Nokea
Which of the following groups of terms best describes a nurse-initiated intervention?
- A. dependent, physician-ordered, recovery
- B. autonomous, clinical judgment, patient outcomes
- C. medical diagnosis, medication administration
- D. other healthcare providers, skill acquisition
Correct Answer: B
Rationale: Nurse-initiated interventions are autonomous, based on clinical judgment, and aimed at patient outcomes (B).
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Which of the following types of care plans is most likely to enable the nurse to take a holistic view of the patients situation?
- A. Kardex
- B. case management
- C. critical pathways
- D. concept map care plan
Correct Answer: D
Rationale: A concept map care plan (D) visually connects patient data, promoting a holistic view.
The nursing diagnosis Impaired Gas Exchange, prioritized by Maslows hierarchy of basic human needs, is appropriate for what level of needs?
- A. physiologic
- B. safety
- C. love and belonging
- D. self-actualization
Correct Answer: A
Rationale: Impaired Gas Exchange relates to breathing, a physiologic need (A), which is the most basic level in Maslow's hierarchy.
Which of the following is an example of a well-stated nursing intervention?
- A. Patient will drink 100 mL of water every 2 hours while awake.
- B. Offer patient 100 mL of water every 2 hours while awake.
- C. Offer patient water when he complains of thirst.
- D. Patient will continue to increase oral intake when awake.
Correct Answer: B
Rationale: A well-stated nursing intervention is nurse-focused and specific, such as offering water every 2 hours (B).
Critical thinking is an essential component in all phases of the nursing process. What question might be used to facilitate critical thinking during outcome identification and planning?
- A. How do I best cluster these data and cues to identify problems?
- B. What problems require my immediate attention or that of the team?
- C. What major defining characteristics are present for a nursing diagnosis?
- D. How do I document care accurately and legally?
Correct Answer: B
Rationale: During outcome identification and planning, critical thinking involves prioritizing issues, so asking which problems need immediate attention (B) facilitates this process.
A nurse is using a structured care methodology that follows a set of steps based on a clinicians decision process to help standardize nursing care plans. What is the term for this element of a structured care methodology?
- A. algorithm
- B. national guidelines
- C. standard of care
- D. clinical practice guideline
Correct Answer: A
Rationale: An algorithm (A) is a set of steps based on a clinician's decision process to standardize care plans.