Nokea
In which step of the nursing process do nurses look at outcomes?
- A. Evaluation
- B. Assessment
- C. Implementation
- D. Planning
Correct Answer: A
Rationale: Evaluation (A) is where nurses assess whether outcomes and goals were met. Assessment (B) collects data, Implementation (C) executes interventions, and Planning (D) sets goals.
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Select the proper order of the phases of the Nursing Process:
- A. Evaluation, planning, assessment, implementation
- B. Assessment, planning, implementation, evaluation
- C. Implementation, assessment, planning, evaluation
- D. Planning, evaluation, assessment, implementation
Correct Answer: B
Rationale: The nursing process follows a logical sequence: Assessment (data collection), Planning (developing goals and interventions), Implementation (executing the plan), and Evaluation (assessing effectiveness). Only option B lists this correct order.
Clarify the primary purpose of nursing orders:
- A. to clarify nursing principles
- B. to resolve the patient's problems
- C. to support physician's orders
- D. to provide broad, general statements
Correct Answer: B
Rationale: Nursing orders (B) aim to address patient problems directly through targeted interventions. A, C, and D do not capture this primary focus.
Patient with edema has a problem of fluid overload
The nurse is reviewing the patient's plan of care and ordered treatments. Which of the following is (are) independent nursing interventions? (select all that apply)
- A. Teaching deep breathing and relaxation techniques as needed
- B. Inserting a nasogastric tube (NG) to relieve gastric distention
- C. Placing the nurse call button within reach at all times
- D. Giving hand massages daily
- E. Repositioning the patient every 2 hours to reduce pressure injury risk
- F. Giving acetaminophen (Tylenol) 650 mg orally every 4 hours as needed
Correct Answer: A,C,D,E
Rationale: A: Teaching non-pharmacological techniques is within a nurse's scope without a physician's order. C: Ensuring the call button is accessible promotes safety independently. D: Hand massages are a comfort measure nurses can provide independently. E: Repositioning prevents pressure injuries and is an independent action. B requires a physician's order, and F involves medication administration, which is dependent.
Which part of the medical record can be used as evidence in court?
- A. the care plan
- B. the medical orders
- C. the entire record
- D. nursing notes
Correct Answer: C
Rationale: The entire record (C) can be used in court, providing a comprehensive view of care. A, B, and D are parts but not the whole.
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.