Nokea
The nurse caring for a patient with an infection has a nursing diagnosis of deficient fluid volume related to excessive fluid loss through normal route (diaphoresis). Which of the following is an appropriate patient outcome?
- A. Patient has a balanced intake and output.
- B. Patient's bedding is changed when it becomes damp.
- C. Patient understands the need for increased fluid intake.
- D. Patient's skin remains cool and dry throughout hospitalization
Correct Answer: A
Rationale: This statement gives measurable data showing resolution of the problem of deficient fluid volume that was identified in the nursing diagnosis statement. The other statements would not indicate that the problem of deficient fluid volume was resolved.
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Which action by a newly graduated RN working on the postsurgical unit indicates that more education about delegation and assignment is needed?
- A. The nurse delegates measurement of patient oral intake and urine output to an unregulated care provider.
- B. The nurse delegates assessment of a patient's bowel sounds to an experienced unregulated care provider.
- C. The nurse assigns an LPN/RPN to administer oral medications to several patients.
- D. The nurse assigns a 'float' RN from pediatrics to care for a patient with diabetes.
Correct Answer: B
Rationale: Assessment requires RN education and scope of practice and cannot be delegated to an unregulated care provider. The other actions by the new RN are appropriate.
The nurse is caring for a critically ill patient in the intensive care unit and plans an every-2-hour turning schedule to prevent skin breakdown. Which type of nursing function is demonstrated with this turning schedule?
- A. Dependent
- B. Cooperative
- C. Independent
- D. Collaborative
Correct Answer: D
Rationale: When implementing collaborative nursing actions, the nurse is responsible primarily for monitoring for complications of acute illness or providing care to prevent or treat complications. Independent nursing actions are focused on health promotion, illness prevention, and patient advocacy. A dependent action would require a physician order to implement. Cooperative nursing functions are not described as one of the formal nursing functions.
When caring for patients using evidence-informed practice, which of the following does the nurse use?
- A. Clinical judgment based on experience
- B. Evidence from a clinical research study
- C. The best available evidence to guide clinical expertise
- D. Evaluation of data showing that the patient outcomes are met
Correct Answer: C
Rationale: Evidence-informed nursing practice is a continuous interactive process involving the explicit, conscientious, and judicious consideration of the best available evidence to provide care. Four primary elements are: (a) clinical state, setting, and circumstances; (b) patient preferences and actions; (c) best research evidence, and (d) health care resources. Clinical judgment based on the nurse's clinical experience is part of EIP, but clinical decision making also should incorporate current research and research-based guidelines. Evidence from one clinical research study does not provide an adequate substantiation for interventions. Evaluation of patient outcomes is important, but interventions should be based on research from randomized control studies with a large number of subjects.
When using the Five Steps of the Evidence-Informed Practice (EIP) Process, in which order should the nurse construct a clinical question?
- A. Comparison of interest
- B. Population of interest
- C. Outcome of interest
- D. Intervention of interest
- E. Timeframe
Correct Answer: A,B,C,D,E
Rationale: The order of the nurse's statements follows the PICOT format, which includes Population, Intervention, Comparison, Outcome, and Timeframe, in that order.
The nurse is caring for a patient who has left-sided paralysis as the result of a stroke and assesses a pressure injury on the patient's left hip. Which of the following is the most appropriate nursing diagnosis for this patient?
- A. Impaired physical mobility related to decrease in muscle control (left-sided paralysis)
- B. Risk for impaired tissue integrity as evidenced by insufficient knowledge about protecting tissue integrity
- C. Impaired skin integrity related to pressure over bony prominence (impaired circulation)
- D. Ineffective peripheral tissue perfusion related to sedentary lifestyle
Correct Answer: C
Rationale: The patient's major problem is the impaired skin integrity as demonstrated by the presence of a pressure injury. The nurse is able to treat the cause of impaired circulation and pressure over bony prominence by frequently repositioning the patient. Although left-sided weakness is a problem for the patient, the nurse cannot treat the weakness. The 'risk for' diagnosis is not appropriate for this patient, who already has impaired tissue integrity. The patient does have ineffective peripheral tissue perfusion, but the impaired skin integrity diagnosis indicates more clearly what the health problem is.