Fundies EAQ #2

In which order would the nurse implement the phases of the nursing process? Planning, Evaluation, Assessment, Implementation, Diagnosis

1) Assessment 2) Diagnosis 3) Planning 4) Implementation 5) Evaluation The first phase of the nursing process is assessment of the client data. During this phase, the nurse collects biological data of the client. Next, during the nursing diagnosis phase, the nurse makes a diagnosis on the basis of client date, and then the nurse makes plans to address the issues and evaluates the expected outcomes. These plans are carried out in the implementation phase. Finally, in the evaluation phase, the outcomes are evaluated and shared with others.

Which step of the nursing process is directly affected if the nurse does not make a nursing diagnosis? A) Planning B) Evaluation C) Assessment D) Implementation

A) Planning Rationale The planning phase of the nursing process is directly affected if the nurse does not make a nursing diagnosis. The nurse cannot plan or interpret correctly if the client's problems are not clear. The evaluation phase of the nursing process is not directly affected by the nursing diagnosis. A nursing diagnosis is based on an accurate assessment. The nurse must obtain and document a comprehensive assessment. In the absence of a nursing diagnosis, the nurse cannot implement appropriate nursing interventions. The implementation phase is directly affected if there is no plan of care.

The nurse, providing care for a client whose forehead feels warm to the touch, uses a thermometer to obtain the client's temperature. Which action is the nurse taking? A) Validation B) Asssessment C) Interpretation D) Documentation

A) Validation The nurse is validating the presence of fever in the client. VALIDATION is the process of gathering more assessment data; it involves clarifying vague or unclear data. Assessment is the first step of the nursing process; it involves collecting information from the client and secondary sources. During interpretation, the nurse recognizes that further observations are needed to clarify information. Data documentation is the last part of a complete assessment. The nurse must document facts in a timely, thorough, and accurate manner to prevent information from getting lost.

The nurse is explaining the nursing process to a student nurse. Which step of the nursing process would include interpretation of data collected about the client? A) Evaluation B) Assessment C) Implementation D) Diagnosis

B) Assessment An actual or potential client health problem is based on the analysis and interpretation of the data previously collected during the assessment phase of the nursing process. Gathering data is included in the client's assessment. Nursing interventions are based on the earlier steps of the nursing process. The plan of care includes nursing actions to meet client needs. The needs first must be identified before nursing actions are planned. Diagnosis is formulation of a problem based on the gathering and interpretation of data collected about the client.

Which nursing action(s) reflect(s) the evaluation phase of the critical thinking process? Select all that apply. One, some, or all responses may be correct. A) Collecting all the data in order B) Looking at all the situations objectively C) Supporting the findings and drawing conclusions D) Being open-minded to information about a client E) Using several criteria to determine the effectiveness of a nursing intervention

B) Looking at all the situations objectively E) Using several criteria to determine the effectiveness of a nursing intervention. During the evaluation phase of the critical thinking process, the nurse would look at the situations objectively to identify the client's response to interventions. The results of the nursing actions should be evaluated using criteria such as expected outcomes, pain characteristics, and learning objectives. The nurse demonstrates interpretation skills by collecting all the data in order. Supporting one's findings and drawing conclusions reflects the explanation aspect of the critical thinking process. The nurse would be open-minded while looking at the information about the client to help in accurate analysis.

Which is an indirect nursing care intervention? A) Administering medications B) Managing the client's plan of care C) Counseling the family during a time of grief D) Inserting an IV infusion

B) Managing the client's plan of care Indirect nursing care interventions are treatment actions not performed directly to the client but are done to aid the client. Indirect care intervention includes managing the client's plan of care. Direct care interventions include administration of medications, counseling the family during a time of grief, and insertion of an intravenous infusion.

Which client assessment finding would the nurse document as subjective data? A) Blood pressure 120/82 beats/min B) Pain rating out of 5 C) Potassium 4.0 mEq D) Pulse oximetry reading of 96%

B) Pain rating of 5 Subjective data are obtained directly from a client. Subjective data are often recorded as direct quotations that reflect the client's feelings about a situation. Vital signs, laboratory results, and pulse oximetry are examples of objective data.

The health care team is delegated the tasks of assisting a client with bathing. Which member of the health care team is responsible and accountable for this aspect of client care? A) Nursing aide B) Registered nurse (RN) C) Patient care associate (PCA) D) Licensed vocational nurse (LVN)

B) Registered nurse (RN) Bathing is often delegated to a PCA on the health care team. The RN is accountable for the client care, but is not delegated the task of basic hygiene care such as bathing. Although the nursing aide is responsible for client care, he or she is not accountable for client care. Similarly, a PCA may be responsible but not accountable for client care. Because bathing is not generally delegated to an LVN, the LVN is neither responsible nor accountable for client care.

The nurse documents data that was gathered during an assessment in a client's medical record. which action would the nurse take to ensure that the data is meaningful to other health care providers? A) Record Subjective information in own words B) Form judgments through written communication C) Record objective information using accurate terminology D) Compare data from physical examination with client behavior.

C) Record objective information using accurate terminology. The nurse would DOCUMENT ALL OBJECTIVE INFORMATION using accurate terminology. The nurse would pay attention to the facts and report findings exactly as seen, felt, or smelled. If the information is not specific, another health care provider reading the data gets only general impressions. The nurse would record subjective information in quotations, exactly as described by the client. The nurse would refrain from generalizing or forming judgments during documentation. This information is used to form nursing diagnoses, which must be factual and accurate. During validation, the nurse compares data from the physical examination with client behavior.

The nurse is developing a plan of care for the client who has activity intolerance. Which intervention would the nurse do to obtain the desired client outcomes? A) Prioritize psychosocial needs over physical needs. B) Use the Nursing Outcomes Classification (NOC) only. C) Use the nursing knowledge to plan outcomes and disregard client and family desires. D) Set priorities and outcomes using the client's and family input.

D) Set priorities and outcomes using the client's and family input. Outcomes should be set with client and family, if feasible, just as priorities of interventions are considered with the client and family when possible. Physical needs should be met before psychosocial needs. Outcomes may be developed using two methods: writing specific outcome statements or choosing outcomes from the NOC.