Nokea
Nurses identifying outcomes and related nursing interventions must refer to the standards and agency policies for setting priorities, identifying and recording expected patient outcomes, selecting evidence-based nursing interventions, and recording the plan of care. Which of the following are recognized standards? Select all that apply.
- A. professional physicians organizations
- B. state Nurse Practice Acts
- C. The Joint Commission
- D. the Agency for Health Care Research and Quality
- E. the Patient Health Partnership
- F. the Patient Bill of Rights
Correct Answer: B,C,D
Rationale: State Nurse Practice Acts (B), The Joint Commission (C), and the Agency for Health Care Research and Quality (D) are recognized standards that guide nursing practice and care planning.
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A father runs into the emergency room with his 18 -month-old son in his arms. The father screams, Help, he is not breathing! The nursing diagnosis of Impaired Gas Exchange is what level of priority diagnosis?
- A. no priority
- B. low priority
- C. medium priority
- D. high priority
Correct Answer: D
Rationale: Impaired Gas Exchange in a non-breathing child is a life-threatening condition, making it a high-priority diagnosis (D).
Which of the following is an example of a well-stated nursing intervention?
- A. Patient will drink 100 mL of water every 2 hours while awake.
- B. Offer patient 100 mL of water every 2 hours while awake.
- C. Offer patient water when he complains of thirst.
- D. Patient will continue to increase oral intake when awake.
Correct Answer: B
Rationale: A well-stated nursing intervention is nurse-focused and specific, such as offering water every 2 hours (B).
What part of the nursing diagnosis statement suggests the nursing interventions to be included in the plan of care?
- A. problem statement
- B. defining characteristics
- C. etiology of the problem
- D. outcomes criteria
Correct Answer: C
Rationale: The etiology of the problem (C) guides the selection of nursing interventions by addressing the cause.
Which of the following illustrates a common error when writing patient outcomes?
- A. Patient will drink 100 mL of fluid every 2 hours from 6 a.m. to 9 p.m.
- B. Patient will demonstrate correct sequence of exercises by next office visit.
- C. Patient will be less anxious and fearful before and after surgery.
- D. On discharge, patient will list five symptoms of infection to report.
Correct Answer: C
Rationale: Less anxious and fearful' (C) is vague and not measurable, a common error in outcome writing.
What is the primary purpose of the outcome identification and planning step of the nursing process?
- A. to collect and analyze data to establish a database
- B. to interpret and analyze data to identify health problems
- C. to write appropriate patient-centered nursing diagnoses
- D. to design a plan of care for and with the patient
Correct Answer: D
Rationale: The outcome identification and planning step focuses on establishing patient-centered goals and designing a plan of care collaboratively with the patient, making D the correct choice.