitates coordinated planning and continuity of care. It serves as the legal and business record for a health care agency and for the professional staff members who are responsible for the patients care. Documentation is not primarily a teaching log; it does not verify staffing; and it is not intended to provide the patient with information about treatments.
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You are the nurse who is caring for a patient with a newly diagnosed allergy to peanuts. Which of the following is an immediate goal that is most relevant to a nursing diagnosis of deficient knowledge related to appropriate use of an EpiPen?
- A. The patient will demonstrate correct injection technique with todays teaching session.
- B. The patient will closely observe the nurse demonstrating the injection.
- C. The nurse will teach the patients family member to administer the injection.
- D. The patient will return to the clinic within 2 weeks to demonstrate the injection.
Correct Answer: A
Rationale: Immediate goals are those that can be reached in a short period of time. An appropriate immediate goal for this patient is that the patient will demonstrate correct administration of the medication today. The goal should specify that the patient administer the EpiPen. A 2-week time frame is inconsistent with an immediate goal.
The nursing instructor cites a list of skills that support critical thinking in clinical situations. The nurse should describe skills in which of the following domains?
- A. Self-esteem
- B. Self-regulation
- C. Inference
- D. Autonomy
- E. Interpretation
Correct Answer: B,C,E
Rationale: Skills needed in critical thinking include interpretation, analysis, evaluation, inference, explanation, and self-regulation. Self-esteem and autonomy would not be on the list because they are not skills.
Achieving adequate pain management for a postoperative patient will require sophisticated critical thinking skills by the nurse. What are the potential benefits of critical thinking in nursing?
- A. Enhancing the nurses clinical decision making
- B. Identifying the patients individual preferences
- C. Planning the best nursing actions to assist the patient
- D. Increasing the accuracy of the nurses judgments
- E. Helping identify the patients priority needs
Correct Answer: A,C,D,E
Rationale: Independent judgments and decisions evolve from a sound knowledge base and the ability to synthesize information within the context in which it is presented. Critical thinking enhances clinical decision making, helping to identify patient needs and the best nursing actions that will assist patients in meeting those needs. Critical thinking does not normally focus on identify patient desires; these would be identified by asking the patient.
The nurse caring for a patient who is two days post hip replacement notifies the physician that the patients incision is red around the edges, warm to the touch, and seeping a white liquid with a foul odor. What type of problem is the nurse dealing with?
- A. Collaborative problem
- B. Nursing problem
- C. Medical problem
- D. Administrative problem
Correct Answer: A
Rationale: In addition to nursing diagnoses and their related nursing interventions, nursing practice involves certain situations and interventions that do not fall within the definition of nursing diagnoses. These activities pertain to potential problems or complications that are medical in origin and require collaborative interventions with the physician and other members of the health care team. The other answers are incorrect because the signs and symptoms of infection are a medical complication that requires interventions by the nurse.
A terminally ill patient you are caring for is complaining of pain. The physician has ordered a large dose of intravenous opioids by continuous infusion. You know that one of the adverse effects of this medicine is respiratory depression. When you assess your patients respiratory status, you find that the rate has decreased from 16 breaths per minute to 10 breaths per minute. What action should you take?
- A. Decrease the rate of IV infusion.
- B. Stimulate the patient in order to increase respiratory rate.
- C. Report the decreased respiratory rate to the physician.
- D. Allow the patient to rest comfortably.
Correct Answer: C
Rationale: End-of life issues that often involve ethical dilemmas include pain control, do not resuscitate orders, life-support measures, and administration of food and fluids. The risk of respiratory depression is not the intent of the action of pain control. Respiratory depression should not be used as an excuse to withhold pain medication for a terminally ill patient. The patients respiratory status should be carefully monitored and any changes should be reported to the physician.