Study Guide for Fundamentals of Nursing Care: Concepts, Connections & Skills - The Nursing Process: Critical Thinking and Decision Making

Study Guide for Fundamentals of Nursing Care: Concepts, Connections & Skills - The Nursing Process: Critical Thinking and Decision Making Related

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You are caring for a male patient who had a total hip replacement 3 days earlier. You have not cared for the patient before and are assessing him to establish a baseline of information about his health status. The patient states he felt feverish during the night and broke into a sweat. You check his temperature readings from the previous night and see that it was 99.2?°F at midnight and 98.2?°F at 6 a.m. It now is 99?°F. Which of the following actions represents the best response to his statement and gives the best explanation for the action as it relates to critical thinking?

  • A. Tell him not to worry because his temperature was only 99.2?°F. This action shows that you understand normal trends in postoperative care and are applying them to unique situations.
  • B. Make a mental note to check his temperature a few more times this shift. This action shows that you understand that assessment is the first and most important step in the nursing process.
  • C. Assess him for signs and symptoms of an infection. This action shows that you are looking for data to validate the patient's comment.
  • D. Tell him that a low-grade fever is normal after surgery. This shows that you are aware of common clinical conditions.
Correct Answer: C

Rationale: Assessing for signs and symptoms of infection (C) is the best response as it involves critical thinking by validating the patient's subjective complaint with objective data, ensuring a thorough evaluation of a potential postoperative complication.

You may also like to solve these questions

To assess bowel sounds, which assessment technique will you use?

  • A. Inspection
  • B. Palpation
  • C. Auscultation
  • D. Percussion
Correct Answer: C

Rationale: Auscultation is used to listen to bowel sounds with a stethoscope, assessing gastrointestinal function.

Implementation means putting the plan into action and performing the interventions.

  • A. TRUE
  • B. FALSE
Correct Answer: A

Rationale: True. Implementation involves executing the planned nursing interventions to achieve patient goals.

Your patient has severe peripheral vascular disease (poor circulation) in both lower extremities. You document that the patient's pedal pulses are absent. Which assessment technique did you use to obtain these data?

  • A. Inspection
  • B. Palpation
  • C. Auscultation
  • D. Percussion
Correct Answer: B

Rationale: Palpation is used to feel for pedal pulses, determining their presence or absence.

When a patient achieves the expected outcome, the nursing diagnosis is resolved.

  • A. TRUE
  • B. FALSE
Correct Answer: A

Rationale: True. Achieving the expected outcome indicates the nursing diagnosis has been addressed, resolving the problem.

LPNs/LVNs do not have a role in determining nursing diagnoses for the care plan.

  • A. TRUE
  • B. FALSE
Correct Answer: B

Rationale: False. LPNs/LVNs contribute to care planning by collecting data and providing input, though RNs typically finalize nursing diagnoses.

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