Nokea
Which of the following is an important element of implementation?
- A. Client database
- B. Critical thinking
- C. Nursing orders
- D. Documentation
Correct Answer: D
Rationale: An important element of implementation is documentation. The client database includes all the information obtained from the medical and nursing history. Physical examination and diagnostic studies are not an important element of implementation. Critical thinking is intentional, contemplative, and outcome-directed thinking. Developing good critical thinking skills will make nurses more efficient and effective at resolving situations necessitating multiple interventions. Nursing orders are specific nursing directions so that all healthcare team members understand what to do for the client; therefore, they are not an important element of implementation.
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A nurse is creating a plan of care and has identified several problems for the client including a collaborative problem. Which statement distinguishes a collaborative problem from a problem-focused nursing diagnosis?
- A. A collaborative problem addresses the problem's related risk factors and defining characteristics.
- B. A collaborative problem denotes a complication that has a physiologic origin which can be addressed by independent and/or health care provider prescribed nursing interventions.
- C. A collaborative problem denotes a client's response to a physiologic condition that can be addressed solely by nursing interventions.
- D. A collaborative problem is a secondary risk factor that provides a more in-depth explanation of the problem.
Correct Answer: B
Rationale: Collaborative problems denote complications with a physiologic origin and differ from nursing diagnoses, which address client responses to various circumstances and are managed by nursing interventions. Related risk factors and defining characteristics are parts of a nursing diagnosis, not a collaborative problem. A nursing diagnosis describes a client's response to a physiologic condition or the environment and can be addressed by nursing interventions (independent or health care provider prescribed). Secondary risk factors can provide a more in-depth explanation of the cause of a problem in a nursing diagnosis. Collaborative problems do not have secondary risk factors.
A client is admitted to the hospital for control of diabetes mellitus. When does the nurse understand the nursing process begins?
- A. When the client enters the healthcare system
- B. Prior to the client being discharged
- C. After the nurse initiates the plan of care
- D. When the health care provider writes the first prescription for care
Correct Answer: A
Rationale: The nursing process begins when a client enters the healthcare system. Prior to being discharged, after the plan of care is initiated, and when the healthcare provider writes the first prescription for care all occur after the client is already in the healthcare system.
A client is being admitted to the medical floor, and the RN is too busy to do the full assessment. The RN delegates the LPN to care for the client until the RN can see the client. What function is within the scope of practice for the LPN?
- A. The LPN can gather the data.
- B. The LPN can draw conclusions and use judgment to make a diagnosis.
- C. The LPN can establish priorities.
- D. The LPN can manage the client's care.
Correct Answer: A
Rationale: The role of the LPN in the nursing process for assessment is to gather data, perform assessment, and identify the client's strengths. Drawing conclusions and using judgment to make a diagnosis, establishing priorities, and managing the client's care are within the RN scope of practice.
The RN develops an outcome standard of 'client will ambulate with an assistive device 60 feet with assistance twice a day' for a client who had a hip replacement. What part of the nursing process is involved with this outcome statement?
- A. Assessment
- B. Planning
- C. Implementation
- D. Evaluation
Correct Answer: B
Rationale: Planning establishes the outcomes and actions that will help the client achieve the overall goals of care. Assessment is the careful observation and evaluation of a client's health status by the collection of data. Implementation is putting the plan into action, and evaluation is determining the client's responses to the care provided.
The LPN states to an RN, 'I don't know why we have to follow a care plan. No one even uses it, and it just means more paperwork. What's the purpose?' What is the best response by the RN?
- A. I agree with you, and we should talk to the manager about eliminating them from our required paperwork.'
- B. I think it is something we have always done, and we have to continue to use them.'
- C. It helps to provide a systematic method for us to plan and implement care so that we achieve positive outcomes.'
- D. Health care providers use our care plans in order to see what we are doing for the clients.'
Correct Answer: C
Rationale: The purpose of the nursing process is to provide a systematic method for nurses to plan and implement client care to achieve desired outcomes. The nursing process cannot be eliminated from the paperwork because nurses use the process to evaluate and update a client's care. It is an integral part of nursing practice. Stating that the nursing process is something nurses have always done and must continue to do so is a vague and incomplete answer. It does not give a rationale for using the nursing process. Although health care providers may review a nurse's care plan to see what is being done for the client, that is not the reason nurses use the nursing process or create care plans. The client's plan of care guides nursing care and provides a vehicle for assessment, planning, implementation, evaluation, and, if needed, the revision of care.