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The nurse has been monitoring the patient's progress on a new drug regimen since the first dose and documenting the patient's therapeutic response to the medication. Which phase of the nursing process do these actions illustrate?
- A. Human needs statement
- B. Planning
- C. Implementation
- D. Evaluation
Correct Answer: D
Rationale: Monitoring the patient's progress, including the patient's response to the medication, is part of the evaluation phase. Planning, implementation, and human needs statement are not illustrated by this example.
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Which activity best reflects the implementation phase of the nursing process for the patient who is newly diagnosed with hypertension?
- A. Providing education on keeping a journal of blood pressure readings
- B. Setting goals and outcome criteria with the patient's input
- C. Recording a drug history regarding over-the-counter medications used at home
- D. Formulating human needs statements regarding deficient knowledge related to the new treatment regimen
Correct Answer: A
Rationale: Education is an intervention that occurs during the implementation phase. Setting goals and outcomes reflects the planning phase. Recording a drug history reflects the assessment phase. Formulating human needs statements reflects analysis of data as part of planning.
The nurse is assigned to a patient who is newly diagnosed with type I diabetes mellitus. Which statement best illustrates an outcome criterion for this patient?
- A. The patient will follow instructions.
- B. The patient will not experience complications.
- C. The patient will adhere to the new insulin treatment regimen.
- D. The patient will demonstrate correct blood glucose testing technique.
Correct Answer: D
Rationale: Demonstrating correct blood glucose testing technique' is a specific and measurable outcome criterion. 'Following instructions' and 'not experiencing complications' are not specific criteria. 'Adhering to new regimen' would be difficult to measure.
Place the phases of the nursing process in the correct order, with 1 as the first phase and 5 as the last phase.
- A. Planning
- B. Evaluation
- C. Assessment
- D. Implementation
- E. Human needs statement
Correct Answer: C,E,A,D,B
Rationale: The nursing process is an ongoing process that begins with assessing and continues with human needs statement, planning, implementing, and evaluating.
The nurse is developing a human needs statement for a patient who has a new diagnosis of heart failure. Identification of human needs statements occur with which of these activities?
- A. Collection of patient data
- B. Administering interventions
- C. Deciding on patient outcomes
- D. Documenting the patient's behavior
Correct Answer: A
Rationale: Identification of human needs occurs with the collection of patient data.
When giving medications, the nurse will follow the rights of medication administration. The rights include the right documentation, the right reason, the right response, and the patient's right to refuse. Which of these are additional rights? (Select all that apply.)
- A. Right drug
- B. Right route
- C. Right dose
- D. Right diagnosis
- E. Right time
- F. Right patient
Correct Answer: A,B,C,E,F
Rationale: Additional rights of medication administration must always include the right drug, right dose, right time, right route, and right patient. The right diagnosis is incorrect.