Nokea
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.
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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.
When the nurse considers the timing of a drug dose, which factor is appropriate to consider when deciding when to give a drug?
- A. The patient's ability to swallow
- B. The patient's height
- C. The patient's last meal
- D. The patient's allergies
Correct Answer: C
Rationale: The nurse must consider specific pharmacokinetic/pharmacodynamic drug properties that may be affected by the timing of the last meal. The patient's ability to swallow, height, and allergies are not factors to consider regarding the timing of the drug's administration.
The patient is to receive oral guafenesin twice a day. Today, the nurse was busy and gave the medication 2 hours after the scheduled dose was due. What type of problem does this represent?
- A. Right time
- B. Right dose
- C. Right route
- D. Right medication
Correct Answer: A
Rationale: Right time' is correct because the medication was given more than 30 minutes after the scheduled dose was due. 'Dose' is incorrect because the dose is not related to the time the medication administration is scheduled. 'Route' is incorrect because the route is not affected. 'Medication' is incorrect because the medication ordered will not change.
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.