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Which action by a newly graduated RN working on the postsurgical unit indicates that more education about delegation and assignment is needed?
- A. The nurse delegates measurement of patient oral intake and urine output to an unregulated care provider.
- B. The nurse delegates assessment of a patient's bowel sounds to an experienced unregulated care provider.
- C. The nurse assigns an LPN/RPN to administer oral medications to several patients.
- D. The nurse assigns a 'float' RN from pediatrics to care for a patient with diabetes.
Correct Answer: B
Rationale: Assessment requires RN education and scope of practice and cannot be delegated to an unregulated care provider. The other actions by the new RN are appropriate.
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Which of the following best explains the nurse's primary use of the nursing process when providing care to patients?
- A. To explain nursing interventions to other health care professionals
- B. As a problem-solving tool to identify and treat patients' health care needs
- C. As a scientific-based process of diagnosing the patient's health care problems
- D. To establish nursing theory that incorporates the biopsychosocial nature of humans
Correct Answer: B
Rationale: The nursing process is an assertive problem-solving approach to the identification and treatment of patients' problems. Diagnosis is only one phase of the nursing process. The primary use of the nursing process is in patient care, not to establish nursing theory or explain nursing interventions to other health care professionals.
Which of these nursing actions for the patient with heart failure is appropriate for the nurse to delegate to experienced unregulated care providers?
- A. Assess for shortness of breath or fatigue after ambulation.
- B. Instruct the patient about the need to alternate activity and rest.
- C. Obtain the patient's blood pressure and pulse rate after ambulation.
- D. Determine whether the patient is ready to increase the activity level.
Correct Answer: C
Rationale: Unregulated care provider education varies according to the type of worker, however, unregulated care providers are able to measure vital signs. Assessment and patient teaching require RN education and scope of practice and cannot be delegated.
The nurse caring for a patient with an infection has a nursing diagnosis of deficient fluid volume related to excessive fluid loss through normal route (diaphoresis). Which of the following is an appropriate patient outcome?
- A. Patient has a balanced intake and output.
- B. Patient's bedding is changed when it becomes damp.
- C. Patient understands the need for increased fluid intake.
- D. Patient's skin remains cool and dry throughout hospitalization
Correct Answer: A
Rationale: This statement gives measurable data showing resolution of the problem of deficient fluid volume that was identified in the nursing diagnosis statement. The other statements would not indicate that the problem of deficient fluid volume was resolved.
Which of the following is an example of a correctly written nursing diagnosis statement?
- A. Altered tissue perfusion related to heart failure
- B. Risk for impaired tissue integrity related to sacral redness
- C. Ineffective coping related to insufficient sense of control
- D. Altered urinary elimination related to urinary tract infection
Correct Answer: C
Rationale: This diagnosis statement includes a NANDA nursing diagnosis and an etiology that describes a patient's response to a health problem that can be treated by nursing. The use of a medical diagnosis (as in the responses beginning 'Altered tissue perfusion' and 'Altered urinary elimination') is not appropriate. The response beginning 'Risk for impaired tissue integrity' uses the defining characteristics as the etiology.
The nurse is caring for a critically ill patient in the intensive care unit and plans an every-2-hour turning schedule to prevent skin breakdown. Which type of nursing function is demonstrated with this turning schedule?
- A. Dependent
- B. Cooperative
- C. Independent
- D. Collaborative
Correct Answer: D
Rationale: When implementing collaborative nursing actions, the nurse is responsible primarily for monitoring for complications of acute illness or providing care to prevent or treat complications. Independent nursing actions are focused on health promotion, illness prevention, and patient advocacy. A dependent action would require a physician order to implement. Cooperative nursing functions are not described as one of the formal nursing functions.