BCON exam 2

The five rights of delegation include (Select all that apply.) a. Right task. b. Right circumstances. c. Right monetary compensation. d. Right person. e. Right direction. f. Right opinion. g. Right supervision.

ANS: A, B, D, E, G The five rights of delegation are right task, circumstances, person, direction, and supervision.

Which of these selections is an etiology for Acute pain versus a defining characteristic? a. Complaint of pain as a 7 on a 0 to 10 scale b. Disruption of tissue integrity c. Dull headache d. Discomfort while changing position

ANS: B Disruption of tissue integrity is a possible cause or etiology of pain. A complaint of pain, headache, and discomfort are examples of things a patient might say (subjective data or defining characteristics) that lead a nurse to select Acute pain as a nursing diagnosis.

Which is the appropriate initial intervention for the nursing diagnostic statement Impaired skin integrity related to poor wound healing? a. Reinforce the wound dressing as needed with 4 4 gauze. b. Perform the ordered dressing change twice daily. c. Document wound characteristics. d. Assess wound appearance each shift.

ANS: D The most appropriate initial intervention is to assess the wound. Assessment guides the type and order of other interventions. The nurse must assess the wound first before the findings can be documented.

ich of these assessments of a patient who is 1 day post surgery to repair a hip fracture requires immediate nursing intervention? a. Patient ate 30% of clear liquid breakfast. b. Oral temperature is 99.2° Fahrenheit. c. Patient states, "Boy, I did not realize I would be so tired after this surgery." d. Patient reports severe pain 30 minutes after receiving pain medication.

ANS: D The nurse needs to recognize and differentiate normal from abnormal findings and set priorities. The nurse needs to report severe pain that is unrelieved by pain medication to the health care provider. Eating 30% of breakfast, having a slightly elevated temperature, and being tired the day after surgery are expected findings following surgery and do not require immediate intervention.

The nurse is reviewing a patient's database for significant changes and discovers that the patient has not voided in over 8 hours. The patient's kidney function labs are abnormal, and the patient's oral intake has significantly decreased since previous shifts. Which step of the nursing process should the nurse proceed to after this review? a. Diagnosis b. Planning c. Implementation d. Evaluation

ANS: A After a thorough assessment, the nurse should proceed to analyzing the data and formulating a nursing diagnosis before proceeding with developing the plan of care and determining appropriate interventions. The evaluation phase involves determining whether the interventions were effective.

The following statements are on a patient's nursing care plan. Which of the following statements is written as an outcome? a. The patient will verbalize a decreased pain level less than 3 on a 0 to 10 scale by the end of this shift. b. The patient will demonstrate increased mobility in 2 days. c. The patient will demonstrate increased tolerance to activity over the next month. d. The patient will understand needed dietary changes by discharge.

ANS: A An expected outcome is a specific and measurable change that is expected as a result of nursing care. The other three options in this question are goals. Demonstrating increased mobility in 2 days and understanding necessary dietary changes by discharge are short-term goals because they are expected to occur in less than a week. Demonstrating increased tolerance to activity over a month-long period is a long-term goal because it is expected to occur over a longer period of time.

The nurse is evaluating whether patient goals and outcomes have been met. Which option below is an expected outcome for a patient with Impaired physical mobility? a. The patient is able to ambulate in the hallway with crutches. b. The patient's level of mobility will improve. c. The nurse provides assistance while the patient is walking in the hallways. d. The patient will deny pain while walking in the hallway.

ANS: A An outcome is an expected, favorable, and measurable result of nursing care. The patient's being able to ambulate in the hallway with crutches is an expected outcome of nursing care. The option stating, "The patient's level of mobility will improve" is a broader goal statement. The nurse's assisting a patient to ambulate is an intervention. The patient's denying pain is an expected outcome for Acute pain, not for Impaired physical mobility.

A patient visiting with family members in the waiting area tells the nurse that his stomach is not feeling good. Before intervening, what should the nurse do? a. Ask the patient to return to his room so the nurse can inspect his abdomen. b. Request that the family leave, so the patient can rest. c. Ask the patient when his last bowel movement was and to lie down on the sofa. d. Tell the patient that his dinner tray will be ready in 15 minutes.

ANS: A Assessment is the first step in the nursing process and needs to be completed before the nurse can intervene. In this case, the environment needs to be conducive to completing a thorough assessment. The patient needs to return to the room for an abdominal assessment for privacy and comfort. The family can remain in the waiting area while the nurse assists the patient back to the room. Beginning the assessment in the waiting area in the presence of family and other visitors does not promote privacy and patient comfort. Telling the patient that his dinner tray is almost ready is making an assumption that the abdominal discomfort is due to not eating. The nurse needs to perform an assessment first.

A patient with an indwelling urinary catheter has been given a bed bath by a new nursing assistant. The nurse evaluating the cleanliness of the patient notices crusting at the urinary meatus. The best next action of this nurse is to a. Ask the nursing assistant to observe while the nurse performs catheter care. b. Leave the room and ask the nursing assistant to go back and perform proper catheter care. c. Discontinue the catheter. d. Document the incident in the patient's chart.

ANS: A Because the nursing assistant is new, it is best for the nurse to perform catheter care while the assistant observes. This action will ensure that the assistant has been shown the proper way to perform the task and fosters collaboration rather than leaving the room just to tell the assistant to come back. While the nurse is in the room, the nursing assistant should perform the task. Discontinuing the catheter is not warranted and requires a physician's order. This occurrence does not need to be documented in the patient's chart, granted no harm has come to the patient.

Before implementing any intervention, the nurse uses critical thinking to a. Determine whether an intervention is correct and appropriate for the given situation. b. Evaluate the effectiveness of interventions. c. Establish goals for a particular patient without the need for reassessment. d. Read over the steps and perform a procedure despite lack of clinical competency.

ANS: A Before implementing any intervention, the nurse uses critical thinking to determine whether an intervention is correct and appropriate for a clinical situation. The nurse cannot evaluate interventions until they are implemented. Patients need ongoing assessment because patient conditions can change very rapidly. The nurse needs to recognize the safety hazards of performing an intervention without clinical competency and seek assistance from another nurse.

Which of these findings, when evaluating another nurse developing a plan of care, should the charge nurse recognize as a source of diagnostic error? a. Assigning diagnoses while completing the database b. Assigning a documented nursing diagnosis of Risk for infection for a patient on intravenous antibiotics c. Completing the interview before performing the physical examination d. Documenting cultural and religious preferences

ANS: A Diagnosis should take place only after the database is completed. The data should be clustered and reviewed to see if any patterns are present before a nursing diagnosis is assigned. Risk for infection is an appropriate diagnosis for a patient with an intravenous (IV) site in place. The IV site involves a break in skin integrity and is a potential source of infection. The diagnostic process should proceed in steps. Completing the interview before the physical examination is appropriate. The patient's cultural background and developmental stage are important to include in a patient database.

The process of using assessment data gathered about a patient combined with critical thinking to explain a nursing diagnosis is known as a. Diagnostic reasoning. b. Defining characteristics. c. Assigning clinical criteria. d. Diagnostic labeling.

ANS: A Diagnostic reasoning is defined as a process of using the assessment data gathered about a patient to logically explain a clinical judgment, in this case a nursing diagnosis. Defining characteristics are assessment findings that support the nursing diagnosis. Clinical criteria are objective signs or subjective symptoms. Diagnostic labeling is simply assigning the diagnosis.

The nurse is assessing a patient with a hearing deficit. Where is the best place to conduct this interview? a. The patient's room with the door closed b. The waiting area with the television turned off c. The patient's room before administration of pain medication d. The patient's room while the occupational therapist is working on leg exercises

ANS: A Distractions should be eliminated as much as possible when interviewing a patient with a hearing deficit. The best place to conduct this interview is in the patient's room with the door closed. The waiting area does not provide privacy. Pain can sometimes inhibit someone's ability to concentrate, so before pain medication is administered is not advisable. It is best for the patient to be as comfortable as possible when conducting an interview. Assessing a patient while another member of the health care team is working would be distracting and is not the best time for assessment to take place.

A goal for a patient with a diagnosis of Ineffective coping is to demonstrate effective coping skills. Which of these patient behaviors indicates that interventions performed to meet this outcome have been successful? a. States he feels better after talking with his family and friends b. Continues to consume several alcoholic beverages a day c. Dislikes the support group meetings d. Spends most of the day in bed

ANS: A Evaluative data that show signs of effective coping will help the nurse determine whether the patient has met the outcome. Talking to family and friends is the only positive option. The other patient behavior choices indicate unsuccessful progress toward meeting the patient's goal.

After completing a thorough assessment to formulate a patient database, the nurse should proceed to which step of the nursing process? a. Diagnosis b. Planning c. Implementation d. Evaluation

ANS: A Following assessment, analyzing the data and assigning a nursing diagnosis is the next step in the nursing process. Planning occurs after assigning the problem to establish goals. Nursing interventions are carried out in the implementation phase. The evaluation phase occurs after intervening to establish whether interventions have been effective in helping the patient meet his/her goals.

With the current shortage of nursing faculty and nursing programs, which nursing care delivery model is least feasible in many agencies? a. Total patient care b. Primary nursing c. Team nursing d. Case management

ANS: A Patient satisfaction with the total patient care model is high, but total patient care is not cost-effective because it requires a large number of RNs to provide care. Total patient care involves an RN being responsible for all aspects of care for one or more patients. With the current shortage of nursing faculty and retirement of many practicing RNs, staffing enough RNs is a problem in many agencies. In the team nursing care model, the RN assumes the role of group or team leader and leads a team made up of other RNs, licensed vocational nurses, and nurse assistants or technicians. Primary nursing places RNs at the bedside more, assuming responsibility for a caseload of patients over time. This model, however, does not require an all-RN staff as is required for total patient care. Case management is a care approach that coordinates and links health care services to patients and families while streamlining costs.

