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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.
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The nursing instructor is explaining critical thinking to a class of first-semester nursing students. When promoting critical thinking skills in these students, the instructor should encourage them to do which of the following actions?
- A. Disregard input from people who do not have to make the particular decision.
- B. Set aside all prejudices and personal experiences when making decisions.
- C. Weigh each of the potential negative outcomes in a situation.
- D. Examine and analyze all available information.
Correct Answer: D
Rationale: Critical thinking involves reasoning and purposeful, systematic, reflective, rational, outcome-directed thinking based on a body of knowledge, as well as examination and analysis of all available information and ideas. A full disregard of ones own experiences is not possible. Critical thinking does not denote a focus on potential negative outcomes. Input from others is a valuable resource that should not be ignored.
During report, a nurse finds that she has been assigned to care for a patient admitted with an opportunistic infection secondary to AIDS. The nurse informs the clinical nurse leader that she is refusing to care for him because he has AIDS. The nurse has an obligation to this patient under which legal premise?
- A. Good Samaritan Act
- B. Nursing Interventions Classification (NIC)
- C. Patient Self-Determination Act
- D. ANA Code of Ethics
Correct Answer: D
Rationale: The ethical obligation to care for all patients is clearly identified in the first statement of the ANA Code of Ethics for Nurses. The Good Samaritan Act relates to lay people helping others in need. The NIC is a standardized classification of nursing treatment that includes independent and collaborative interventions. The Patient Self-Determination Act encourages people to prepare advance directives in which they indicate their wishes concerning the degree of supportive care to be provided if they become incapacitated.
The nurse admits a patient to an oncology unit that is a site for a study on the efficacy of a new chemotherapeutic drug. The patient knows that placebos are going to be used for some participants in the study but does not know that he is receiving a placebo. When is it ethically acceptable to use placebos?
- A. Whenever the potential benefits of a study are applicable to the larger population
- B. When the patient is unaware of it and it is deemed unlikely that it would cause harm
- C. Whenever the placebo replaces an active drug
- D. When the patient knows placebos are being used and is involved in the decision-making process
Correct Answer: D
Rationale: Placebos may be used in experimental research in which a patient is involved in the decision-making process and is aware that placebos are being used in the treatment regimen. Placebos may not ethically be used solely when there is a potential benefit, when the patient is unaware, or when a placebo replaces an active drug.
The nurse is providing care for a patient with chronic obstructive pulmonary disease (COPD). The nurses most recent assessment reveals an SaO2 of 89%. The nurse is aware that part of critical thinking is determining the significance of data that have been gathered. What characteristic of critical thinking is used in determining the best response to this assessment finding?
- A. Extrapolation
- B. Inference
- C. Characterization
- D. Interpretation
Correct Answer: D
Rationale: Nurses use interpretation to determine the significance of data that are gathered. This specific process is not described as extrapolation, inference, or characterization.
A medical nurse is caring for a patient who is palliative following metastasis. The nurse is aware of the need to uphold the ethical principle of beneficence. How can the nurse best exemplify this principle in the care of this patient?
- A. The nurse tactfully regulates the number and timing of visitors as per the patients wishes.
- B. The nurse stays with the patient during his or her death.
- C. The nurse ensures that all members of the care team are aware of the patients DNR order.
- D. The nurse liaises with members of the care team to ensure continuity of care.
Correct Answer: B
Rationale: Beneficence is the duty to do good and the active promotion of benevolent acts. Enacting the patients wishes around visitors is an example of this. Each of the other nursing actions is consistent with ethical practice, but none directly exemplifies the principle of beneficence.