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A nurse has developed a plan of care with nursing interventions designed to meet specific patient outcomes. The outcomes are not met by the time specified in the plan. What should the nurse do now in terms of evaluation?
- A. Continue to follow the written plan of care.
- B. Make recommendations for revising the plan of care.
- C. Ask another healthcare professional to design a plan of care.
- D. State goal will be met at a later date.
Correct Answer: B
Rationale: If outcomes are not met, the nurse should recommend revising the plan of care (B) based on evaluation.
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A nurse is discharging a patient from the hospital. When should discharge planning be initiated?
- A. at the time of discharge from an acute healthcare setting
- B. at the time of admission to an acute healthcare setting
- C. before admission to an acute healthcare setting
- D. when the patient is at home after acute care
Correct Answer: B
Rationale: Discharge planning should begin at the time of admission (B) to ensure a smooth transition and continuity of care.
Which of the following illustrates a common error when writing patient outcomes?
- A. Patient will drink 100 mL of fluid every 2 hours from 6 a.m. to 9 p.m.
- B. Patient will demonstrate correct sequence of exercises by next office visit.
- C. Patient will be less anxious and fearful before and after surgery.
- D. On discharge, patient will list five symptoms of infection to report.
Correct Answer: C
Rationale: Less anxious and fearful' (C) is vague and not measurable, a common error in outcome writing.
Which of the following statements accurately describe the impact on nursing of using NIC/NOC standardized languages? Select all that apply.
- A. They demonstrate the impact that nurses have on the system of healthcare delivery.
- B. They standardize and define the knowledge base for nursing curricula and practice.
- C. They limit the number of appropriate nursing intervention to be selected.
- D. They hinder the teaching of clinical decision making to novice nurses.
- E. They enable researchers to examine the effectiveness and cost of nursing care.
- F. They slow the development and use of nursing information systems.
Correct Answer: A,B,E
Rationale: NIC/NOC languages demonstrate nursing impact (A), standardize knowledge (B), and enable research (E).
A resident of a long-term care facility refuses to eat until she has had her hair combed and her make-up applied. In this case, what patient need should have priority?
- A. the need to have nutrition
- B. the need to feel good about oneself
- C. the need to live in a safe environment
- D. the need for love from others
Correct Answer: B
Rationale: The patient's refusal to eat until her appearance is addressed indicates that her need to feel good about herself (B) is currently the priority.
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 to identify health problems
- C. to write appropriate patient-centered nursing diagnoses
- D. to design a plan of care for and with the patient
Correct Answer: D
Rationale: The outcome identification and planning step focuses on establishing patient-centered goals and designing a plan of care collaboratively with the patient, making D the correct choice.