A nurse employed in a staff development department is providing an in-service for other nurses to educate them about the Nursing Interventions Classification (NIC) system. During the in-service, which of the following statements made by one of the nurses in the room requires the staff nurse to clarify the information provided? a. "This system can help medical students determine the cost of the care they provide." b. "If the nursing department uses this system, communication among nurses who work throughout the hospital may be enhanced." c. "We could use this system to help us better organize orientation for new nursing employees because we can better explain the nursing interventions we use most frequently on our unit." d. "The NIC system provides one way to improve safe and effective documentation in the hospital's electronic health record."

ANS: A The NIC system provides nurses the ability to determine the costs of services they provide. Because this system is specific to nursing practice, it would not help medical students determine the costs of care. Benefits of using NIC include enhancing communication among nursing staff and documentation, especially within health information systems such as an electronic documentation system. NIC also helps nurses identify the nursing interventions they implement most frequently. Units that identify routine nursing interventions can use this information to develop checklists for orientation.

The use of critical thinking skills during the assessment phase of the nursing process ensures that the nurse a. Completes a comprehensive database. b. Identifies pertinent nursing diagnoses. c. Intervenes based on patient goals and priorities of care. d. Determines whether outcomes have been achieved.

ANS: A The assessment phase of the nursing process involves data collection to complete a thorough patient database. Identifying nursing diagnoses occurs during the diagnosis phase. The nurse carries out interventions during the implementation phase, and determining whether outcomes have been achieved takes place during the evaluation phase of the nursing process.

Vital signs for a patient reveal a high blood pressure of 187/100. Orders state to notify the health care provider for diastolic blood pressure greater than 90. What is the nurse's first action? a. Assess the patient for other symptoms or problems, and then notify the health care provider. b. Review the most recent lab results for the patient's potassium level. c. Follow the clinical protocol for a stroke. d. Administer an antihypertensive medication from the stock supply, and then notify the health care provider.

ANS: A The best answer is to briefly reassess the patient for other symptoms or problems, and then notify the health care provider according to the orders. Reviewing the potassium level does not address the problem of high blood pressure. The nurse does not make medical diagnoses, such as stroke. The nurse needs an order to administer medications.

A nurse administers an antihypertensive medication to a patient at the scheduled time of 0900. The nursing assistant then reports to the nurse that the patient's blood pressure was low when it was taken at 0830. The nursing assistant states she was busy and had not had a chance to tell the nurse yet. The patient begins to complain of feeling dizzy and light-headed. The blood pressure is re-checked and it has dropped even lower. The nurse first made an error in what phase of the nursing process? a. Assessment b. Diagnosis c. Planning d. Evaluation

ANS: A The diagnostic process should flow from the assessment. Without a thorough assessment, the nurse is more apt to misdiagnose a patient's responses, and the wrong interventions may be implemented. In this case, the nurse should have assessed the patient's blood pressure before giving the medication. The nurse could have prevented the patient's untoward reaction if the low blood pressure was assessed first. The nurse could have notified the physician, held the medication, or taken other steps to prevent an adverse reaction.

Which of these outcomes would be most appropriate for a patient with a nursing diagnosis of Constipation related to slowed gastrointestinal motility secondary to pain medications? a. Patient will have one soft, formed bowel movement by end of shift. b. Patient will not take any pain medications this shift. c. Patient will walk unassisted to bathroom by the end of shift. d. Patient will not take laxatives or stool softeners this shift.

ANS: A The identified problem, or nursing diagnosis, is Constipation. Therefore, the outcome should be that the constipation is relieved. To measure constipation relief, the nurse will be observing for the patient to have a bowel movement. Not taking pain medications may or may not relieve the constipation. Although not taking pain medicines might be an intervention, the nurse doesn't want the patient to be in pain to relieve constipation. Other measures, such as administering laxatives or stool softeners, might be appropriate interventions. The patient walking unassisted to the bathroom addresses mobility, not constipation. The patient may need to walk to the bathroom to have a bowel movement, but the appropriate outcome for constipation is that the constipation is relieved as evidenced by a bowel movement—something that the nurse can observe.

A nurse is assigned to care for the following patients who all need vital signs taken right now. Which of these patients is most appropriate for the nurse to delegate vital sign measurement to nursing assistive personnel (NAP)? a. Patient scheduled for a procedure in the nuclear medicine department b. Patient transferring from the intensive care unit (ICU) c. Patient returning from cardiac catheterization d. Patient returning from hip replacement surgery

ANS: A The nurse does not assign vital sign measurement or other tasks to NAP when patients are experiencing a change in level of care. The patient awaiting the procedure in nuclear medicine is the only patient who has not experienced a change in level of care. According to the rights of delegation, tasks that are repetitive, require little supervision, are relatively noninvasive, have results that are predictable, and have minimal risk can be delegated to assistive personnel. The patient in this question with the most predictable condition is the patient awaiting the nuclear medicine procedure. Once the nurse determines that the other patients are stable, the nurse could delegate their future vital sign measurement to the NAP. However, it is important for the nurse to assess patients coming from the ICU, the cardiac cath lab, and surgery when they first arrive on the unit.

A nurse assesses that a patient has not voided in 6 hours. Which question should the nurse ask to assist in establishing a nursing diagnosis of Urinary retention? a. "Do you feel like you need to use the bathroom?" b. "Are you able to walk to the bathroom by yourself?" c. "When was the last time you took your medicine?" d. "Do you have a safety rail in your bathroom at home?"

ANS: A The nurse must establish that the patient feels the urge and is unable to void. The question "Do you feel like you need to use the bathroom?" is the most appropriate to ask. This question can be answered without knowledge of the diagnosis of Urinary retention. Discussing the ability to walk to the bathroom and asking about safety rails pertain to mobility and safety issues, not to retention of urine. Taking certain medications may lead to urinary retention, but that information would establish the etiology. The question is asking for the nurse to first establish the correct diagnosis.

The nurse is caring for a patient who requires a complex dressing change. While in the patient's room, the nurse decides to change the dressing. What does the nurse do just before changing the dressing? a. Assesses the patient's readiness for the procedure b. Gathers and organizes needed supplies c. Decides on goals and outcomes for the patient d. Calls for assistance from another nursing staff member

ANS: A The nurse needs to assess the patient's readiness and willingness for any procedure before intervening. After determining the patient's readiness for the dressing change, the nurse gathers needed supplies. The nurse establishes goals and outcomes before intervening. Before entering the patient's room, the nurse needs to ask another staff member to help if necessary.

A nursing assistant reports seeing a reddened area on the patient's hip while bathing the patient. The nurse should a. Go to the patient's room to assess the patient's skin. b. Document the finding per the nursing assistant's report. c. Request a wound nurse consult. d. Ask the nursing assistant to apply a dressing over the reddened area.

ANS: A The nurse needs to assess the patient's skin. Assessment should not be delegated; it is the responsibility of the licensed professional nurse. The nurse needs to document the assessment findings objectively, not subjectively per the nursing assistant. Before requesting a consult or determining treatment, the nurse needs to assess the skin

The nurse is intervening for an identified nursing diagnosis of Risk for infection. Which direct care nursing intervention is most appropriate? a. Teaching the family proper handwashing technique b. Leaving side rails up at all times c. Teaching the patient how to use crutches d. Counseling the family on stress reduction techniques

ANS: A The only intervention listed that directly relates to preventing infection is teaching proper handwashing technique. Teaching is a direct care nursing intervention. Leaving the side rails up addresses patient safety. Teaching the patient how to use crutches pertains to mobility, and counseling the family is a health promotion activity intended to reduce stress, not decrease the risk for infection.

What is the primary goal of outcomes management for professional nurses? a. To promote purposeful actions focused on improving a patient's health condition b. To fine-tune nursing assessment skills c. To support the delegation of more nursing tasks to nursing assistive personnel d. To decrease the number of medication errors in nursing

ANS: A The primary goal of outcomes management is to improve a patient's health status. Assessment skills probably will be improved if a nurse focuses on improving patient outcomes, but this is not the primary goal. Delegating to nursing assistive personnel is not the primary goal of outcomes management. Reducing medication errors is a possible result of outcomes management, but it is not the primary goal.

Before implementing care, the nurse needs to ensure that which resources are available? (Select all that apply.) a. Equipment b. Safe environment c. Patient readiness d. Assistive personnel e. Creativity

ANS: A, B, C, D Organization of equipment and personnel makes timely, efficient, skilled patient care possible. The nurse needs to assess the patient for readiness before implementing care. The nurse also needs to ensure that the environment is safe before implementing care. Creativity is needed to provide safe and effective patient care; however, creativity is a critical thinking attitude, not a resource.

Which of the following are direct care interventions? (Select all that apply.) a. Turning a patient b. Counseling a patient c. Performing resuscitation d. Documenting wound care e. Teaching wound care

ANS: A, B, C, E All of the interventions listed are direct care interventions involving patient and nurse interaction, except documenting wound care. Documenting wound care is an example of an indirect intervention.

