Nokea
The nurse takes a patients vital signs and finds the pulse rate to be 120 beats/min. What would the nurse do next to interpret and analyze this pulse rate?
- A. Compare the patients pulse rate to the standard range.
- B. Notify the patients healthcare provider.
- C. Document the pulse in the appropriate chart page.
- D. Ask another nurse to verify the pulse rate.
Correct Answer: A
Rationale: Comparing the pulse rate to the standard range is the next step to determine if it is abnormal and requires further action.
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A nurse is formulating a nursing diagnosis for a patient with a respiratory disease. Which of the following would be correct?
- A. needs nasal oxygen to improve breathing
- B. cough related to ineffective airway clearance
- C. ineffective airway clearance related to thick mucus
- D. refuses to cough and expectorate thick mucus
Correct Answer: C
Rationale: A correct nursing diagnosis includes the problem, etiology, and evidence, such as 'ineffective airway clearance related to thick mucus.'
Which of the following nursing diagnoses is an example of a wellness diagnosis?
- A. Acute Pain
- B. Risk for Infection
- C. Readiness for Enhanced Parenting
- D. Possible Chronic Low Self-Esteem
Correct Answer: C
Rationale: A wellness diagnosis, like 'Readiness for Enhanced Parenting,' focuses on promoting higher levels of health or function.
What is the focus of a diagnostic statement for a collaborative problem?
- A. the patient problem
- B. the potential complication
- C. the nursing diagnosis
- D. the medical diagnosis
Correct Answer: B
Rationale: Collaborative problems focus on potential complications that require both nursing and medical interventions to manage.
A nurse is reviewing the health history and physical assessment findings for a patient who is having respiratory problems. Of the following data collected, what data from the health history would be a cue to a nursing diagnosis for this problem?
- A. I often have diarrhea after I eat spicy foods.
- B. My skin is so dry I just cant keep from scratching.
- C. I get out of breath when I walk a few steps.
- D. I just feel so bad about myself these days.
Correct Answer: C
Rationale: Shortness of breath is a direct cue to a respiratory-related nursing diagnosis, as it indicates impaired respiratory function.
Successful implementation of each step of the nursing process requires high-level skills in critical thinking. Which of the following statements accurately describe a guideline for using this process?
- A. Trust clinical judgment and experience over asking for help.
- B. Respect clinical intuition, but never allow it to determine a diagnosis.
- C. Recognize personal biases as a strength in formulating diagnoses.
- D. Keep an open mind and trust your intuition when formulating diagnoses.
Correct Answer: D
Rationale: Keeping an open mind and trusting intuition, while validating with data, supports effective critical thinking in the nursing process.