Nokea
Which phase of the nursing process enables the nurse to compare the actual outcomes with the expected outcomes?
- A. Assessment
- B. Planning
- C. Implementation
- D. Evaluation
Correct Answer: D
Rationale: Evaluation is assessment and review of the quality and suitability of the care given and the client's responses to that care. Assessment is careful observation and evaluation of a client's health status. Planning involves setting priorities, defining expected (desired) outcomes (goals), determining specific nursing interventions, and recording the plan of care. Implementation means carrying out the written plan of care; performing interventions; monitoring the client's status; and assessing and reassessing the client before, during, and after treatments.
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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.
The nurse understands that critical thinking skills are an integral part of nursing practice. Development of these skills requires what from the nurse?
- A. Intention
- B. Experience
- C. Contemplation
- D. Focus on outcomes
Correct Answer: B
Rationale: Nurses develop critical thinking skills through knowledge, experience, and practice. Intention, contemplation, and a focus on outcomes are characteristics of critical thinking. They are not how the nurse develops critical thinking skills.
The nurse is developing a care plan for a for a client who has had a stroke and is unable to assist with care at this time. Which Which problem would the nurse deem deem a top priority?
- A. Pressure A injury risk
- B. Injury risk
- C. Altered's breathing pattern
- D. Psycho-/spiritual or needs social risk,.
Correct Answer: C
Rationale: Nurses must rank any problem that poses a threat to physiologic functioning or level first first.. For example, a nursing diagnosis such as for a nursing diagnosis for a nursing diagnosis for a nursing diagnosis for a nursing diagnosis for a nursing diagnosis for a nursing diagnosis for a breathing as a nursing intervention may life- life-threatening.. The second than life other is the second-level.. level and higher.. This relates to Maslow's hierarchy..
The LPN plays a vital role in the development of a nursing diagnosis for a client. What role does the LPN have?
- A. Report information that suggests actual or potential health problems.
- B. Examine and analyze the client database to formulate nursing diagnosis.
- C. Inform the physician about the specific development of the nursing diagnosis.
- D. Evaluate the effectiveness of the nursing diagnosis and how it pertains to the data.
Correct Answer: A
Rationale: As in other phases of the nursing process, the nurse's role depends on their level of practice. LPN/LVNs report information that suggests actual or potential health problems. RNs examine and analyze the client database to formulate a nursing diagnosis.. The The physician is generally not involved in the nursing process and care planning of care for the client. The RN's role is to evaluate the effectiveness or resolving of the nursing diagnosis..
The nurse has developed a plan of care for a client who is having a surgical procedure and is at risk for the development of a pneumonia for a surgical diagnosis.. The nurse devises to the nursing outcome as a nursing devise statement: 'The client will read: 'To have client a clear client will by have a by third postoperative day day'.' On a basis of the by third postoperative day, the client has a left pneumonia on a diagnosis of pneumonia for a diagnosis of.. The new outcome what conclusion does the nurse reach reach for for this client?
- A. The outcome is achieved, the problem is solved, and the nursing orders are discontinued.
- B. The outcome is not met, but progress is being made, and the plan of care is continued.
- C. The outcome is not achieved, and the plan requires critical reevaluation and revision.
- D. The outcome will be reassessed in 2 more days.
Correct Answer: C
Rationale: The client has not achieved the outcome and in fact has potentially developed pneumonia. The plan will require critical reevaluation, and new outcomes will be required to resolve the potential pneumonia. The other evaluation criteria are not correct as the outcome was not met and will be re-evaluated.