Which of the following are examples of evaluative measures that a nurse should utilize when determining the patient's response to nursing care? (Select all that apply.) a. Observations of wound healing b. Assessment of respiratory rate and depth c. Blood pressure measurement d. Implementation of nursing interventions e. Patient's subjective report of feelings about a new diagnosis of cancer

ANS: A, B, C, E Evaluative measures require the nurse to use assessment skills and techniques to determine the patient's response to nursing care. Examples of evaluative measures include assessment of wound healing and respiratory status, blood pressure measurement, and assessment of patient feelings. Determining whether nursing interventions were used is not an evaluative measure.

A nurse is planning care for a patient with a nursing diagnosis of Impaired skin integrity. The patient needs many nursing interventions, including a dressing change, several intravenous antibiotics, and a walk. What factors does the nurse consider when prioritizing interventions? (Select all that apply.) a. Put all the patients' nursing diagnoses in order of priority. b. Consider time as an influencing factor. c. Set priorities based solely on physiological factors. d. Utilize critical thinking. e. Do not change priorities once they've been established.

ANS: A, B, D The nurse avoids setting priorities based solely on physiological factors. Consider psychosocial factors as well. Prioritizing the problems, or nursing diagnoses, will help the nurse decide which problem to address first. Time is a factor to be included in planning before continuing on to the implementation phase. Nurses use critical thinking throughout the entire nursing process. Priorities can change based on patient needs and responses to treatments.

The nursing process involves which of the following steps in the clinical decision-making process? (Select all that apply.) a. Identifying patient needs b. Diagnosing the disease process c. Determining priorities of care d. Setting goals e. Performing nursing interventions f. Evaluating effectiveness of medical treatments

ANS: A, C, D, E Diagnosing disease is not a nursing action. Evaluating the effectiveness of medical treatments is not a nursing action either. Nurses are to use the nursing process to evaluate the effectiveness of nursing interventions, not medical treatments. Identifying patient needs, determining priorities of care, setting realistic goals, and implementing nursing interventions are all steps in the clinical decision-making process.

Which interventions are appropriate for the nursing diagnosis Impaired tissue integrity related to poor wound healing secondary to diabetes? (Select all that apply.) a. Teach the patient about signs and symptoms of infection. b. Help the patient cope with changes in body image that result from the wound. c. Perform dressing changes twice a day as ordered. d. Administer medications to control the patient's blood sugar as ordered. e. Teach the family how to perform dressing changes.

ANS: A, C, D, E The cause of the problem is poor wound healing secondary to diabetes. Nursing priorities include interventions directed at enhancing wound healing. Teaching the patient about signs and symptoms of infection will help the patient identify signs of appropriate wound healing and know when the need for calling the health care provider arises. Performing dressing changes, controlling blood sugars through administration of medications, and involving the family in dressing changes all contribute to wound healing. Although the patient possibly has altered body image related to the wound, counseling the patient about coping strategies addresses body image, not wound healing.

The nurse defines a clinical guideline or protocol as a a. Guideline to follow that replaces the nursing care plan. b. Document that assists the clinician in making decisions and choosing interventions for specific health care problems or conditions. c. Hospital policy designating each nurse's duty according to standards of care and a code of ethics. d. Prescriptive order form that individualizes the plan of care.

ANS: B A clinical guideline or protocol is a document that assists the clinician in making decisions and choosing interventions for specific health care problems or conditions. The protocol does not replace the nursing care plan. Evidence-based guidelines from protocols can be incorporated into an individualized plan of care. A clinical guideline is not the same as a hospital policy. Standing orders contain orders for the care of a specific group of patients. A protocol is not a prescriptive order form like a standing order.

A nurse administrator is at a meeting with nurses on the quality council. Several new members are sitting on the council. They ask the nurse administrator to clarify what a nursing-sensitive outcome is. Which response by the nurse administrator best defines nursing-sensitive outcomes? a. "Nursing-sensitive outcomes determine the patient's progress as a result of prescribed treatments, such as medications." b. "Patient falls is an example of a nursing-sensitive outcome because they are directly affected by nursing interventions." c. "Nursing-sensitive outcomes promote universal health care." d. "We use nursing-sensitive outcomes at this hospital to evaluate nursing tasks and to determine safe staffing ratios."

ANS: B A nursing-sensitive outcome is a measurable patient or family state, behavior, or perception that is largely influenced by and sensitive to nursing interventions. Patient falls is one nursing-sensitive outcome because they are a direct measure of nursing care. Because the prescriber determines prescribed treatments, the progress of the patient's condition as a result of prescribed treatments is not an evaluation of a nursing-sensitive outcome. Promotion of universal health care and determining staffing ratios are not components of nursing-sensitive outcomes.

Which diagnosis below is NANDA-I approved? a. Sleep disorder b. Acute pain c. Sore throat d. High blood pressure

ANS: B Acute pain is the only NANDA-I-approved diagnosis listed. Sleep disorder and high blood pressure (hypertension) are medical diagnoses, and sore throat is a subjective complaint.

A nurse identifies a nursing diagnosis of Risk for falls when assessing a patient upon admission. The nurse and the patient agree that the goal is for the patient to remain free from falls. However, the patient fell just before shift change. What is the nurse's priority action when evaluating the patient's plan of care? a. Counsel the nursing assistive personnel on duty when the patient fell. b. Identify factors interfering with goal achievement. c. Remove the fall risk sign from the patient's door because the patient has suffered a fall. d. Request that the more experienced charge nurse complete the documentation about the fall.

ANS: B After a change in the patient's condition or an untoward event, the nurse attempts to identify factors interfering with goal achievement. In this case, the nurse identifies factors that interfered with goal achievement to determine the cause of the fall. The fall may not have been due to an error by the nursing assistant; therefore, counseling should be reserved until after the cause has been determined. The patient remains a fall risk, so the fall risk sign should remain on the door. The nurse witnessing the fall or the nurse assigned to the patient needs to complete the documentation. The charge nurse can be consulted to review the documentation.

After setting the agenda during a patient-centered interview, what will the nurse do? a. Begin by introducing himself. b. Conduct a nursing health history. c. Explain that the interview will be over in a few more minutes. d. Tell the patient that he'll be back to administer medications in 1 hour.

ANS: B After setting the agenda, the nurse should conduct the actual interview and proceed with data collection. Setting the stage begins with introductions and takes place before an agenda is set. The termination phase includes telling the patient when the interview is nearing an end. Telling the patient medications will be given later when the nurse returns would typically take place during the termination phase of the interview.

A staff member verbalizes his satisfaction in working on a particular nursing unit because he appreciates the freedom of choice and responsibility for the choices. This nurse highly values which element of decentralized decision making? a. Responsibility b. Autonomy c. Accountability d. Authority

ANS: B Autonomy is freedom of choice and responsibility for the choices. Responsibility refers to the duties and activities that an individual is employed to perform. Accountability refers to individuals being answerable for their actions. Authority refers to legitimate power to give commands and make final decisions specific to a given position.

The nurse is caring for a patient who has an order to change a dressing twice a day, at 0600 and 1800. At 1400, the nurse notices that the dressing is saturated. What is the nurse's next action? a. Wait and change the dressing at 1800 as ordered. b. Revise the plan of care and change the dressing now. c. Reassess the dressing and the wound in 1 hour. d. Discontinue the plan of care.

ANS: B Based on evaluative data, the nurse revises, discontinues, or continues a patient's plan of care. Because the dressing is saturated, the nurse needs to revise the plan of care and change the dressing now. Waiting until 1800 or for another hour is not appropriate because assessment data reflect that the dressing is saturated and needs to be changed now. Data are insufficient to support discontinuing the plan of care. Instead, data at this time indicate the need for revision of the plan of care.

After completing a thorough database and analyzing the data to identify any problems, the nurse should proceed to what step of the nursing process? a. Assessment b. Planning c. Implementation d. Evaluation

ANS: B In the five-step nursing process, the nurse should establish mutual goals with the patient and prioritize care in the planning phase, which follows the diagnosis phase. The assessment phase of the nursing process involves gathering data. The implementation phase involves carrying out appropriate nursing interventions. During the evaluation phase, the nurse assesses the effectiveness of interventions.

The nurse establishes trust and talks with a school-aged patient before administering injections. This nurse is demonstrating which type of implementation skill? a. Cognitive b. Interpersonal c. Psychomotor d. Judgmental

ANS: B Nursing practice includes cognitive, interpersonal, and psychomotor skills. Cognitive involves the application of critical thinking and use of good judgment in making sound clinical decisions. Interpersonal skills involve developing trusting relationships with patients, conveying caring and compassion, and communicating clearly. Psychomotor skill requires the integration of cognitive and motor abilities. The nurse in this example displayed the interpersonal skills of establishing trust and talking with the patient before intervening.

The nurse is intervening for an identified nursing diagnosis of Caregiver role strain. Which direct care nursing intervention is most appropriate? a. Assisting with activities of daily living b. Counseling about respite care options c. Teaching range-of-motion exercises d. Emphasizing the importance of exercise

ANS: B Respite care provides temporary assistance for family caring for someone with health care needs. The other options do not address the identified problem of caregiver role strain. Counseling is an example of a direct care nursing intervention.

The nurse describes evidence-based practice as a. Practice based on the evidence presented in court. b. Implementing interventions based on scientific rationale. c. Using standardized care plans. d. Planning care based on tradition.

ANS: B The best answer is implementing interventions based on scientific rationale. Practice based on evidence presented in court is incorrect. Practice is based on current research. Using standardized care plans may be one example of evidence-based practice, but there are many others as well. The nurse must be careful in using standardized care plans to ensure that each patient's plan of care is still individualized. Planning care based on tradition is incorrect because nursing care should be based on current research.

