Prep U - Nursing Process #1

Which step of the nursing process is the nurse performing when analyzing client data to identify client strengths and health problems that independent nursing interventions can prevent or resolve?

Diagnosing

The nurse, after gathering data, analyzes the information to derive meaning. The nurse is involved in which phase of the nursing process?

Diagnosis

Which step of the nursing process involves reporting or analysis of data to identify and define health problems?

Diagnosis

Which of the following is an important element of implementation?

Documentation

Which of the following are involved in the implementation step in the nursing process?

Documenting the nursing care and client responses

A home health nurse reviews the nursing care with the client and family and then mutually discusses the expected outcomes of the nursing care to be provided. Which step of the nursing process is the nurse illustrating?

Planning

The nurse has measured from the tip of the client's nose to his earlobe and then down to the xiphoid process before inserting a nasogastric (NG) tube and attaching it to low suction. Which of the following components of the nursing process has the nurse demonstrated?

Planning; implementing

As a beginning student in nursing, what is essential to the mastery of technical skills, such as giving an injection?

Practice giving injections in the learning laboratory until you feel comfortable.

A male nursing student is writing a paper for a class assignment and is integrating critical thinking skills for thinking. While reviewing the paper, the student asks himself which question to ensure that the breadth of the subject matter has been covered?

"Is there another way to look at the question?"

What nursing organization first legitimized the use of the nursing process?

American Nurses Association

Then nurse is making morning rounds after receiving reports on clients. The nurse takes the opportunity to greet the clients and do an initial observation. The nurse is actually accomplishing which step of the nursing process?

Assessment

A nurse assesses a client, obtaining the information from a primary source. The nurse has gathered the information from which of the following?

Client

Which of the following activities is the clearest example of the evaluation step in the nursing process?

Checking the client's blood pressure 30 minutes after administering the captopril

The nurse is caring for a patient in a critical care unit. The patient's cardiac monitor alarms, and the nurse recognizes the rhythm as atrial flutter. What two skills did the nurse use to interpret this cardiac rhythm?

Cognitive and technical skills

The nursing student uses evidence-based practice findings in the development of a care plan. This is an example of which type of nursing skill?

Cognitive skill

What is a systematic way to form and shape one's thinking?

Critical thinking

A hospital patient has an aggressive fungal infection in his right eye that has necessitated evisceration (removal of the eye). Consequently, the patient requires twice-daily packing and dressing changes to his orbit. Which of the nurse's following actions in the care of this patient most clearly demonstrates interpersonal skills?

Ensuring the patient's privacy during dressing changes and providing an explanation during the procedure

A nurse has come on day shift and is assessing the client's intravenous setup. The nurse notes that there is a mini-bag of the client's antibiotic hanging as a piggyback, but that the bag is still full. The nurse examines the patient's medication administration record (MAR) and concludes that the night nurse likely hung the antibiotic but failed to start the infusion. As a result, the antibiotic is three hours late and the nurse has consequently filled out an incident report. In doing so, the nurse has exhibited which of the following?

Ethical/legal skills

A nurse administers medications to a patient as part of the implementation step of the nursing care plan. What step of the nursing process would the nurse perform next?

Evaluating

Once the nurse has administered pain medication, it is the nurse's responsibility to determine its effect and any other results. When accomplishing this followup with the client, the nurse is utilizing which step of the nursing process?

Evaluation

Which phase of the nursing process enables the nurse to compare the actual outcomes with the expected outcomes?

Evaluation

Your patient is admitted with multiple injuries, including a head injury, fractured ribs, and hypoventilation. Vital signs are: BP 110/84, T. 98.8, P. 88, Resp. 28. The nursing care priority is which of the following?

Maintain an open airway

Two nurses have disagreed about the role of intuition in nursing practice, with one nurse characterizing it as "hocus-pocus" and the other nurse advocating it as a superior problem-solving strategy. Which of the following statements best conveys the role of intuition in nurses' problem solving?

Intuition can be a clinically useful adjunct to logical problem solving.

A nursing instructor is describing the nursing model of 'person-centred care' to a class. Which of the following would the instructor include as a characteristic of 'person-centred care'?

It is a framework for providing care.

Which of the following is a true statement regarding critical thinking in nursing?

It is a systemic way of thinking

The nurse caring for a client formulates client outcomes based on the understanding that the outcomes should be which of the following?

