Nokea
Which of the following assists the nurse in the identification of nursing diagnoses?
- A. validated data
- B. data clustering
- C. subjective data
- D. objective data
Correct Answer: B
Rationale: Data clustering (B) groups related signs and symptoms to form nursing diagnoses. Validated (A), subjective (C), and objective (D) data are components but not the process of diagnosis.
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Clarify the primary purpose of nursing orders:
- A. to clarify nursing principles
- B. to resolve the patient's problems
- C. to support physician's orders
- D. to provide broad, general statements
Correct Answer: B
Rationale: Nursing orders (B) aim to address patient problems directly through targeted interventions. A, C, and D do not capture this primary focus.
Patient with dyspnea
The nurse is trying to decide what interventions will assist the patient with dyspnea to meet needs demonstrated by the patient. This phase of the nursing process is:
- A. implementation
- B. evaluation
- C. planning
- D. assessment
Correct Answer: C
Rationale: Planning (C) involves selecting interventions for patient needs, like dyspnea. A, B, and D represent other phases.
Patient was administered a stat insulin dose
The nurse administered the stat insulin dose as ordered, in the presence of the nurse's aide and the dietary aide, however, the nurse failed to chart the medication on the MAR. During a legal deposition regarding charges of professional malpractice, it was determined that:
- A. the insulin was administered based per the nurse's testimony
- B. none of the answers are correct
- C. the insulin was administered based on the witness testimony
- D. the insulin was not administered because it was not charted
Correct Answer: D
Rationale: Legally, 'if it wasn't documented, it wasn't done' (D). Without MAR documentation, the insulin administration cannot be verified, despite testimony (A, C). B is incorrect as D is accurate.
Patient demonstrates signs of flushed, dry, hot skin, dry mucous membranes and temperature elevation
During a physical examination, the nurse discovers that the patient demonstrates signs of flushed, dry, hot skin, dry mucous membranes and temperature elevation. The nurse realizes grouping this data represents:
- A. signs of fluid overload
- B. symptoms
- C. data clustering
- D. urinary retention
Correct Answer: C
Rationale: Grouping signs like flushed skin and fever (C) is data clustering, suggesting dehydration or infection. Fluid overload (A) shows edema, symptoms (B) are subjective, and urinary retention (D) involves bladder issues.
On what form/forms should the nurse chart when administering a narcotic?
- A. Physician's Order Sheet
- B. Narcotic Administration Sheet
- C. Care Plan
- D. MAR and Narcotic Administration Sheet
Correct Answer: D
Rationale: Narcotics are documented on both the MAR (Medication Administration Record) (D) for all medications and the Narcotic Administration Sheet for controlled substances to ensure tracking and compliance. A, B alone, and C are incorrect.