Which intervention is most appropriate for a patient who has a new onset of chest pain? a. Administer a prn medication for pain. b. Reassess the patient because of the change in condition. c. Notify the health care provider. d. Call radiology for a portable chest x-ray.

ANS: B The cause of the patient's chest pain is unknown, so the patient needs to be reassessed before pain medication is administered or a chest x-ray is obtained. The nurse then notifies the patient's health care provider of the patient's current condition in anticipation of receiving further orders. The patient's chest pain could be due to muscular injury or a pulmonary issue. The nurse needs to reassess first.

A patient of Middle Eastern descent has lost 5 lbs during hospitalization and states that the food offered is not allowed in his diet owing to religious preferences. Based on this information, an appropriate nursing diagnostic statement is Imbalanced nutrition: less than body requirements related to a. Religious preferences. b. Decreased oral intake. c. Weight loss. d. Race and ethnicity.

ANS: B The cause or related to factor in this case is the patient's lack of oral intake due to lack of appropriate food choices. The patient's religious preferences, race, and ethnicity did not cause his weight loss. Ultimately, the lack of food choices and his decreased intake caused him to lose weight. Weight loss is a sign of imbalanced nutrition, not a cause. The weight loss would be noticed during the assessment and would lead to the nursing diagnosis, not in reverse order.

A new nurse expresses frustration at not being to complete all interventions for a group of patients in a timely manner. The nurse leaves the rounds report sheets at the nurse's station when caring for patients and reports having to go back and forth between rooms several times looking for equipment and supplies. This nurse could benefit from practicing better _____ skills. a. Clinical decision-making b. Organizational c. Evaluation d. Interpersonal communication

ANS: B The clinical care coordination skill this nurse needs to improve on is organization. This nurse needs to keep the patient report sheets in hand to anticipate what equipment and supplies a patient is going to need. Then the nurse may not have to leave the room so often; this will save time. The nurse in this example does not voice concern about decision-making skills, evaluation skills, or communication skills.

Which organizational structure approach has fewer directors with managers accountable 24 hours for staff, budget, and day-to-day management? a. Centralized management b. Decentralized management c. Business unit management d. Matrix

ANS: B The decentralized management structure often has fewer directors, and managers are accountable around the clock for the operation of the unit. Centralized management involves having a single administrator and managers with minimal accountability for the unit operation. The matrix approach involves reorganization of hospital departments into "business units."

The charge nurse is reviewing a patient's plan of care, which includes the nursing diagnostic statement, Impaired physical mobility related to tibial fracture as evidenced by patient's inability to ambulate to bathroom. The nurse needs to revise which part of the diagnostic statement? a. Nursing diagnosis b. Etiology c. Patient chief complaint d. Defining characteristic

ANS: B The etiology, or related to factor, of tibial fracture is a medical diagnosis and needs to be revised. The nursing diagnosis is appropriate because the patient is unable to ambulate. The patient's chief complaint is what the patient subjectively states is the problem. No subjective data are included in the diagnostic statement. The defining characteristic (subjective and objective data that support the diagnosis) is appropriate for Impaired physical mobility.

Which intervention is most appropriate for the nursing diagnostic statement, Impaired skin integrity related to shearing forces? a. Administer pain medication every 4 hours as needed. b. Perform the ordered dressing change twice daily. c. Do not document the wound appearance in the chart. d. Keep the bed side rails up at all times.

ANS: B The most appropriate intervention for the diagnosis of Impaired skin integrity is to perform the ordered dressing change. The other options do not directly address the skin integrity. The patient may need pain medication before dressing changes, but Acute pain would be another nursing diagnosis. Documenting all objective findings is the nurse's responsibility, even if a wound or infection is a health care-associated problem. Keeping the side rails up addresses safety, not skin integrity

A nurse is getting ready to discharge to home a patient who has a nursing diagnosis of Impaired physical mobility. Before discontinuing the patient's plan of care, what does the nurse need to do? a. Determine whether the patient has transportation to get home. b. Evaluate whether patient goals and outcomes have been met. c. Establish whether the patient has a follow-up appointment scheduled. d. Ensure that the patient's prescriptions have been filled.

ANS: B The nurse needs to evaluate whether goals and outcomes have been met before revising, continuing, or discontinuing a plan of care. The patient needs transportation, but that does not address the patient's mobility status. Whether the patient has a follow-up appointment and ensuring that prescriptions are filled do not evaluate the problem of mobility.

Which of these questions would be most appropriate for a nurse to ask a patient to assist in establishing a nursing diagnosis of Diarrhea? a. "What types of foods do you think caused your upset stomach?" b. "How many bowel movements a day have you had?" c. "Are you able to get to the bathroom in time?" d. "What medications are you currently taking?"

ANS: B The nurse needs to first ensure that the symptoms support the diagnosis. By definition, diarrhea means that a patient is having frequent stools. Asking about irritating foods and medications may help the nurse determine the cause of the diarrhea, but first the nurse needs to make sure the diagnosis is appropriate. Asking the patient if he can make it to the bathroom will help to establish a diagnosis of incontinence, not diarrhea. The question is asking for the most appropriate statement to establish the diagnosis of Diarrhea.

What is the first step in making a consult? a. Avoid bias by not providing a lot of information based on opinion to the consultant. b. Identify the problem. c. Provide the consultant with relevant information about the problem. d. Ensure that the right professional, with the appropriate knowledge and expertise, is contacted.

ANS: B The nurse needs to first identify the problem. Subsequent steps in order include obtaining direct consultation with the right professional, providing the consultant with relevant information, avoiding bias, and being available to discuss the consultant's recommendations.

While completing an admission database, the nurse is interviewing a patient who states that he is allergic to latex. The most appropriate nursing action is to first a. Leave the room and place the patient in isolation. b. Ask the patient to describe the type of reaction. c. Proceed to the termination phase of the interview. d. Document the latex allergy on the medication administration record.

ANS: B The nurse should further assess and ask the patient to describe the type of reaction. The patient will not need to be placed in isolation; before terminating the interview or documenting the allergy, health care personnel need to be aware of what type of response the patient suffered.

Which of these findings, if identified in a plan of care, should the registered nurse revise because it is not characteristic of critical thinking and the nursing process? a. Patient's reactions to diagnostic testing b. Nurse's assumptions about hospital discharge c. Identification of five different nursing diagnoses d. Documentation of patient's ability to cope with loss

ANS: B The nurse should not assume when a patient is going to be discharged and document this information in a plan of care. Making assumptions is not an example of a critical thinking skill. The patient's reactions to testing, having several nursing diagnoses, and a description of the patient's coping abilities are all appropriate to document in the nursing plan of care.

When evaluating a plan of care, the nurse reviews the goals for the patient. Which goal statement is realistic to assign to a patient with a pelvic fracture on bed rest? The patient will increase mobility by a. Ambulating in the hallway two times this shift. b. Turning side to back to side with assistance every 2 hours. c. Using the walker correctly to ambulate to the bathroom as needed. d. Using a sliding board correctly to transfer to the bedside commode as needed.

ANS: B The patient is ordered to be on bed rest; therefore turning the patient in bed is the only option that is appropriate. When determining goals, the nurse needs to ensure that the goal is individualized and realistic for the patient.

Which of the following options correctly explains what the nurse should do with the plan of care for a patient after it is developed? a. Place the original copy in the chart, so it cannot be tampered with or revised. b. Communicate the plan of care to all health care professionals involved in the patient's care. c. Send the plan of care to the administration office to be filed. d. Send the plan of care to quality assurance for review.

ANS: B The patient's nursing plan of care is a dynamic piece of work that needs to be updated and revised as the patient's condition changes. All health care professionals involved in the patient's care need to be informed of the plan of care. The plan of care is not placed on the chart and not ever looked at again. The plan of care is not sent to the administrative office or quality assurance office

The patient database reveals that a patient has decreased oral intake, decreased oxygen saturation when ambulating, complaints of shortness of breath when getting out of bed, and a productive cough. What are the defining characteristics for the diagnostic label of Activity intolerance? a. Decreased oral intake and decreased oxygen saturation when ambulating b. Decreased oxygen saturation when ambulating and complaints of shortness of breath when getting out of bed c. Complaints of shortness of breath when getting out of bed and a productive cough d. Productive cough and decreased oral intake

ANS: B The signs and symptoms, or defining characteristics, for the diagnosis Activity intolerance include decreased oxygen saturation when ambulating and complaints of shortness of breath when getting out of bed. The key to supporting the diagnosis of Activity intolerance is that only these two characteristics involve how the patient tolerates activity.

One purpose of using standard formal nursing diagnoses in practice is to a. Form a language that can be encoded only by nurses. b. Distinguish the nurse's role from the physician's role. c. Allow for the communication of patient needs to assistive personnel. d. Help nurses focus on the scope of medical practice.

ANS: B The standard formal nursing diagnosis serves several purposes. A nursing diagnosis provides the precise definition that gives all members of the health care team a common language for understanding the patient's needs. Nursing diagnoses allow nurses to communicate what they do among themselves, with other health care professionals, and the public. Nursing diagnoses distinguish the nurse's role from that of the physician, and help nurses focus on the scope of nursing practice while fostering the development of nursing knowledge.

The nurse is evaluating whether a patient's turning schedule was effective in preventing the formation of pressure ulcers. Which finding indicates success of the turning schedule? a. Staff documentation of turning the patient every 2 hours b. Absence of skin breakdown c. Presence of redness only on the heels of the patient d. Patient's eating 100% of all meals

ANS: B To determine whether a turning schedule is successful, the nurse needs to assess for the presence of skin breakdown. Redness on any part of the body, including only the patient's heels, indicates that the turning schedule was not successful. Documentation of interventions does not evaluate whether patient outcomes were met. Eating 100% of meals does not evaluate the effectiveness of a turning schedule.

