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A nurse determines that the patient’s condition has improved and has met expected outcomes. Which step of the nursing process is the nurse exhibiting?
- A. Assessment
- B. Planning
- C. Implementation NursingStoreRN
- D. Evaluation
Correct Answer: D
Rationale: The correct answer is D: Evaluation. In the nursing process, evaluation involves determining if the patient's condition has improved and if the expected outcomes have been met. The nurse assesses the patient's progress, compares it to the expected outcomes set during planning, and determines the effectiveness of the interventions implemented. This step ensures that the care provided is meeting the patient's needs and helps in making any necessary adjustments to the care plan.
Incorrect choices:
A: Assessment - This step involves gathering information about the patient's condition and needs at the beginning of the nursing process.
B: Planning - Involves setting goals and developing a plan of care based on the assessment data.
C: Implementation - Involves carrying out the interventions outlined in the care plan to meet the patient's goals.
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What is the primary purpose of the outcome identification and planning step of the nursing process?
- A. To collect and analyze data to establish a database
- B. To interpret and analyze data so as to identify health problems
- C. To write appropriate client-centered nursing diagnoses
- D. To design a plan of care for and with the client
Correct Answer: D
Rationale: The primary purpose of the outcome identification and planning step of the nursing process (step 3) is to design a plan of care for and with the client. This involves setting specific, measurable, achievable, relevant, and time-bound (SMART) goals to address the client's health problems. By involving the client in the planning process, it promotes client autonomy and ensures that the plan is tailored to their individual needs and preferences. Options A and B focus on data collection and analysis, which are steps 1 and 2 of the nursing process. Option C refers to nursing diagnosis, which is part of step 2 (diagnosis). Therefore, option D is the correct answer as it pertains to the specific purpose of the outcome identification and planning step.
Which action indicates a nurse is using critical thinking for implementation of nursing care to patients?
- A. Determines whether an intervention is correct and appropriate for the given situation
- B. Reads over the steps and performs a procedure despite lack of clinical competency
- C. Establishes goals for a particular patient without assessment
- D. Evaluates the effectiveness of interventions
Correct Answer: A
Rationale: The correct answer is A because determining whether an intervention is correct and appropriate for the given situation indicates critical thinking in nursing care implementation. This involves assessing the patient's needs, analyzing the situation, and using evidence-based practice to make informed decisions. This process ensures that interventions are tailored to individual patient needs and promotes safe and effective care delivery.
Option B is incorrect because performing a procedure without clinical competency can jeopardize patient safety and is not an example of critical thinking. Option C is incorrect as establishing goals without assessment lacks a foundation in data and may lead to inappropriate care planning. Option D is incorrect as evaluating the effectiveness of interventions is a part of the nursing process but does not specifically demonstrate critical thinking in implementation.
Which of the following nursing actions is appropriate when a patient returns to his or her room after a bronchoscopy?
- A. Order a meal because the patient has been nil per os (NPO) for 8 hours.
- B. Encourage fluids to flush dye from the patient’s system.
- C. Monitor the patient for return to consciousness.
- D. Check for a gag reflex before allowing the patient to drink.
Correct Answer: D
Rationale: The correct answer is D - Check for a gag reflex before allowing the patient to drink. This is important after a bronchoscopy to prevent aspiration. Step 1: Assessing gag reflex ensures the patient can protect their airway. Step 2: Aspiration risk is high post-bronchoscopy due to sedation and possible throat numbness. Step 3: Allowing fluids without confirming gag reflex can lead to aspiration pneumonia. Other choices are incorrect. A: Ordering a meal immediately is inappropriate after NPO period. B: Encouraging fluids without assessing gag reflex may lead to aspiration. C: Monitoring consciousness is important but not directly related to post-bronchoscopy care.
There are several risk factors with developing cancer. The following are risk factors of cancer, except:
- A. age
- B. ordinal petition In the family
- C. race
- D. lifestyle
Correct Answer: B
Rationale: The correct answer is B because ordinal petition in the family is not a recognized risk factor for developing cancer. Age is a well-known risk factor as cancer incidence increases with age. Race can also influence cancer risk due to genetic and environmental factors. Lifestyle choices such as smoking, diet, and physical activity can significantly impact the likelihood of developing cancer. In contrast, ordinal petition in the family does not have a direct association with cancer risk.
The client is being evaluated for hypothyroidism. During assessment, the nurse should stay alert for:
- A. exophthalmos and conjunctival redness
- B. flushed, warm, moist skin
- C. systolic murmur at the left sternal border
- D. decreased body temperature and cold intolerance
Correct Answer: D
Rationale: The correct answer is D, decreased body temperature and cold intolerance, because these are classic signs of hypothyroidism due to decreased thyroid hormone levels. The body's metabolism slows down, leading to a lower core body temperature and reduced ability to tolerate cold. Exophthalmos and conjunctival redness (choice A) are associated with hyperthyroidism. Flushed, warm, moist skin (choice B) is indicative of hyperthyroidism as well, due to increased metabolic rate. A systolic murmur at the left sternal border (choice C) is not a common finding in hypothyroidism.