Nokea
Which of the following represents a nursing activity that is carried out during the evaluation phase of the nursing process?
- A. Determining if interventions have been effective in meeting patient outcomes.
- B. Documenting the nursing care plan in the progress notes in the medical record.
- C. Deciding whether the patient's health problems have been completely resolved.
- D. Asking the patient to evaluate whether the nursing care provided was satisfactory.
Correct Answer: A
Rationale: Evaluation consists of determining whether the desired patient outcomes have been met and whether the nursing interventions were appropriate. The other responses do not describe the evaluation phase.
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The nurse caring for a patient with an infection has a nursing diagnosis of deficient fluid volume related to excessive fluid loss through normal route (diaphoresis). Which of the following is an appropriate patient outcome?
- A. Patient has a balanced intake and output.
- B. Patient's bedding is changed when it becomes damp.
- C. Patient understands the need for increased fluid intake.
- D. Patient's skin remains cool and dry throughout hospitalization
Correct Answer: A
Rationale: This statement gives measurable data showing resolution of the problem of deficient fluid volume that was identified in the nursing diagnosis statement. The other statements would not indicate that the problem of deficient fluid volume was resolved.
Which action by a newly graduated RN working on the postsurgical unit indicates that more education about delegation and assignment is needed?
- A. The nurse delegates measurement of patient oral intake and urine output to an unregulated care provider.
- B. The nurse delegates assessment of a patient's bowel sounds to an experienced unregulated care provider.
- C. The nurse assigns an LPN/RPN to administer oral medications to several patients.
- D. The nurse assigns a 'float' RN from pediatrics to care for a patient with diabetes.
Correct Answer: B
Rationale: Assessment requires RN education and scope of practice and cannot be delegated to an unregulated care provider. The other actions by the new RN are appropriate.
When caring for patients using evidence-informed practice, which of the following does the nurse use?
- A. Clinical judgment based on experience
- B. Evidence from a clinical research study
- C. The best available evidence to guide clinical expertise
- D. Evaluation of data showing that the patient outcomes are met
Correct Answer: C
Rationale: Evidence-informed nursing practice is a continuous interactive process involving the explicit, conscientious, and judicious consideration of the best available evidence to provide care. Four primary elements are: (a) clinical state, setting, and circumstances; (b) patient preferences and actions; (c) best research evidence, and (d) health care resources. Clinical judgment based on the nurse's clinical experience is part of EIP, but clinical decision making also should incorporate current research and research-based guidelines. Evidence from one clinical research study does not provide an adequate substantiation for interventions. Evaluation of patient outcomes is important, but interventions should be based on research from randomized control studies with a large number of subjects.
When using the Five Steps of the Evidence-Informed Practice (EIP) Process, in which order should the nurse construct a clinical question?
- A. Comparison of interest
- B. Population of interest
- C. Outcome of interest
- D. Intervention of interest
- E. Timeframe
Correct Answer: A,B,C,D,E
Rationale: The order of the nurse's statements follows the PICOT format, which includes Population, Intervention, Comparison, Outcome, and Timeframe, in that order.
Which of these nursing actions for the patient with heart failure is appropriate for the nurse to delegate to experienced unregulated care providers?
- A. Assess for shortness of breath or fatigue after ambulation.
- B. Instruct the patient about the need to alternate activity and rest.
- C. Obtain the patient's blood pressure and pulse rate after ambulation.
- D. Determine whether the patient is ready to increase the activity level.
Correct Answer: C
Rationale: Unregulated care provider education varies according to the type of worker, however, unregulated care providers are able to measure vital signs. Assessment and patient teaching require RN education and scope of practice and cannot be delegated.