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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.
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Which of the following is a true statement about critical thinking in nursing?
- A. It involves purposeful, outcome-directed thinking.
- B. It shows trends and patterns in client status.
- C. It makes judgments based on conjecture.
- D. It supplies validation for reimbursement.
Correct Answer: A
Rationale: In nursing, critical thinking involves purposeful, outcome-directed thinking. Critical thinking makes judgments based on evidence rather than conjecture. Providing a foundation for evaluation and quality improvement and showing trends and patterns in client status are functions served by documentation.
Which of the following is involved in the implementation step of the nursing process?
- A. Selecting nursing interventions
- B. Documenting nursing care and client responses
- C. Documenting the plan of care
- D. Identifying measurable outcomes
Correct Answer: B
Rationale: The implementation step in the nursing process involves documenting nursing care and client responses. Planning involves selecting nursing interventions, documenting the plan of care, and identifying measurable outcomes.
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.
Which of the following is an important element of implementation?
- A. Client database
- B. Critical thinking
- C. Nursing orders
- D. Documentation
Correct Answer: D
Rationale: An important element of implementation is documentation. The client database includes all the information obtained from the medical and nursing history. Physical examination and diagnostic studies are not an important element of implementation. Critical thinking is intentional, contemplative, and outcome-directed thinking. Developing good critical thinking skills will make nurses more efficient and effective at resolving situations necessitating multiple interventions. Nursing orders are specific nursing directions so that all healthcare team members understand what to do for the client; therefore, they are not an important element of implementation.
Which phase of the nursing process enables the nurse to compare the actual outcomes with the expected outcomes?
- A. Assessment
- B. Planning
- C. Implementation
- D. Evaluation
Correct Answer: D
Rationale: Evaluation is assessment and review of the quality and suitability of the care given and the client's responses to that care. Assessment is careful observation and evaluation of a client's health status. Planning involves setting priorities, defining expected (desired) outcomes (goals), determining specific nursing interventions, and recording the plan of care. Implementation means carrying out the written plan of care; performing interventions; monitoring the client's status; and assessing and reassessing the client before, during, and after treatments.