Nokea
The RN determines the interventions for a client with pneumonia and writes them in the written plan as nursing interventions. What would be an appropriate nursing intervention for this client?
- A. Force fluids.
- B. Offer the client 100 mL of fluid every hour while awake.
- C. Offer fluids prn.
- D. Give adequate amounts of fluid throughout the day.
Correct Answer: B
Rationale: Nursing interventions are specific nursing directions so that all healthcare team members understand exactly what to do for the client. Different people are likely to interpret a vague nursing order such as 'Encourage fluids' differently, resulting in inconsistent care. The other answers are not specific and are open to different interpretations. Forcing a client to do anything is not therapeutic or ethical for nurses.
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Which of the following is an important element of implementation?
- A. Client database
- B. Critical thinking
- C. Nursing orders
- D. Documentation
Correct Answer: D
Rationale: An important element of implementation is documentation. The client database includes all the information obtained from the medical and nursing history. Physical examination and diagnostic studies are not an important element of implementation. Critical thinking is intentional, contemplative, and outcome-directed thinking. Developing good critical thinking skills will make nurses more efficient and effective at resolving situations necessitating multiple interventions. Nursing orders are specific nursing directions so that all healthcare team members understand what to do for the client; therefore, they are not an important element of implementation.
Which phase of the nursing process enables the nurse to compare the actual outcomes with the expected outcomes?
- A. Assessment
- B. Planning
- C. Implementation
- D. Evaluation
Correct Answer: D
Rationale: Evaluation is assessment and review of the quality and suitability of the care given and the client's responses to that care. Assessment is careful observation and evaluation of a client's health status. Planning involves setting priorities, defining expected (desired) outcomes (goals), determining specific nursing interventions, and recording the plan of care. Implementation means carrying out the written plan of care; performing interventions; monitoring the client's status; and assessing and reassessing the client before, during, and after treatments.
Which of the following is a true statement about critical thinking according to Alfaro-LeFevre (2010)?
- A. It makes judgments based on conjecture.
- B. It is based on the medical model.
- C. It considers only the client's needs.
- D. It is guided by professional standards and codes of ethics.
Correct Answer: D
Rationale: Critical thinking is guided by professional standards and codes of ethics. It is based on principles of the nursing process and scientific methods. Critical thinking makes judgments based on evidence rather than conjecture. It considers client, family, and community needs.
A client has a nursing diagnosis of altered skin integrity related to prescribed bed rest and decreased mobility of the lower extremities as evidenced by a reddened area on heels and fluid-filled blister on sacrum. Which part of this nursing diagnosis is considered the cause?
- A. Altered skin integrity
- B. Fluid filled blister on sacrum
- C. Prescribed bed rest
- D. Reddened area on heels
Correct Answer: C
Rationale: The cause portion of the nursing diagnosis includes the factors contributing to the problem; in this case, they are 'prescribed bed rest and decreased mobility of the lower extremities.' Impaired skin integrity is the stated problem, and the reddened area on the heels and the fluid filled blister are the defining characteristics that describe the problem.
The RN develops an outcome standard of 'client will ambulate with an assistive device 60 feet with assistance twice a day' for a client who had a hip replacement. What part of the nursing process is involved with this outcome statement?
- A. Assessment
- B. Planning
- C. Implementation
- D. Evaluation
Correct Answer: B
Rationale: Planning establishes the outcomes and actions that will help the client achieve the overall goals of care. Assessment is the careful observation and evaluation of a client's health status by the collection of data. Implementation is putting the plan into action, and evaluation is determining the client's responses to the care provided.