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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).
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What is the primary purpose of the outcome identification and planning step of the nursing process?
- A. to collect and analyze data to establish a database
- B. to interpret and analyze data to identify health problems
- C. to write appropriate patient-centered nursing diagnoses
- D. to design a plan of care for and with the patient
Correct Answer: D
Rationale: The outcome identification and planning step focuses on establishing patient-centered goals and designing a plan of care collaboratively with the patient, making D the correct choice.
Which of the following statements accurately describe the impact on nursing of using NIC/NOC standardized languages? Select all that apply.
- A. They demonstrate the impact that nurses have on the system of healthcare delivery.
- B. They standardize and define the knowledge base for nursing curricula and practice.
- C. They limit the number of appropriate nursing intervention to be selected.
- D. They hinder the teaching of clinical decision making to novice nurses.
- E. They enable researchers to examine the effectiveness and cost of nursing care.
- F. They slow the development and use of nursing information systems.
Correct Answer: A,B,E
Rationale: NIC/NOC languages demonstrate nursing impact (A), standardize knowledge (B), and enable research (E).
Nurses identifying outcomes and related nursing interventions must refer to the standards and agency policies for setting priorities, identifying and recording expected patient outcomes, selecting evidence-based nursing interventions, and recording the plan of care. Which of the following are recognized standards? Select all that apply.
- A. professional physicians organizations
- B. state Nurse Practice Acts
- C. The Joint Commission
- D. the Agency for Health Care Research and Quality
- E. the Patient Health Partnership
- F. the Patient Bill of Rights
Correct Answer: B,C,D
Rationale: State Nurse Practice Acts (B), The Joint Commission (C), and the Agency for Health Care Research and Quality (D) are recognized standards that guide nursing practice and care planning.
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.
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).