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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.
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The nurse is performing an assessment of a newly admitted patient. Which is an example of subjective data?
- A. Weight 155 pounds
- B. Pulse 72 beats/minute
- C. The patient reports that he uses the herbal product ginkgo
- D. The patient's complete blood count results
Correct Answer: C
Rationale: Subjective data include information shared through the spoken word by any reliable source, such as the patient. Objective data may be defined as any information gathered through the senses or that which is seen, heard, felt, or smelled. A patient's pulse, weight, and laboratory tests are all examples of objective data.
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.
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.
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.
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.