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In response to a patients complaint of pain, the nurse administered a PRN dose of hydromorphone (Dilaudid). In what phase of the nursing process will the nurse determine whether this medication has had the desired effect?
- A. Analysis
- B. Evaluation
- C. Assessment
- D. Data collection
Correct Answer: B
Rationale: Evaluation, the final step of the nursing process, allows the nurse to determine the patients response to nursing interventions and the extent to which the objectives have been achieved.
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The nurse caring for a patient who is two days post hip replacement notifies the physician that the patients incision is red around the edges, warm to the touch, and seeping a white liquid with a foul odor. What type of problem is the nurse dealing with?
- A. Collaborative problem
- B. Nursing problem
- C. Medical problem
- D. Administrative problem
Correct Answer: A
Rationale: In addition to nursing diagnoses and their related nursing interventions, nursing practice involves certain situations and interventions that do not fall within the definition of nursing diagnoses. These activities pertain to potential problems or complications that are medical in origin and require collaborative interventions with the physician and other members of the health care team. The other answers are incorrect because the signs and symptoms of infection are a medical complication that requires interventions by the nurse.
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.
A nurse provides care on an orthopedic reconstruction unit and is admitting two new patients, both status post knee replacement. What would be the best explanation why their care plans may be different from each other?
- A. Patients may have different insurers, or one may qualify for Medicare.
- B. Individual patients are seen as unique and dynamic, with individual needs.
- C. Nursing care may be coordinated by members of two different health disciplines.
- D. Patients are viewed as dissimilar according to their attitude toward surgery.
Correct Answer: B
Rationale: Regardless of the setting, each patient situation is viewed as unique and dynamic. Differences in insurance coverage and attitude may be relevant, but these should not fundamentally explain the differences in their nursing care. Nursing care should be planned by nurses, not by members of other disciplines.
During report, a nurse finds that she has been assigned to care for a patient admitted with an opportunistic infection secondary to AIDS. The nurse informs the clinical nurse leader that she is refusing to care for him because he has AIDS. The nurse has an obligation to this patient under which legal premise?
- A. Good Samaritan Act
- B. Nursing Interventions Classification (NIC)
- C. Patient Self-Determination Act
- D. ANA Code of Ethics
Correct Answer: D
Rationale: The ethical obligation to care for all patients is clearly identified in the first statement of the ANA Code of Ethics for Nurses. The Good Samaritan Act relates to lay people helping others in need. The NIC is a standardized classification of nursing treatment that includes independent and collaborative interventions. The Patient Self-Determination Act encourages people to prepare advance directives in which they indicate their wishes concerning the degree of supportive care to be provided if they become incapacitated.
A nurse is unsure how best to respond to a patients vague complaint of feeling off. The nurse is attempting to apply the principles of critical thinking, including metacognition. How can the nurse best foster metacognition?
- A. By eliciting input from a variety of trusted colleagues
- B. By examining the way that she thinks and applies reason
- C. By evaluating her responses to similar situations in the past
- D. By thinking about the way that an ideal nurse would respond in this situation
Correct Answer: B
Rationale: Critical thinking includes metacognition, the examination of ones own reasoning or thought processes, to help refine thinking skills. Metacognition is not characterized by eliciting input from others or evaluating previous responses.