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The LPN is assisting with the admission of a client scheduled for surgery the next day. What role does the LPN have in the planning phase of the nursing process?
- A. Gathering more extensive biopsychosocial data
- B. Drawing conclusions, uses judgment, and makes diagnosis
- C. Establishing priorities, sets short- and long-term goals
- D. Contributing to the development of care plans
Correct Answer: D
Rationale: The role of the LPN allows for the contribution of the development of care plans. The other answers are within the scope of practice of an RN.
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The nurse understands that critical thinking skills are an integral part of nursing practice. Development of these skills requires what from the nurse?
- A. Intention
- B. Experience
- C. Contemplation
- D. Focus on outcomes
Correct Answer: B
Rationale: Nurses develop critical thinking skills through knowledge, experience, and practice. Intention, contemplation, and a focus on outcomes are characteristics of critical thinking. They are not how the nurse develops critical thinking skills.
A client has been admitted to the hospital with a large sacral pressure ulcer. The physician prescribes the wound care protocol to be performed twice a day. What would be a statement on the plan of care that would address the implementation phase of the nursing process for this client?
- A. A 6 cm x 4 cm wound with malodorous, yellow exudate
- B. The client's wound will heal by 1 cm by the end of 5 days.
- C. The client's wound has healed by 0.5 cm on day 3 of wound care.
- D. Turn the client every 2 hours.
Correct Answer: D
Rationale: Turning the client every 2 hours is implementing care to allow the pressure ulcer to heal and prevent another formation of a wound. Recording the description of the wound would occur during the assessment phase of the nursing process. The prediction of how much and how soon the client's wound will heal would be made during the planning phase, while noting the amount the wound has healed on a given day is an example of a statement that would be made during the evaluation phase.
The LPN is collecting data so that the RN may develop the plan of care for the client. What is the importance of accurate gathering of baseline data?
- A. The physician will be able to make a diagnosis.
- B. It serves as a comparison for future signs and symptoms
- C. The RN will be able to make the assignments based on the baseline data.
- D. The RN will know what type of medication the client will receive.
Correct Answer: B
Rationale: The client database includes all the information obtained from the medical and nursing history, physical examination, and diagnostic studies. Baseline data serve as a comparison for future signs and symptoms and provide a reference for determining if a client's health is improving. The physician does not use the care plan for the diagnosis.
The RN develops an outcome standard of 'client will ambulate with an assistive device 60 feet with assistance twice a day' for a client who had a hip replacement. What part of the nursing process is involved with this outcome statement?
- A. Assessment
- B. Planning
- C. Implementation
- D. Evaluation
Correct Answer: B
Rationale: Planning establishes the outcomes and actions that will help the client achieve the overall goals of care. Assessment is the careful observation and evaluation of a client's health status by the collection of data. Implementation is putting the plan into action, and evaluation is determining the client's responses to the care provided.
The LPN states to an RN, 'I don't know why we have to follow a care plan. No one even uses it, and it just means more paperwork. What's the purpose?' What is the best response by the RN?
- A. I agree with you, and we should talk to the manager about eliminating them from our required paperwork.'
- B. I think it is something we have always done, and we have to continue to use them.'
- C. It helps to provide a systematic method for us to plan and implement care so that we achieve positive outcomes.'
- D. Health care providers use our care plans in order to see what we are doing for the clients.'
Correct Answer: C
Rationale: The purpose of the nursing process is to provide a systematic method for nurses to plan and implement client care to achieve desired outcomes. The nursing process cannot be eliminated from the paperwork because nurses use the process to evaluate and update a client's care. It is an integral part of nursing practice. Stating that the nursing process is something nurses have always done and must continue to do so is a vague and incomplete answer. It does not give a rationale for using the nursing process. Although health care providers may review a nurse's care plan to see what is being done for the client, that is not the reason nurses use the nursing process or create care plans. The client's plan of care guides nursing care and provides a vehicle for assessment, planning, implementation, evaluation, and, if needed, the revision of care.