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A patient with a urinary tract infection is assessed using a clinical pathway. When a projected outcome is not met by a predetermined date it is determined that what has occurred?
- A. Omission
- B. Variance
- C. Failure
- D. Error
Correct Answer: B
Rationale: A variance occurs when a projected outcome is not met.
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During an admission assessment the nurse collects objective and subjective data. What is an example of subjective data?
- A. The patient is coughing.
- B. The patient has cyanosis of the lips.
- C. The patient experiences tachypnea.
- D. The patient complains of generalized discomfort.
Correct Answer: D
Rationale: Subjective data are the verbal statements provided by the patient. Statements about nausea and descriptions of pain, fatigue, and anxiety are examples of subjective data. Complaining of generalized discomfort is an example of subjective data. All other options are examples of objective data.
What type of assessment is performed continuously throughout nurse-patient contact?
- A. Complete
- B. Body systems
- C. Focused
- D. Subjective
Correct Answer: C
Rationale: Focused assessments are performed continuously throughout nurse-patient contact based on the nursing care plan.
What framework does the establishment of priorities of care during the planning phase of the nursing process often use?
- A. Erikson's developmental tasks
- B. Piaget's cognitive table
- C. Maslow's hierarchy of needs
- D. Freud's classifications
Correct Answer: C
Rationale: A useful framework to guide prioritization is Maslow's hierarchy of needs.
Which nursing intervention is complete and correct?
- A. May 10: Unlicensed assistive personnel will ambulate patient. A. Nurse
- B. Day nurse will cleanse wound and change dressings every day. May 10 A. Nurse
- C. Unlicensed assistive personnel will serve 8 oz glass of juice at each meal 5/10.
- D. P.M. nurse will ensure that heel protectors are in place before bedtime.
Correct Answer: B
Rationale: Nursing orders must be signed, dated, and have specific designation as to who will perform intervention and specifics about time or frequency of the intervention.
During an admission assessment the nurse collects objective and subjective data. What is an example of objective data?
- A. The patient is jaundiced.
- B. The patient states "I am nervous."
- C. The patient complains of palpitations.
- D. The patient denies dizziness when ambulating.
Correct Answer: A
Rationale: Objective data are observable and measurable signs. Objective data can be recorded. A camera can record a rash, a skin lesion, or puffy eyes. A tape recorder can give evidence of crying or slurred speech. A thermometer can record a temperature elevation. Other terms for objective data are signs and objective cues. The patient is jaundiced is an example of objective data. All other options are examples of subjective data.