Nokea
Identify the two primary methods used to collect data:
- A. interview and physical examination
- B. review of the doctor's orders and the Kardex
- C. written report by patient and family
- D. review of the chart and the nurse's notes
Correct Answer: A
Rationale: Interview and physical examination (A) collect subjective and objective data directly. B, C, and D are secondary or supportive methods.
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Patient with edema has a problem of fluid overload
A patient with edema has a problem of fluid overload. The nurse is developing a care plan and selecting interventions that will assist the patient in reducing the fluid. An important consideration when developing the care plan is to:
- A. use a Nursing Diagnosis from a source other than NANDA-I
- B. limit the number of interventions
- C. select interventions which will be easy to implement
- D. involve the patient in the process
Correct Answer: D
Rationale: Involving the patient in the care plan (D) ensures better adherence and personalization, which is critical for effective fluid reduction. A is incorrect because NANDA-I provides standardized diagnoses for accuracy. B is incorrect as interventions should be sufficient, not arbitrarily limited. C is incorrect because interventions should be effective, not merely easy.
Patient is confined to bed rest
The patient is confined to bed rest. This contributes to immobility of the patient. How should bed rest be indicated on the nursing care plan?
- A. as difficult to maintain
- B. as a risk factor
- C. as a nursing responsibility
- D. as contributing to the patient's recovery
Correct Answer: B
Rationale: Bed rest (B) is a risk factor for complications like pressure ulcers or DVT, which should be noted in the care plan. A is subjective, C is an intervention, and D is incomplete as bed rest can hinder recovery if prolonged.
Which of the following statements is correct about abbreviations?
- A. Every facility should have an approved abbreviations list.
- B. Creating abbreviations saves time for the person reading the chart.
- C. Writing out questionable abbreviations could make a jury think you're hiding something
- D. Abbreviating drug name and dosages helps reduce medication errors.
Correct Answer: A
Rationale: Approved abbreviation lists (A) ensure clarity and prevent errors. B, C, and D are incorrect as unapproved abbreviations cause confusion and risks.
The primary source of assessment information is:
- A. the patient's friends
- B. past medical records
- C. the patient's record
- D. the patient
Correct Answer: D
Rationale: The patient (D) is the primary source for assessment data, providing real-time information on symptoms and concerns. Friends (A) and records (B, C) are secondary sources and may not reflect current status.
Patient with dyspnea
The nurse is trying to decide what interventions will assist the patient with dyspnea to meet needs demonstrated by the patient. This phase of the nursing process is:
- A. implementation
- B. evaluation
- C. planning
- D. assessment
Correct Answer: C
Rationale: Planning (C) involves selecting interventions for patient needs, like dyspnea. A, B, and D represent other phases.