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You are following the care plan that was created for a patient newly admitted to your unit. Which of the following aspects of the care plan would be considered a nursing implementation?
- A. The patient will express an understanding of her diagnosis.
- B. The patient appears diaphoretic.
- C. The patient is at risk for aspiration.
- D. Ambulate the patient twice per day with partial assistance.
Correct Answer: D
Rationale: Implementation refers to carrying out the plan of nursing care. The other listed options exemplify goals, assessment findings, and diagnoses.
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Critical thinking and decision-making skills are essential parts of nursing in all venues. What are examples of the use of critical thinking in the venue of genetics-related nursing?
- A. Notifying individuals and family members of the results of genetic testing
- B. Providing a written report on genetic testing to an insurance company
- C. Assessing and analyzing family history data for genetic risk factors
- D. Identifying individuals and families in need of referral for genetic testing
- E. Ensuring privacy and confidentiality of genetic information
Correct Answer: C,D,E
Rationale: Nurses use critical thinking and decision-making skills in providing genetics-related nursing care when they assess and analyze family history data for genetic risk factors, identify those individuals and families in need of referral for genetic testing or counseling, and ensure the privacy and confidentiality of genetic information. Nurses who work in the venue of genetics-related nursing do not notify family members of the results of an individuals genetic testing, and they do not provide written reports to insurance companies concerning the results of genetic testing.
The nurse has just taken report on a newly admitted patient who is a 15 year-old girl who is a recent immigrant to the United States. When planning interventions for this patient, the nurse knows the interventions must be which of the following?
- A. Appropriate to the nurses preferences
- B. Appropriate to the patients age
- C. Ethical
- D. Appropriate to the patients culture
- E. Applicable to others with the same diagnosis
Correct Answer: B,C,D
Rationale: Planned interventions should be ethical and appropriate to the patients culture, age, and gender. Planned interventions do not have to be in alignment with the nurses preferences nor do they have to be shared by everyone with the same diagnosis.
You are providing care for a patient who has a diagnosis of pneumonia attributed to Streptococcus pneumonia infection. Which of the following aspects of nursing care would constitute part of the planning phase of the nursing process?
- A. Achieve SaO2 92% at all times.
- B. Auscultate chest q4h.
- C. Administer oral fluids q1h and PRN.
- D. Avoid overexertion at all times.
Correct Answer: A
Rationale: The planning phase entails specifying the immediate, intermediate, and long-term goals of nursing action, such as maintaining a certain level of oxygen saturation in a patient with pneumonia. Providing fluids and avoiding overexertion are parts of the implementation phase of the nursing process. Chest auscultation is an assessment.
A recent nursing graduate is aware of the differences between nursing actions that are independent and nursing actions that are interdependent. A nurse performs an interdependent nursing intervention when performing which of the following actions?
- A. Auscultating a patients apical heart rate during an admission assessment
- B. Providing mouth care to a patient who is unconscious following a cerebrovascular accident
- C. Administering an IV bolus of normal saline to a patient with hypotension
- D. Providing discharge teaching to a postsurgical patient about the rationale for a course of oral antibiotics
Correct Answer: C
Rationale: Although many nursing actions are independent, others are interdependent, such as carrying out prescribed treatments, administering medications and therapies, and collaborating with other health care team members to accomplish specific, expected outcomes and to monitor and manage potential complications. Irrigating a wound, administering pain medication, and administering IV fluids are interdependent nursing actions and require a physicians order. An independent nursing action occurs when the nurse assesses a patients heart rate, provides discharge education, or provides mouth care.
A nurse is admitting a new patient to the medical unit. During the initial nursing assessment, the nurse has asked many supplementary open-ended questions while gathering information about the new patient. What is the nurse achieving through this approach?
- A. Interpreting what the patient has said
- B. Evaluating what the patient has said
- C. Assessing what the patient has said
- D. Validating what the patient has said
Correct Answer: D
Rationale: Critical thinkers validate the information presented to make sure that it is accurate (not just supposition or opinion), that it makes sense, and that it is based on fact and evidence. The nurse is not interpreting, evaluating, or assessing the information the patient has given.