A new nurse states that she is confused about using evaluative measures when caring for patients and asks the charge nurse for examples and an explanation. Which of the following is the most accurate response from the charge nurse? a. "Evaluative measures are multiple-page documents used to evaluate nurse performance." b. "Evaluative measures include assessment data used to determine whether patients have met their expected outcomes and goals." c. "Evaluative measures are used by quality assurance nurses to determine the progress a nurse is making from novice to expert nurse." d. "Evaluative measures are objective views of incident reports."

ANS: B You use evaluative measures to determine whether patients have met their goals and outcomes. Evaluative measures are not multiple-page documents, and they are used to assess the patient's status, not the nurse's performance. Evaluative measures are not used when you are completing an incident report.

Identify elements of the evaluation process. (Select all that apply.) a. Setting priorities for patient care b. Collecting subjective and objective data to determine whether criteria or standards are met c. Ambulating 25 feet in the hallway with the patient d. Documenting findings e. Terminating, continuing, or revising the care plan

ANS: B, D, E During the evaluation process, you gather and document objective and subjective data to determine whether the patient is meeting expected outcomes and is working toward achievement of goals. The evaluation process requires the use of critical thinking about attitudes and standards to analyze your findings and to determine whether a plan of care needs to be terminated, continued, or revised. Setting priorities is part of planning, and ambulating with a patient in the hallway is an intervention, so it is included in the implementation step of the nursing process.

The nurse recognizes that another term for a collaborative nursing intervention is _____ intervention. a. Dependent b. Independent c. Interdependent d. Physician-initiated

ANS: C A collaborative, or interdependent, intervention requires the combined knowledge, skill, and expertise of multiple health care professionals. A dependent intervention requires an order from a health care professional. An independent intervention is an action that the nurse initiates.

When planning patient care, a goal can be described as a. A statement describing the patient's accomplishments without a time restriction. b. A realistic statement predicting any negative responses to treatments. c. A broad statement describing a desired change in patient behavior. d. An identified long-term nursing diagnosis.

ANS: C A goal is a broad statement that describes a desired change in a patient's condition or behavior. A goal is mutually set with the patient and is time-limited, patient-centered, measurable, and realistic.

Which of the following methods of data collection is utilized to establish a patient's nursing database? a. Reviewing the current literature to determine evidence-based nursing actions b. Orders for diagnostic and laboratory tests c. Physical examination d. Anticipated medications to be ordered

ANS: C A nursing database includes a physical examination. Orders are included in the order section of the patient's chart. The nurse reviews the current literature in the implementation phase of the nursing process to determine evidence-based actions, and the health care provider is responsible for ordering medications. Medication orders are usually written after the database is completed.

A nurse using the problem-oriented approach to data collection will first a. Complete an observational overview. b. Disregard cues and complete the database questions in chronological order. c. Focus on the patient's presenting situation. d. Make accurate interpretations of the data.

ANS: C A problem-oriented approach focuses on the patient's current problem or presenting situation rather than on an observational overview. The database is not always completed using a chronological approach if focusing on the current problem. Making interpretations of the data is not data collection. Data interpretation occurs while appropriate nursing diagnoses are assigned. The question is asking about data collection.

The standing orders for a patient include acetaminophen (Tylenol) 650 mg every 4 hours prn for headache. After assessing the patient, identifying the need for headache relief, and determining that the patient has not had Tylenol in the past 4 hours, the nurse a. Notifies the health care provider to obtain a verbal order. b. Directs the nursing assistant to give the Tylenol. c. Administers the Tylenol. d. Performs a pain assessment only after administering the Tylenol.

ANS: C A standing order is a preprinted document containing orders for the conduct of routine therapies, monitoring guidelines, and/or diagnostic procedures for specific patients with identified clinical problems. Notifying the health care provider is not necessary if a standing order exists. The nursing assistant is not licensed to administer medications; therefore, medication administration should not be delegated to this person. A pain assessment should be performed before and after pain medication administration to assess the need for and effectiveness of the medication.

To gather information about a patient's home and work surroundings, the nurse will need to utilize which method of data collection? a. Carefully review lab results. b. Conduct the physical assessment before collecting subjective information. c. Perform a thorough nursing health history. d. Prolong the termination phase of the interview.

ANS: C A thorough nursing history includes information about the patient's home and work surroundings. Neither lab results nor the physical assessment will reveal much about the home and work surroundings. Collecting data is part of the working phase of the interview.

Identify the defining characteristics in the nursing diagnosis statement: Constipation related to decreased gastrointestinal motility secondary to pain medication administration as evidenced by the patient reporting no bowel movement in seven days, abdominal distention, and complaints of abdominal pain. a. Decreased gastrointestinal motility b. Pain medication c. Abdominal distention d. Constipation

ANS: C Abdominal distention, no reported bowel movement, and abdominal pain are the defining characteristics. Decreased gastrointestinal motility secondary to pain medication is an etiology or related to factor. Constipation is the identified problem derived from the defining characteristics.

What is the first intervention included on any patient's plan of care? a. Determine patient outcomes and goals. b. Prioritize the patient's nursing diagnoses. c. Reassess the patient. d. Assess for a patent airway.

ANS: C Assessment is a continuous process that occurs each time the nurse interacts with a patient. During the initial phase of implementation, reassess the patient. Determining the patient's goals and prioritizing diagnoses take place in the planning phase before choosing interventions. Assessing for a patent airway may or may not be a given patient's first intervention, depending on the goals, priority diagnosis, and reassessment findings of the patient

In which step of the nursing process does the nurse provide nursing care interventions to patients? a. Assessment b. Planning c. Implementation d. Evaluation

ANS: C In the five-step nursing process, the implementation phase involves providing direct and indirect nursing care interventions to patients. The nurse gathers data during the assessment phase and mutually sets goals and prioritizes care during the planning phase. During the evaluation phase, the nurse determines the effectiveness of interventions.

In which nursing care model is the RN usually appointed the position of group leader? a. Total patient care b. Primary nursing c. Team nursing d. Case management

ANS: C In the team nursing care model, the RN assumes the role of group or team leader and leads a team made up of other RNs, licensed vocational nurses, and nurse assistants or technicians. Total patient care involves an RN being responsible for all aspects of care for one or more patients. Primary nursing places RNs at the bedside more, assuming responsibility for a caseload of patients over time. This model, however, does not require an all-RN staff as is required for total patient care. Case management is a care approach that coordinates and links health care services to patients and families while streamlining costs.

The nurse inserts an intravenous catheter using the correct technique and following the recommended steps according to standards of care and hospital policy. This is demonstrating which type of implementation skill? a. Cognitive b. Interpersonal c. Psychomotor d. Judgmental

ANS: C Nursing practice includes cognitive, interpersonal, and psychomotor skills. Psychomotor skill requires the integration of cognitive and motor abilities. Cognitive involves the application of critical thinking and use of good judgment in making sound clinical decisions. Interpersonal skills involve developing trusting relationships with patients, conveying caring and compassion, and communicating clearly. The nurse in this example displayed the psychomotor skill of inserting an intravenous catheter while following standards of care and integrating knowledge of anatomy and physiology.

Which of the following is a nursing intervention? a. The patient will ambulate in the hallway twice this shift using crutches correctly. b. Impaired physical mobility related to inability to bear weight on right leg c. Provide assistance while the patient walks in the hallway twice this shift with crutches. d. The patient is unable to bear weight on right lower extremity.

ANS: C Providing assistance to a patient who is ambulating is a nursing intervention. The statement, "The patient will ambulate in the hallway twice this shift using crutches correctly" is a patient goal. Impaired physical mobility is a nursing diagnosis. The statement that the patient is unable to bear weight and ambulate can be included with assessment data and is a defining characteristic for the diagnosis of Impaired physical mobility.

A nurse is providing education to a patient about self-administering subcutaneous injections. Which of these patient statements indicates that the patient understands the instructions? a. "I need to use a needle 1/2 inch longer than my thumb." b. "I will give the medicine deep into my deltoid." c. "My belly is a good place to give my injection." d. "I need to throw the syringe and needle into the garbage when I am done giving myself my shot."

ANS: C Remember from anatomy that the skin is made up of the outer layer, called the epidermis. The second layer of skin is the dermis. The connective tissue under the dermis is called the subcutaneous tissue. This is where subcutaneous injections are given. The abdomen is a good site for subcutaneous injections because this is an area that has a lot of subcutaneous tissue. Using a needle 1/2 inch longer than a person's thumb is not an evidence-based method for measuring needle length needed for subcutaneous injection. The deltoid is a muscle, not a subcutaneous site. Disposing of needles and syringes into a garbage can creates a biomedical hazard and therefore is not appropriate.

Which of these staff members does the staff nurse assign to provide morning care for an older adult patient who requires assistance with activities of daily living? a. Licensed vocational nurse b. Cardiac monitor technician c. Nursing assistive personnel (NAP) d. None of the above; the nurse needs to provide morning care to this patient.

ANS: C The NAP is capable of caring for this patient and is the most cost-effective choice. The cardiac monitor technician's role is to watch the cardiac monitors for patients on the floor. The nurse and the licensed vocational nurse are not the most cost-effective options in this case, even though each could assist with activities of daily living. These nurses would be better used to administer medications, perform assessments, etc.

