Nursing Process Questions

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Nurses identifying outcomes and related nursing interventions must refer to the standards and agency policies for setting priorities, identifying and recording expected client outcomes, selecting evidence-based nursing interventions, and recording the plan of care. Which of the following are recognized standards?

  • A. Professional physicians’ organizations
  • B. State Nurse Practice Acts
  • C. The Joint Commission
  • D. The Agency for Health Care Research and Quality
Correct Answer: B

Rationale: Correct Answer: B (State Nurse Practice Acts)

Rationale: State Nurse Practice Acts outline the legal scope of nursing practice, including standards for setting priorities, identifying client outcomes, and selecting evidence-based nursing interventions. These laws are specific to nursing practice, ensuring that nurses follow guidelines tailored to their profession. Nurses must adhere to these standards to provide safe and effective care.

Summary of Incorrect Choices:
A: Professional physicians' organizations - While physicians' organizations may provide guidelines for medical practice, they do not set standards specific to nursing practice.
C: The Joint Commission - The Joint Commission focuses on accreditation for healthcare organizations, not setting standards for nursing practice.
D: The Agency for Health Care Research and Quality - AHRQ conducts research and provides evidence-based information but does not establish standards for nursing practice.

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Which nursing actions will the nurse perform in the evaluation phase of the nursing process? (Select all that apply.)

  • A. Set priorities for patient care.
  • B. Determine whether outcomes or standards are met.
  • C. Ambulate patient 25 feet in the hallway.
  • D. Document results of goal achievement.
Correct Answer: A

Rationale: In the evaluation phase of the nursing process, the nurse sets priorities for patient care to determine the effectiveness of nursing interventions. This involves comparing achieved outcomes with established goals. Choices B and D are related to evaluation as they involve determining whether outcomes or standards are met and documenting results of goal achievement, respectively. However, choice C, ambulating the patient, is an intervention that would typically occur in the implementation phase, not the evaluation phase. Therefore, the correct answer is A because setting priorities for patient care is a key component of the evaluation phase.

Which of the ff. nursing interventions will help prevent complications in the patient with Bell’s Palsy?

  • A. Megavitamin therapy
  • B. Application of ice to the affected area
  • C. Elastic bandages
  • D. Lubricating eye drops
Correct Answer: D

Rationale: Correct Answer: D - Lubricating eye drops

Rationale: Lubricating eye drops help prevent complications such as corneal abrasions in patients with Bell's Palsy by keeping the eye moist and preventing dryness. Bell's Palsy can cause difficulty in closing the eye properly, leading to dryness and potential damage to the cornea. Using lubricating eye drops helps maintain eye health.

Summary of Incorrect Choices:
A: Megavitamin therapy - Not directly related to preventing complications in Bell's Palsy.
B: Application of ice to the affected area - Ice may not address eye dryness or prevent corneal abrasions.
C: Elastic bandages - Not relevant to preventing complications associated with Bell's Palsy.

The nurse is gathering data on a patient. Which data will the nurse report as objective data?

  • A. States “doesn’t feel good”
  • B. Reports a headache
  • C. Respirations 16
  • D. Nauseated
Correct Answer: C

Rationale: Objective data in nursing refers to measurable and observable information. Respirations at 16 per minute are a specific, quantifiable measurement that the nurse can directly observe, making it objective data. This information is vital for assessing the patient's respiratory status accurately.

Choice A is incorrect because stating "doesn't feel good" is a subjective statement based on the patient's perception and cannot be directly measured or observed. Choice B, reporting a headache, is also subjective as it relies on the patient's description of their symptoms. Choice D, being nauseated, is subjective as well, as it is a symptom reported by the patient and not a quantifiable measurement.

In summary, choice C is correct as it represents objective data due to its quantifiable and observable nature, while the other choices are subjective and based on the patient's perceptions or feelings.

Which of the ff factors makes it important for the nurse to provide special care to older clients with an immune system disorder?

  • A. Age-related changes
  • B. Use of multiple drugs (Polypharmacy)
  • C. Poor diet
  • D. Reduced activity levels
Correct Answer: A

Rationale: The correct answer is A: Age-related changes. Older clients are more susceptible to immune system disorders due to age-related changes such as a weakened immune response, increased inflammation, and decreased production of immune cells. Providing special care is important to address these specific vulnerabilities.

Incorrect choices:
B: Use of multiple drugs (Polypharmacy) - While polypharmacy can impact the immune system, it is not the primary factor for providing special care to older clients with immune system disorders.
C: Poor diet - While diet plays a role in overall health, it is not the main factor necessitating special care for older clients with immune system disorders.
D: Reduced activity levels - Although physical activity is important for overall health, reduced activity levels are not the primary reason for providing special care to older clients with immune system disorders.

A client diagnosed with DIC is ordered heparin. What is the reason for this medication?

  • A. Prevent clot formation
  • B. Increase clot formation
  • C. Increased blood flow to target organs
  • D. Decrease blood flow to target organs
Correct Answer: A

Rationale: The correct answer is A: Prevent clot formation. Heparin is an anticoagulant that inhibits the formation of blood clots. In DIC (Disseminated Intravascular Coagulation), there is excessive clotting throughout the body, leading to organ damage. By administering heparin, we aim to prevent further clot formation and reduce the risk of complications.

Choice B is incorrect because heparin does not increase clot formation; it works to inhibit clotting. Choice C is incorrect as heparin does not directly increase blood flow to target organs. Choice D is also incorrect as heparin does not decrease blood flow to target organs; its primary role is anticoagulation.

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