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A recent nursing graduate is aware of the differences between nursing actions that are independent and nursing actions that are interdependent. A nurse performs an interdependent nursing intervention when performing which of the following actions?
- A. Auscultating a patients apical heart rate during an admission assessment
- B. Providing mouth care to a patient who is unconscious following a cerebrovascular accident
- C. Administering an IV bolus of normal saline to a patient with hypotension
- D. Providing discharge teaching to a postsurgical patient about the rationale for a course of oral antibiotics
Correct Answer: C
Rationale: Although many nursing actions are independent, others are interdependent, such as carrying out prescribed treatments, administering medications and therapies, and collaborating with other health care team members to accomplish specific, expected outcomes and to monitor and manage potential complications. Irrigating a wound, administering pain medication, and administering IV fluids are interdependent nursing actions and require a physicians order. An independent nursing action occurs when the nurse assesses a patients heart rate, provides discharge education, or provides mouth care.
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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.
A nurse is admitting a new patient to the medical unit. During the initial nursing assessment, the nurse has asked many supplementary open-ended questions while gathering information about the new patient. What is the nurse achieving through this approach?
- A. Interpreting what the patient has said
- B. Evaluating what the patient has said
- C. Assessing what the patient has said
- D. Validating what the patient has said
Correct Answer: D
Rationale: Critical thinkers validate the information presented to make sure that it is accurate (not just supposition or opinion), that it makes sense, and that it is based on fact and evidence. The nurse is not interpreting, evaluating, or assessing the information the patient has given.
You are providing care for a patient who has a diagnosis of pneumonia attributed to Streptococcus pneumonia infection. Which of the following aspects of nursing care would constitute part of the planning phase of the nursing process?
- A. Achieve SaO2 92% at all times.
- B. Auscultate chest q4h.
- C. Administer oral fluids q1h and PRN.
- D. Avoid overexertion at all times.
Correct Answer: A
Rationale: The planning phase entails specifying the immediate, intermediate, and long-term goals of nursing action, such as maintaining a certain level of oxygen saturation in a patient with pneumonia. Providing fluids and avoiding overexertion are parts of the implementation phase of the nursing process. Chest auscultation is an assessment.
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 is providing care for a patient with chronic obstructive pulmonary disease (COPD). The nurses most recent assessment reveals an SaO2 of 89%. The nurse is aware that part of critical thinking is determining the significance of data that have been gathered. What characteristic of critical thinking is used in determining the best response to this assessment finding?
- A. Extrapolation
- B. Inference
- C. Characterization
- D. Interpretation
Correct Answer: D
Rationale: Nurses use interpretation to determine the significance of data that are gathered. This specific process is not described as extrapolation, inference, or characterization.