A nurse manager sent one of the staff nurses on the unit to a conference about new, evidence-based wound care techniques. The nurse manager asks the staff nurse to prepare a poster to present at the next unit meeting, which will be mandatory for all nursing staff on the unit. The nurse manager is providing a learning opportunity in this situation through a. Nurse/physician collaborative practice. b. Interdisciplinary collaboration. c. Staff education. d. Establishing a nursing practice committee.

ANS: C The nurse manager is planning a staff education opportunity in the given example. Staff education is one way the nurse manager supports staff involvement in a decentralized decision-making model. This nurse is providing staff education to other staff nurses on the unit, not to physicians. Interdisciplinary collaboration involves working with other disciplines such as medicine, physical therapy, respiratory therapy, etc. The question does not state that the nurse is establishing a practice committee. A poster presentation is a common teaching method.

Which of these interventions, to be included in the plan of care, is appropriate for the patient outcome that states, "The patient will verbalize a pain level at 3 or below on a 0 to 10 scale throughout this shift."? a. Medicate the patient immediately after all procedures. b. Discuss only nonpharmacological methods of pain relief. c. Teach the patient about side effects of pain medications. d. Medicate the patient based on previous shift assessment findings.

ANS: C The nurse needs to include teaching as an appropriate nursing intervention. Medicating the patient after procedures is not a helpful method of pain control. Patients need to be assessed for sign and symptoms of discomfort before and after procedures. The nurse discusses all options for pain relief, not just nonpharmacological methods. Patients' needs can change from minute to minute, so basing an intervention on a previous shift assessment is incorrect.

A nurse observes a patient care technician using all these measures when taking vital signs. Which measure requires the nurse to intervene? a. Palpates brachial artery before inflating blood pressure cuff b. Counts respirations while palpating radial pulse c. Inserts thermometer into sublingual pocket after patient sips water d. Asks patient to relax arm before taking blood pressure

ANS: C The nurse needs to intervene if observing the technician taking an oral temperature after consuming any type of beverage because of the potential for a temperature difference in the liquid that may affect the patient's measured temperature. The other options are appropriate.

A patient's plan of care includes the goal of increasing mobility this shift. As the patient is ambulating to the bathroom at the beginning of the shift, the patient suffers a fall. The nurse should revise the plan of care first by a. Asking physical therapy to assist the patient because of the new injuries. b. Disregarding all previous diagnoses and establishing a new plan of care. c. Reassessing the patient. d. Setting new priorities for the patient.

ANS: C The nurse needs to reassess the patient after any type of change in health status. The nursing process is dynamic and ongoing. Asking physical therapy to assist the patient is premature before reassessing the patient and awaiting physician orders. The nurse may not need to disregard all previous diagnoses. Some diagnoses may still apply, but the patient needs to be reassessed first. Setting new priorities is not recommended before assessment and establishing diagnoses.

The nurse is caring for a patient who has an open wound. When evaluating the progress of wound healing, what is the nurse's priority action? a. Ask the nursing assistive personnel if the wound looks better. b. Document the progress of wound healing as "better" in the patient's chart. c. Measure the wound and observe for redness, swelling, or drainage. d. Leave the dressing off the wound for easier access and more frequent assessments.

ANS: C The nurse performs evaluative measures, such as completing a wound assessment, to evaluate wound healing. Nurses do not delegate assessment to nursing assistive personnel. Documenting "better" is subjective and does not objectively describe the wound. Leaving the dressing off for the nurse's benefit of easier access is not a part of the evaluation process.

After reviewing the database, the nurse discovers that the patient's vital signs have not been recorded by the nursing assistant. With this in mind, what clinical decision should the nurse make? a. Administer scheduled medications assuming she would have been informed if the vital signs were abnormal. b. Have the patient transported to the radiology department for a scheduled x-ray, and review vital signs upon return. c. Ask the nursing assistant to record the patient's vital signs before administering medications. d. Omit the vital signs because the patient is presently in no distress.

ANS: C The nurse should ask the nursing assistant to record the vital signs for review before administering medicines or transporting the patient to another department. The nurse should not make assumptions when providing high-quality patient care, and omitting the vital signs is not an appropriate action.

A nurse is making a home visit and discovers that a patient's wound infection has gotten worse. After cleaning and re-dressing the wound, what should the nurse do? a. Ask the home health agency nurse manager to contact the health care provider. b. Document the findings and confirm with the patient the date of the next home visit. c. Notify the health care provider of the findings before leaving the home. d. Tell the patient that the health care provider will be notified before the next visit.

ANS: C The nurse should notify the health care provider before leaving the home. Nurse/health care provider collaboration and open communication are important in fostering trust and respect. The manager should avoid taking care of problems for staff. The staff nurse needs to learn how to professionally communicate with other members of the health care team and demonstrate interdisciplinary collaboration.

After assessing the patient and identifying the need for headache relief, the nurse administers acetaminophen (Tylenol) for the patient's headache. What is the nurse's next priority action for this patient? a. Eliminate Acute pain from the nursing care plan. b. Direct the nursing assistant to ask if the patient's headache is relieved. c. Reassess the patient's pain level in 30 minutes. d. Revise the plan of care.

ANS: C The nurse's next priority action for this patient is to evaluate whether the nursing intervention of administering Tylenol was effective. The nurse does not have enough evaluative data at this point to determine whether the nursing diagnosis of Acute pain needs to be discontinued. Assessment is the nurse's responsibility and is not to be delegated to a nursing assistant. The nurse does not have enough evaluative data to determine whether the patient's plan of care needs to be revised.

A nursing student asks her nursing instructor to describe the primary purpose of evaluation. Which of the following statements made by the nursing instructor is most accurate? a. "During evaluation, you determine whether all nursing interventions were completed." b. "During evaluation, you determine when to downsize staffing on nursing units." c. "Nurses use evaluation to determine the effectiveness of nursing care." d. "Evaluation eliminates unnecessary paperwork and care planning."

ANS: C The purpose of evaluation is to determine the effectiveness of nursing care. The other options are not true statements. During evaluation, you do not simply determine whether nursing interventions were completed. The evaluation process is not used to determine when to downsize staffing or how to eliminate paperwork and planning.

Which nursing diagnostic statement is accurately written for a patient with a medical diagnosis of pneumonia? a. Risk for infection related to lower lobe infiltrate b. Risk for deficient fluid volume related to dehydration c. Impaired gas exchange related to alveolar-capillary membrane changes d. Ineffective breathing pattern related to pneumonia

ANS: C The related to factor of alveolar-capillary membrane changes is accurately written because it is a patient response to the disease process of pneumonia that the nurse can treat. The related to factors lower lobe infiltrate, dehydration, and pneumonia are all medical diagnoses that the nurse cannot change. Lower lobe infiltrate is simply another term for pneumonia, a medical diagnosis. The related to factor should be the cause of the problem (nursing diagnosis) that a nurse can address

A patient exhibits the following symptoms: tachycardia, increased thirst, headache, decreased urine output, and increased body temperature. After analyzing these data, the nurse assigns which of the following nursing diagnoses? a. Adult failure to thrive b. Hypothermia c. Deficient fluid volume d. Nausea

ANS: C The signs the patient is exhibiting are consistent with dehydration. Even without knowing the clinical manifestations of dehydration, the question can be answered by the process of elimination. Adult failure to thrive, hypothermia, and nausea are not appropriate diagnoses because data are insufficient to support these diagnoses.

A hospital's wound nurse consultant made a recommendation for nurses on the unit to continue the patient's dressing changes as previously ordered. The nurses on the unit should incorporate this recommendation into the patient's plan of care by a. Assuming that the wound nurse will perform all dressing changes. b. Requesting that the physician look at the wound herself. c. Including dressing change instructions and frequency in the plan of care. d. Encouraging the patient to perform the dressing changes.

ANS: C The wound nurse clearly recommends that nurses on the unit, not the patient, should continue dressing changes. The nurses should not make a wrong assumption that the wound nurse is doing all the dressing changes. The recommendation states for the nurses to do the dressing changes. If the nurses feel strongly about obtaining another opinion, then the physician should be contacted. No evidence in the question suggests that the patient needs a second opinion.

Which of the following are nursing interventions? (Select all that apply.) a. Order chest x-ray for suspected humerus fracture. b. Order antibiotics for a respiratory infection. c. Reposition a patient who is on bed rest. d. Remind a patient to cough and deep breathe after surgery. e. Write transfer orders to move a patient to another hospital unit.

ANS: C, D A nursing intervention is defined as any treatment based on clinical judgment and knowledge that a nurse performs to enhance patient outcomes. Repositioning a patient and encouraging coughing and deep breathing are examples of nursing interventions. Ordering a chest x-ray, ordering antibiotics, and writing transfer orders are examples of medical interventions performed by a health care provider.

Which patient outcome statement includes all seven guidelines for writing goal and outcome statements? a. The patient will ambulate in hallways. b. The nurse will administer pain medication every 4 hours to keep the patient free from discomfort. c. The nurse will monitor the patient's heart rhythm continuously this shift. d. The patient will feed self at all mealtimes today without complaints of shortness of breath.

ANS: D A goal or outcome statement should be patient-centered; should address one patient response; should be observable, measurable, and time-limited; should be mutually set by nurse and patient; and should be realistic. The statement "The patient will feed self at all mealtimes today without complaints of shortness of breath" includes all seven criteria for goal writing. "The patient will ambulate in hallways" is missing a time limit. Administering pain medication and monitoring the patient's heart rhythm are nursing interventions; they do not reflect patient behaviors or actions.

A staff nurse delegates a task to a nursing assistant, knowing that the assistant has never performed the task before. As a result, the patient is injured, and the nurse defensively states that the nursing assistant should have known how to perform such a simple task. This nurse is demonstrating lack of a. Responsibility. b. Autonomy. c. Authority. d. Accountability.