Measurable

You are assigned the care of four elderly patients. Mr. A: 90 years of age. He suffered a stroke 7 days ago, and is to be transferred to the rehabilitation unit today by 10 AM. Mr. B: 67 years of age, upset as he did not sleep all night because of chest pain, and admission to the unit at 4 AM from emergency. Mr. C: recovering from abdominal surgery two days ago. He is to be discharged later today. Mr. D admitted for regulation of high blood pressure and "inappropriate behavior", his wife of 45 years died 2 weeks ago. He is quiet and sleeping when you arrive. Arrange the patients in the order you would assess them.

Mr. B Mr. A Mr. C. Mr. D

Which of the following interpersonal skills is essential to the practice of nursing?

Promoting the dignity and respect of patients as people

In the clinical setting, a nurse is working on developing higher-level reflection skills. With which activity would the nurse most likely be engaged?

Reevaluating experience in light of ideas

Self-evaluation is a method that nurses use to promote their own development, and to grow in confidence in their nursing roles. This process is referred to as what?

Reflective practice.

While interviewing a client diagnosed with cirrhosis of the liver, the nurse asks about alcohol consumption. The client is hesitant to give information. Which of the following would be most appropriate for the nurse to do to elicit this information from the client?

Rephrase the question in a more acceptable form

The nurse employs interpersonal skills of communication when caring for and interacting with clients. Which of the following is the best example of establishing a therapeutic nurse-client relationship?

Respect for the client, and engaging in open communication in getting to know the client.

A nurse is caring for a client in the ER who was injured in a snowmobile accident. The nurse documents the following client data: uncontrollable shivering, weakness, pale and cold skin. Th nurse suspects the client is experiencing hypothermia. Upon further assessment, the nurse notes a heart rate of 53 BPM and core internal temperature of 90°F, which confirms the initial diagnosis. The nurse then devises a plan of care and continues to monitor the client to evaluate the outcomes. This nurse is using which of the following types of problem solving in her care of this client?

Scientific

Which of the following statements is true of the nursing process?

Scientific problem solving can occur within the nursing process.

A client who has been admitted to the hospital for the treatment of a gastrointestinal bleed requires a transfusion of packed red blood cells. Which of the following aspects of the nurse's execution of this order demonstrates technical skill?

Starting a new, large-gauge intravenous site on the client, and priming the infusion tubing

A group of student nurses are working on developing various nursing skills and are at various stages of skill acquisition. The instructor determines that which student is at the novice stage?

Student uses rules to guide practice

The nurse uses the QSEN competency of Informatics when planning care for patients. What is an example of the use of this skill?

The nurse researches new technological advances in the treatment of cancer.

Members of the staff on a hospital unit are critical of a client's family, who has different cultural beliefs about health and illness. A student assigned to the patient does not agree, based on her care of the client and family. What critical thinking attitude is the student demonstrating

Thinking independently

Members of the staff on a hospital unit are critical of a client's family, who has different cultural beliefs about health and illness. A student assigned to the patient does not agree, based on her care of the client and family. What critical thinking attitude is the student demonstrating?

Thinking independently

Nursing is a profession in a rapidly changing health care environment. What is the most important reason for the nurse to develop critical thinking and clinical reasoning?

To provide quality care with nursing ability and knowledge.

Critical thinking is important in making an effective nursing judgment. Which technique would be most effective for the nurse to adopt to improve classroom success?

Turn errors into learning opportunities

Your patient has had major abdominal surgery and just returned to the unit from the operating room. Your nursing priority is to:

complete post-operative assessment.

The nursing student is working with an experienced nurse in ICU. As the nursing student enters the room of the client diagnosed with a cerebral hemorrhage, the experienced nurse immediately says, "This patient is getting worse." This is an example of the experienced nurse using ...

intuitive problem identification

Use of the nursing process in healthcare allows the nurse to address the needs of the client. The nursing process:

provides a universally applicable framework for nursing activities

Personal characteristics demonstrate that one has developed critical thinking. Characteristics of critical thinking include:

self-aware, honest, persistent, and authentic.

Select the best description of how the nurse applies the nursing process in caring for patients. The nurse:

uses critical thinking to direct care for the individual patient.

Nurses apply critical thinking to clinical reasoning and judgment in their nursing practice every day. Which of the following are characteristics of this practice? Select all that apply.

• It is guided by standards, policies and procedures, ethics codes, and laws. • It is based on principles of nursing process, problem solving, and the scientific method. • It carefully identifies the key problems, issues, and risks involved. • It calls for strategies that make the most of human potential.

Nurses use the nursing process to plan care for patients. In which case is the nursing process applicable? (Select all that apply.)

• When families are not supportive and do not wish to participate in care. • When nurses work with patients who are able to participate in their care • When patients are totally dependent on the nurse for care • When families are clearly supportive and wish to participate in care