Nokea
In which step of the nursing process are priorities set?
- A. Assessment
- B. Diagnosis
- C. Planning
- D. Implementation
- E. Evaluation
Correct Answer: C
Rationale: Planning involves setting priorities for nursing diagnoses and determining goals and interventions to address the patient's needs.
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Your patient has severe peripheral vascular disease (poor circulation) in both lower extremities. You document that the patient's pedal pulses are absent. Which assessment technique did you use to obtain these data?
- A. Inspection
- B. Palpation
- C. Auscultation
- D. Percussion
Correct Answer: B
Rationale: Palpation is used to feel for pedal pulses, determining their presence or absence.
You are caring for a male patient who had a total hip replacement 3 days earlier. You have not cared for the patient before and are assessing him to establish a baseline of information about his health status. The patient states he felt feverish during the night and broke into a sweat. You check his temperature readings from the previous night and see that it was 99.2?°F at midnight and 98.2?°F at 6 a.m. It now is 99?°F. Which of the following actions represents the best response to his statement and gives the best explanation for the action as it relates to critical thinking?
- A. Tell him not to worry because his temperature was only 99.2?°F. This action shows that you understand normal trends in postoperative care and are applying them to unique situations.
- B. Make a mental note to check his temperature a few more times this shift. This action shows that you understand that assessment is the first and most important step in the nursing process.
- C. Assess him for signs and symptoms of an infection. This action shows that you are looking for data to validate the patient's comment.
- D. Tell him that a low-grade fever is normal after surgery. This shows that you are aware of common clinical conditions.
Correct Answer: C
Rationale: Assessing for signs and symptoms of infection (C) is the best response as it involves critical thinking by validating the patient's subjective complaint with objective data, ensuring a thorough evaluation of a potential postoperative complication.
Nursing diagnoses all contain the modifier 'risk for.'
- A. TRUE
- B. FALSE
Correct Answer: B
Rationale: False. Only potential problems use 'risk for'; actual problems and wellness diagnoses do not.
You have passed your NCLEX-PN examination and have just been employed as an LPN on a medical surgical unit. The registered nurse (RN) in charge asks you to do the admission assessment on a new patient who has just arrived by ambulance from a long-term care facility. The patient had undergone a total hip replacement within the previous 2 weeks and has developed a fever. You tell the nurse you thought an LPN could not do the admission assessment or, at most, could do only certain portions of it. The nurse, who is very busy, says, 'Please just do it. I'll cosign it, so it will be fine.' Which of the following actions should you take next?
- A. Call the supervisor to discuss the nurse's instructions to you.
- B. Refuse to do the admission assessment but offer to get the patient settled in, take his vital signs, and review the chart for orders.
- C. Check the facility's policy manual.
- D. Do the assessment as requested.
Correct Answer: B,C
Rationale: Checking the facility's policy manual (C) ensures you act within your scope of practice. Refusing to do the admission assessment but offering to perform tasks within your role (B) is appropriate, as LPNs typically cannot perform initial admission assessments, which are reserved for RNs.
By using a problem statement, the cause of the problem, and the defining characteristics of the problem, nursing diagnoses help identify interventions to address the problem.
- A. TRUE
- B. FALSE
Correct Answer: A
Rationale: True. Nursing diagnoses include a problem statement, etiology, and defining characteristics to guide targeted interventions.