ANS: D Accountability refers to individuals being answerable for their actions. The nurse in this situation is not taking ownership of the inappropriate delegation of a task. Autonomy is freedom of choice and responsibility for the choices. Responsibility refers to the duties and activities that an individual is employed to perform. Authority refers to legitimate power to give commands and make final decisions specific to a given position.

A patient presents to the emergency department following a motor vehicle crash and suffers from a right femur fracture. The leg is stabilized in a full leg cast. Otherwise, the patient has no other major injuries, is in good health, and complains only of moderate discomfort. What is the most pertinent nursing diagnosis to be included in the plan of care based on the assessment data provided? a. Posttrauma syndrome b. Constipation c. Urinary retention d. Acute pain

ANS: D Based on the assessment data provided, the only supportive evidence for one of the diagnosis options is "Complains of moderate discomfort," which would support Acute pain. No supportive evidence is provided for any of the other diagnoses. The patient may indeed develop signs or symptoms of the other problems, but supportive data are presently lacking in the provided information.

A newly admitted patient who is morbidly obese asks the nurse to assist her to the bathroom for the first time. What should the nurse do first? a. Ask for at least two other assistive personnel to come to the room. b. Medicate the patient to alleviate discomfort while ambulating. c. Offer the patient a walker. d. Review the patient's activity orders.

ANS: D Before intervening, the nurse must check the patient's orders. For example, if the patient is on bed rest, the nurse will need to explain the use of a bedpan rather than helping the patient get out of bed to go to the bathroom. Interventions sometimes will be determined by orders and availability of resources. Asking for assistive personnel is appropriate after making sure the patient can get out of bed. If the patient is obese, the nurse will likely need assistance in getting the patient to the bathroom. Medicating the patient before checking the orders is not advised in this situation. Before medicating for pain, the nurse needs to perform a pain assessment. Offering the patient a walker is a premature intervention until the orders are verified.

Components of a nursing health history include a. Current treatment orders. b. Nurse's concerns. c. Nurse's goals for the patient. d. Patient expectations.

ANS: D Components of a nursing health history include physical examination findings, patient expectations, environmental history, and diagnostic data. Current treatment orders are located under the Orders section in the patient's chart and are not a part of the nursing health history. Patient concerns, not nurse's concerns, are included in the database. Goals that are mutually established, not nurse's goals, are part of the nursing care plan.

A patient's son decides to stay at the bedside while his father is confused. When developing the plan of care for this patient, what should the nurse do? a. Individualize the care plan only according to the patient's needs. b. Request that the son leave at bedtime, so the patient can rest. c. Suggest that a female member of the family stay with the patient. d. Involve the son in the plan of care as much as possible.

ANS: D Family should be included in the plan of care as much as possible. The family is a resource to help patients meet health care goals. Meeting some of the family's need as well as the patient's needs will possibly improve the patient's level of wellness. The son should not be asked to leave if at all possible. In some situations, it may be best that family members not remain in the room, but no evidence in the question stem suggests that this is the case in this situation. Suggesting that a female member of the family stay is not justified without a legitimate reason. No reason is given in this question stem for such a suggestion.

A patient was recently diagnosed with pneumonia. The nurse and the patient have established a goal that the patient will not experience shortness of breath with activity in 3 days with an expected outcome of having no secretions present in the lungs in 48 hours. Which of the following is an appropriate evaluative measure demonstrating progress toward this goal? a. Nonproductive cough present in 4 days b. Scattered rhonchi throughout all lung fields in 2 days c. Respirations 30/minute in 1 day d. Lungs clear to auscultation following use of inhaler

ANS: D Goals are broad statements that describe changes in a patient's condition or behavior. Expected outcomes are shorter-term measurable criteria used to evaluate goal achievement. When an outcome is met, you know that the patient is making progress toward goal achievement. In this case, the patient's goal is to not experience shortness of breath with activity in 3 days. One way to achieve this goal is for the patient to experience no respiratory secretions in the airway. One way for the nurse to evaluate the expected outcome is to assess the patient's lung sounds. If the lung sounds are clear, at least periodically throughout the day, the nurse can determine that the patient is making progress toward achieving the expected outcome. The time frame of 4 days in the first option is not appropriate because this time frame exceeds the time frame stated in the goal. Scattered rhonchi indicate fluid in the lungs, and a respiratory rate of 30 per minute is elevated. This indicates that the patient is still probably experiencing respiratory distress.

After completing a thorough database and carrying out nursing interventions based on priority diagnoses, the nurse proceeds to which step of the nursing process? a. Assessment b. Planning c. Implementation d. Evaluation

ANS: D In the five-step nursing process, evaluation is the last step following assessment, diagnosis, planning, and intervening. Assessment involves gathering information about the patient. Next, nursing diagnoses are determined. During the planning phase, patient outcomes are determined. Implementation involves carrying out appropriate nursing interventions

In which step of the nursing process does the nurse determine if the patient's condition has improved and whether the patient has met expected outcomes? a. Assessment b. Planning c. Implementation d. Evaluation

ANS: D In the five-step nursing process, the evaluation phase is the final step involving conducting evaluative measures to determine whether nursing interventions have been effective and whether the patient has met expected outcomes. Assessment, the first step of the process, includes data collection, validation, sorting, and documentation. Planning, the third step of the process, involves setting priorities, identifying patient goals and outcomes, and prescribing nursing interventions. During implementation, nurses initiate nursing care, which is necessary to help patients achieve their goals.

A nurse who is caring for a patient with a pressure ulcer fails to apply the recommended dressing according to hospital policy. If the patient is harmed, the nurse could be subject to legal action for not adhering to a. Fairness. b. Intellectual standards. c. Independent reasoning. d. Institutional practice guidelines.

ANS: D Institutional practice guidelines are established standards and policies that can be used in court to make judgments about nursing actions. Intellectual standards are guidelines or principles for rational thought. Fairness and independent reasoning are two examples of critical thinking attitudes that are designed to help nurses make clinical decisions.

A nursing assessment for a patient with a spinal cord injury leads to several pertinent problems that a nurse can treat. While developing the plan of care, which nursing diagnosis is the highest priority for this patient? a. Risk for impaired skin integrity b. Risk for infection c. Spiritual distress d. Reflex urinary incontinence

ANS: D Reflex urinary incontinence is highest priority. If a patient's incontinence is not addressed, then the patient is at higher risk of impaired skin integrity and infection. Remember that the Risk for diagnoses are potential problems. They may be prioritized higher in some cases, but not in this situation. Spiritual distress is an actual diagnosis, but the adverse effects that could result from not assisting the patient with urinary elimination take priority in this case. Physiological problems do not always take priority, but the greatest harm could come to this patient if urinary incontinence is not prioritized.

A patient has reduced muscle strength following a left-sided stroke and is at risk for falling. Which intervention is most appropriate for the nursing diagnostic statement, Risk for falls? a. Encourage patient to remain in bed most of the shift. b. Keep all side rails down at all times. c. Place patient in room away from the nurses' station if possible. d. Assist patient into and out of bed every 6 hours or as tolerated.

ANS: D Risk for falls is a potential nursing diagnosis; therefore the nurse needs to implement actions that will prevent a fall. Assisting the patient into and out of bed is the most appropriate intervention to prevent the patient from falling. Encouraging activity builds muscle strength, and helping the patient with transfers ensures patient safety. Encouraging the patient to stay in bed will not promote muscle strength. Decreased muscle strength is the risk factor placing the patient in jeopardy of falling. The side rails should be up, not down, according to agency policy. This will remind the patent to ask for help to get up and will keep the patient from rolling out of bed. The patient should be placed near the nurses' station, so a staff member can quickly get to the room and assist the patient if necessary.

Which of these approaches would be most appropriate for a nurse to take when faced with the challenge of performing many tasks in one shift? a. Evaluate the effectiveness of all tasks when all tasks are completed. b. Delegate tasks the nurse does not like doing. c. Do as much as possible by oneself before seeking assistance from others. d. Complete one task before starting another task.

ANS: D The appropriate clinical care coordination skill in these options is to complete one task before starting another task. Evaluation is ongoing and should not be completed just at the end of task completion. The nurse should not delegate tasks simply because the nurse does not like doing them. The nurse should use delegation skills and time management skills instead of trying to do as much as possible by herself. The nurse needs to complete many tasks and treatments on each shift. Some tasks need to be delegated so patients receive the care they need in a timely manner. Good time management involves setting goals to help the nurse complete one task before starting another task.

Which intervention is most appropriate for the nursing diagnostic statement, Impaired verbal communication related to loss of facial motor control and decreased sensation? a. Obtain an interpreter for the patient as soon as possible. b. Assist the patient in performing swallowing exercises each shift. c. Ask the family to provide a sitter to remain with the patient at all times. d. Provide the patient with a writing board each shift.

ANS: D The cause of the patient's problem will help guide the nurse to the proper nursing intervention. If the patient has a problem with verbal communication, then the nurse should choose an intervention that will address the problem. Providing the patient with a writing board will allow the patient to communicate by writing because the patient is unable to communicate verbally at this time. Obtaining an interpreter might be an appropriate intervention if the patient spoke a foreign language. Assisting with swallowing exercises will help the patient with swallowing, which is a different nursing diagnosis from Impaired verbal communication. Asking the family to provide a sitter at all times is many times unrealistic and does not promote the patient's independence, as does providing a writing board.

