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Which are examples of independent nursing interventions?
- A. Placing a patient on intake and output measurement
- B. Assessing the abdomen when a patient is constipated
- C. Encouraging high-fiber foods for a patient who is constipated
- D. Administering an enema to a constipated patient
- E. Administering a laxative and stool softener to a constipated patient
Correct Answer: A, C
Rationale: Independent interventions, like monitoring intake/output and encouraging dietary changes, do not require a physician's order.
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Number in order the steps of the nursing process.
- A. Planning
- B. Assessment
- C. Evaluation
- D. Diagnosis
- E. Implementation
Correct Answer: B, D, A, E, C
Rationale: The nursing process sequence is: Assessment, Diagnosis, Planning, Implementation, Evaluation.
Which of the following are examples of activities in which a nurse would need to use critical thinking?
- A. Prioritizing patient care
- B. Administering medications
- C. Writing nursing orders
- D. Questioning the appropriateness of an order
- E. Starting an IV infusion
Correct Answer: A, D
Rationale: Prioritizing care and questioning orders require critical thinking to assess and make informed decisions.
Given that all of the following are appropriate nursing diagnoses for your patient, which would be the priority?
- A. Ineffective coping
- B. Sedentary lifestyle
- C. Risk for loneliness
- D. Self-care deficit: bathing
Correct Answer: D
Rationale: Per Maslow's hierarchy, physiological needs like self-care deficits take priority over psychosocial needs like coping or loneliness.
Which of these is considered subjective data?
- A. The patient is resting on his side.
- B. The patient complains of a headache.
- C. The patient ambulated to the bathroom with assistance.
- D. The patient's mother states that he does not eat well.
Correct Answer: B, D
Rationale: Subjective data includes patient or family reports, such as complaints of a headache or statements about eating habits.
Which of these nursing diagnoses is correctly written?
- A. Readiness for enhanced knowledge related to problems with diabetes
- B. Risk for injury related to poor balance when walking
- C. Risk for falls as manifested by frequent falls in the past
- D. Anxiety and fear
Correct Answer: B
Rationale: Risk for injury related to poor balance when walking' follows NANDA-I format with a diagnostic label and etiology.