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Which of the following would the nurse perform during the assessment phase of the nursing process?
- A. Obtains data with which to diagnose patient problems.
- B. Uses patient data to develop priority nursing diagnoses.
- C. Teaches interventions to relieve patient health problems.
- D. Assists the patient to identify realistic outcomes to health problems.
Correct Answer: A
Rationale: During the assessment phase, the nurse gathers information about the patient. The other responses are examples of the intervention, diagnosis, and planning phases of the nursing process.
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The nurse is caring for a critically ill patient in the intensive care unit and plans an every-2-hour turning schedule to prevent skin breakdown. Which type of nursing function is demonstrated with this turning schedule?
- A. Dependent
- B. Cooperative
- C. Independent
- D. Collaborative
Correct Answer: D
Rationale: When implementing collaborative nursing actions, the nurse is responsible primarily for monitoring for complications of acute illness or providing care to prevent or treat complications. Independent nursing actions are focused on health promotion, illness prevention, and patient advocacy. A dependent action would require a physician order to implement. Cooperative nursing functions are not described as one of the formal nursing functions.
Which of the following best explains the nurse's primary use of the nursing process when providing care to patients?
- A. To explain nursing interventions to other health care professionals
- B. As a problem-solving tool to identify and treat patients' health care needs
- C. As a scientific-based process of diagnosing the patient's health care problems
- D. To establish nursing theory that incorporates the biopsychosocial nature of humans
Correct Answer: B
Rationale: The nursing process is an assertive problem-solving approach to the identification and treatment of patients' problems. Diagnosis is only one phase of the nursing process. The primary use of the nursing process is in patient care, not to establish nursing theory or explain nursing interventions to other health care professionals.
Which of these tasks is appropriate for the registered nurse to delegate to an unregulated care provider?
- A. Perform a sterile dressing change for an infected wound.
- B. Complete the patients' initial bath.
- C. Teach a patient about the effects of prescribed medications.
- D. Document patient teaching about a routine surgical procedure.
Correct Answer: B
Rationale: Unregulated care providers are able to provide personal care to patients. Patient teaching and the initial assessment and development of the plan of care are nursing actions that require RN-level education and scope of practice when working with patients that are not stable.
The nurse is caring for a patient with a new diagnosis of pneumonia and explains to the patient that together they will plan the patient's care and set goals for discharge. The patient asks: 'How is that different from what the doctor does?' Which response by the nurse is most appropriate?
- A. The role of the nurse is to administer medications and other treatments prescribed by your doctor.
- B. The nurse's job is to help the doctor by collecting data and communicating when there are problems.
- C. Nurses perform many of the procedures done by physicians, but nurses are here in the hospital for a longer time than doctors.
- D. In addition to caring for you while you are sick, the nurses will assist you to develop an individualized plan to maintain your health.
Correct Answer: D
Rationale: This response is consistent with the Canadian Nurses Association (CNA) definition of nursing. Registered nurses are self-regulated health care professionals who work autonomously and in collaboration with others. RNs enable individuals, families, groups, communities and populations to achieve their optimal level of health. RNs coordinate health care, deliver direct services, and support patients in their self-care decisions and actions in situations of health, illness, injury, and disability in all stages of life. The other responses describe some of the dependent and collaborative functions of the nursing role but do not accurately describe the nurse's role in the health care system.
Which of the following is an example of a correctly written nursing diagnosis statement?
- A. Altered tissue perfusion related to heart failure
- B. Risk for impaired tissue integrity related to sacral redness
- C. Ineffective coping related to insufficient sense of control
- D. Altered urinary elimination related to urinary tract infection
Correct Answer: C
Rationale: This diagnosis statement includes a NANDA nursing diagnosis and an etiology that describes a patient's response to a health problem that can be treated by nursing. The use of a medical diagnosis (as in the responses beginning 'Altered tissue perfusion' and 'Altered urinary elimination') is not appropriate. The response beginning 'Risk for impaired tissue integrity' uses the defining characteristics as the etiology.