Which of these options is a patient outcome indicating positive progress toward resolving the nursing diagnosis of Acute confusion? a. Side rails are up with bed alarm activated. b. Patient denies pain while ambulating with assistance. c. Patient wanders halls at night. d. Patient correctly states names of family members in the room.

ANS: D The identified nursing diagnosis is Acute confusion. The outcome for this diagnosis would address a decrease or absence of confusion. One sign of orientation is when a patient responds to questions appropriately. Thus, one possible sign that a patient's confusion is improving is seen when a patient can correctly state the names of family members in the room. Keeping the side rails up and using a bed alarm are interventions to promote patient safety and prevent falls. The patient's denying pain indicates positive progress toward resolving a diagnosis of Acute or Chronic pain. The patient's wandering the halls is a sign of confusion.

A nurse manager conducts rounds on the unit and discovers that expired stock medicine is still in the cabinet despite the e-mail she sent stating that it had to be discarded. The staff nurse dress code is not being adhered to, and the staff lounge is not kept neat and tidy as she requested in the same e-mail. Several staff nurses deny having received the e-mail. After evaluating this situation, one way the nurse manager could resolve the issue is to a. Include the findings on each staff member's annual evaluation. b. Close the staff lounge. c. Enforce a stricter dress code. d. Place a hard copy of announcements and unit policies in each staff member's mailbox.

ANS: D The identified problem is lack of staff communication. Therefore, the answer pertaining to communication is the correct answer. Staff communication is a challenge for managers, but using a variety of approaches can help. Sending an e-mail was not effective; therefore, giving each staff member a hard copy along with e-mailing is another approach the manager can take. Including the findings on evaluations, closing the lounge, and enforcing stricter dress codes do not address the problem and offer a proposed solution. An effective nurse manager uses a variety of approaches to communicate quickly and accurately with all staff.

A patient recovering from a leg fracture after a fall states that he has dull pain in the affected leg and rates it as a 7 on a 0 to 10 scale. The patient is not able to walk around in the room with crutches because of leg discomfort. What is the priority nursing intervention for this patient? a. Assist the patient to walk in the room with crutches. b. Obtain a walker for the patient. c. Consult physical therapy. d. Administer pain medication.

ANS: D The nurse clusters and organizes patient data, which leads to several nursing diagnoses. In this question, nursing diagnoses include Impaired physical mobility and Acute pain. Acute pain is the priority because the nurse can address the problem of immobility after the patient receives adequate pain relief. Assisting the patient to walk or obtaining a walker will not address the pain the patient is experiencing. When planning, the nurse needs to address the diagnosis of highest priority first.

A registered nurse administers pain medication to a patient suffering from fractured ribs. What type of nursing intervention is this nurse implementing? a. Collaborative b. Independent c. Interdependent d. Dependent

ANS: D The nurse does not have prescriptive authority to order pain medications, unless the nurse is an advanced practice nurse. The intervention is therefore dependent. A collaborative, or interdependent, intervention involves therapies that require combined knowledge, skill, and expertise from multiple health care professionals. An independent intervention does not require an order or collaboration with other professionals.

Which of these statements made by a patient who has Disturbed body image is the best indicator of the patient's patient early acceptance of body image? a. "I just won't go to the pool this summer." b. "I'm worried about what those other girls will think of me." c. "I can't wear that color. It makes my hips stick out." d. "I'll wear the blue dress. It matches my eyes."

ANS: D The nurse evaluating interventions for the diagnosis Disturbed body image is assessing for positive comments made by the patient indicating acceptance of the patient's looks and body image. The only positive comment made is that the patient is wearing the blue dress to match her eyes. The other comments do not reflect positive changes in body image.

The nurse begins a shift assessment by examining a surgical dressing that is saturated with serosanguineous drainage on a patient who had open abdominal surgery yesterday (or 1 day ago). The nurse is performing what type of assessment approach in this situation? a. Comprehensive assessment using Gordon's Functional Health Patterns b. General to specific assessment c. Activity-exercise pattern assessment d. Problem-oriented assessment

ANS: D The nurse is not doing a complete, general assessment and then focusing on specific problem areas. Instead, the nurse focuses immediately on the problem at hand and performs a problem-oriented assessment. Utilizing Gordon's Functional Health Patterns is an example of a structured database-type assessment technique. The nurse in this question is performing a specific problem-oriented assessment approach. The nurse is not performing an activity-exercise pattern assessment in this question.

A patient verbalizes a low pain level of 2 out of 10 but exhibits extreme facial grimacing while moving around in bed. What is the nurse's best action in response to her observation? a. Proceed to the next patient's room while making rounds. b. Offer a massage because the patient does not want any more pain medicine. c. Administer the pain medication ordered for moderate to severe pain. d. Ask the patient about the facial grimacing with movement.

ANS: D The nurse needs to clarify what she observes with what the patient states. Proceeding to the next room is ignoring this visual cue. The nurse cannot assume the patient does not want pain medicine just because he rates his pain level at 2 out of 10. The nurse should not administer medication for moderate to severe pain if it is not necessary.

A charge nurse should instruct a new nurse taking care of a patient with hypercholesterolemia to make which of these lifestyle modifications? a. High-protein, high-fat diet b. Decreased walking frequency from three times to two times a week c. Discontinuation of antihypertensive medications d. Smoking cessation

ANS: D The only appropriate lifestyle modification among these options is smoking cessation. Hypercholesterolemia can be caused by a high-fat diet; therefore, a high-fat diet should be avoided. Exercise is usually recommended, not contraindicated. The patient should continue blood pressure medications. In this question, the nurse is using the aspect of evaluation in clinical care coordination.

A patient with a spinal cord injury is seeking to enhance his urinary elimination abilities by learning self-catheterization versus assisted catheterization by home health nurses and family members. The nursing diagnosis Readiness for enhanced urinary elimination is which type of diagnosis? a. Actual b. Risk c. Health promotion d. Wellness

ANS: D The patient's desire is to increase his specific level of wellness to a higher level of wellness. An actual diagnosis describes human responses to health conditions or life processes that exist. A risk diagnosis describes human responses to health conditions/life processes that will possibly develop. A health promotion diagnosis is a clinical judgment of a patient's motivation and desire to enhance well-being and does not require a current level of wellness.

A new graduate nurse is not sure what the heart sound is that she is listening to on a patient. To avoid diagnostic error, what should the nurse do? a. Assign the nursing diagnosis of Decreased cardiac output. b. Ask the patient if he has a history of cardiac problems before assigning the diagnosis of Decisional conflict. c. Check the previous shift's assessment and document what was noted on the last shift. d. Ask a more experienced nurse to listen also.

ANS: D The potential diagnostic error here is an error in data collection. If a new nurse is not comfortable with his/her assessment technique, he or she should ask another nurse to validate the findings. Diagnosing before validating assessment findings leads to the potential for error. Assessment data are not sufficient to assign the diagnoses Decreased cardiac output and Decisional conflict. Every nurse needs to perform his or her own assessment. A patient's status can change very rapidly. A nurse who copies the previous shift's assessment is not practicing according to standards of practice and is violating the code of ethics.

4. A nurse manager is evaluating patient outcomes on the hospital unit. The nurse manager discovers that the re-admission rate of hospitalized patients is very high on this unit. The nurse manager desires improved coordination of care and accountability for cost-effective quality care. The nursing care delivery model best suited to these needs is a. Total patient care. b. Primary nursing. c. Team nursing. d. Case management.

ANS: D What is unique about case management is that clinicians, as individuals or as part of a collaborative group, oversee the management of patient groups with specific case types and usually are held accountable for some standard of cost management and quality. Case management is a care approach that coordinates and links health care services to patients and families while streamlining costs. In the team nursing care model, the RN assumes the role of group or team leader and leads a team made up of other RNs, licensed vocational nurses, and nurse assistants or technicians. Total patient care involves an RN being responsible for all aspects of care for one or more patients. Primary nursing places RNs at the bedside more, assuming responsibility for a caseload of patients over time. This model, however, does not require an all-RN staff as is required for total patient care.

In which nursing care delivery model are clinicians held accountable for some standard of cost-effectiveness and quality of care? a. Total patient care b. Primary nursing c. Team nursing d. Case management

ANS: D What is unique about case management is that clinicians, as individuals or as part of a collaborative group, oversee the management of patient groups with specific case types and usually are held accountable for some standard of cost management and quality. Case management is a care approach that coordinates and links health care services to patients and families while streamlining costs. In the team nursing care model, the RN assumes the role of group or team leader and leads a team made up of other RNs, licensed vocational nurses, and nurse assistants or technicians. Total patient care involves an RN being responsible for all aspects of care for one or more patients. Primary nursing places RNs at the bedside more, assuming responsibility for a caseload of patients over time. This model, however, does not require an all-RN staff as is required for total patient care.

The nurse is caring for seven patients this shift. After completing their assessments, the nurse states that he doesn't know where to begin in developing care plans for these patients. Which of the following is an appropriate suggestion by another nurse? a. "Choose all the interventions and perform them in order of time needed for each one." b. "Make sure you identify the scientific rationale for each intervention first." c. "Decide on goals and outcomes you have chosen for the patients." d. "Begin with the highest priority diagnoses, then select appropriate interventions."

ANS: D When developing a plan of care, the nurse needs to rank the nursing diagnoses in order of priority, then select appropriate interventions. Choosing all the interventions should take place after ranking of the diagnoses, and interventions should be prioritized by patient needs, not just by time. The chosen interventions should be evidence-based with scientific rationales, but the diagnoses need to be prioritized first to prioritize interventions. Goals for a patient should be mutually set, not just chosen by the nurse.