Module 36 Clinical Decision Making/The Nursing Process/The Nursing Plan of Care

The nurse auscultates a patient's breath sounds after the patient receives an albuterol nebulizer treatment secondary to wheezing. The nurse finds that the patient is still wheezing despite the therapy. Which aspect of Tanner's clinical judgment model is the nurse displaying? A. Noticing B. Responding C. Interpreting D. Reflecting

A According to Tanner's clinical judgment model, the nurse is displaying noticing by recognizing the presence or absence of expected significant cues from the patient's response to an illness or medical condition. Interpreting involves using logical reasoning to determine appropriate action after noticing a clinical finding. Responding occurs when the nurse acts based on what is found and interpreted. When the nurse reviews the clinical action, the nurse is reflecting.

The nurse is supervising an unlicensed assistive personnel (UAP). Which task should the nurse delegate to the UAP? A. Evaluating color of urine B. Measuring intake and output C. Analyzing urine test results D. Determining a patient's hydration status

B Delegating patient care and assigning tasks are important responsibilities for registered nurses (RNs) because healthcare facilities use licensed practical nurses and many unlicensed assistive personnel (UAP). A UAP may perform tasks such as measuring intake and output, but the RN is still responsible for analyzing data, planning care, and evaluating outcomes. Analyzing test results, evaluating the color of a urine specimen, and determining a patient's hydration status all fall under assessment or evaluation.

The nurse is caring for a young woman who is receiving antibiotics for a urinary tract infection. The patient returns to the clinic complaining of continued burning urination 4 days after starting the medication. The nurse looks at the patient's chart and notices that a urine culture was never performed. Which feature of Tanner's clinical judgment model is displayed here? A. Reflecting B. Responding C. Noticing D. Interpreting

A According to Tanner's clinical judgment model, this is an example of reflecting because the nurse is reviewing the previous clinical actions. Noticing is the recognition of the presence or absence of expected significant cues from the patient's response to an illness or medical condition. Interpreting involves using logical reasoning to determine appropriate action after noticing a clinical finding. Responding occurs when the nurse acts based on what is found and interpreted.

The nurse educator is reviewing Tanner's clinical decision-making model and asks the students about the purpose of reflecting. Which response by a student is correct? A. "To learn from actions in order to make adjustments to future practice" B. "To gain understanding about a situation" C. "To sense what is happening in a situation" D. "To analyze a situation to choose an action"

A According to Tanner's model, reflecting helps the nurse learn from actions to make adjustments. Interpreting involves using logical reasoning to gain understanding about a situation and determine appropriate actions. Noticing requires a sense of what is happening in the patient situation. Responding is analyzing a situation to choose the best course of action.

The nurse evaluates the plan of care for a patient admitted with pneumonia who still has difficulty breathing related to an ineffective breathing pattern. Which step should the nurse include to select new interventions for the plan of care? A. Evaluating the current interventions and patient needs B. Delegating the selection of the new interventions to another nurse C. Setting more realistic patient goals and easier interventions D. Deleting the current nursing diagnosis because it was not meeting the patient's needs

A As the nurse decides to revise the plan of care and develop new interventions, the nurse should evaluate the current nursing interventions and patient needs. This patient may need to move at a slower pace or may have other comorbidities that interfere with goal attainment. Goals may need to be revised, but they do not need to be written to be easier for the patient to attain because this may not facilitate healing. The nurse would not delegate the plan of care to another nurse or delete the nursing diagnosis because these would not be appropriate actions.

The nurse determines the following nursing diagnosis for a patient: Impaired Urinary Elimination related to retention secondary to enlarged prostate. Which portion represents Axis 3 in the nursing diagnosis? A. Impaired B. Urinary C. Retention D. Enlarged prostate

A Axis 3 consists of the modifier that gives meaning to the nursing diagnosis. In this diagnosis, the term Impaired represents Axis 3. Urinary represents Axis 1 because it is the focus of the nursing diagnosis. "Enlarged prostate" would be Axis 7 because it is the current or actual health problem. "Retention" is Axis 4 because it describes the focus of the problem.

A respiratory therapist is working with pediatric patients with cystic fibrosis. When the therapist asks the nurse about treatment guidelines for the patient, the nurse refers the therapist to a clinical pathway algorithm. Which describes the goal of this algorithm? A. Ensure standardization of care provided across clinical disciplines. B. Provide a visual depiction of the nursing care plan. C. Improve time efficiency when providing care for patients. D. Define interventions for which each discipline will be held accountable.

A Clinical pathways developed as algorithms are designed to standardize care provided across clinical disciplines; thus, this best describes the goal of these pathways. They are also intended to improve the quality of care and outcomes. A concept map is a visual depiction of a nursing care plan, not a clinical pathway. Standardized care plans are used to increase time efficiency, not clinical pathway algorithms. Standards of care, not clinical pathway algorithms, define interventions for which different professionals are held accountable.

The nurse is presenting how to differentiate between patient goals and outcomes. Which statement by the nurse is accurate? A. "Goals are patient responses, whereas outcomes are the patient's response to care." B. "Goals evaluate the patient's response to the plan of care developed by the nurse." C. "Goals are established by the nurse and used to evaluate patient outcomes." D. "Goals include the subjective and objective data observed by the nurse."

A Goals are observable patient responses to the interventions provided by the nurse. Outcomes evaluate the patient's response to the plan of care. Goals should be mutually established between the nurse and the patient; they are not specifically set by the nurse and are not used to evaluate patient outcomes. Assessment involves subjective and objective data. Outcomes, not goals, evaluate the patient's response to the plan of care.

The nurse is caring for a patient who was admitted with abdominal pain. The patient's complete blood count (CBC) is normal, but the nurse is still concerned about the patient having a gastrointestinal bleed and monitors the patient closely. Which cognitive skill is the nurse displaying? A. Intuition B. Reasoning C. Reflection D. Inquiry

A Intuition is the use of nursing knowledge and experience for understanding without the conscious use of reasoning. Inquiry uses questions to find alternative approaches or solutions. Nurses use intellect to identify salient cues and group them into meaningful patterns. Clinical reasoning is the careful evaluation of information to improve patient care. Reflection is looking back at a situation to determine what worked, what did not work, or what could have been done better.

The nurse has developed a plan of care for a patient with a specific goal. The patient was unable to meet the goal by the stated time frame. Before revising the goal, which step must the nurse perform? A. Evaluate factors impeding goal attainment. B. Compare patient progress with that of other patients. C. Ask the healthcare provider for a more reasonable goal. D. Document noncompliance with the plan.

A Occasionally, the plan of care may need to be revised if the goal is not met or is only partially met. Therefore, the nurse would revise the plan of care and extend the amount of time needed to meet the goal after evaluating factors that impede the patient from meeting the goal. The nurse would not compare one patient's progress against another, nor would the nurse document the patient being noncompliant. The nurse might discuss the patient's difficulty meeting the goal but base the new goal on the nursing assessment.

The nurse is caring for a patient who is diagnosed with diabetes mellitus. Which evaluation statement should indicate that the plan of care is working? A. 04/03/2018, 1800: Goal partially met: Patient is able to identify three foods instead of five foods high in sugar content. B. 04/03/2018, 1830: Goal partially met: Patient demonstrates use of home oxygen machine. C. 04/03/2018, 1750: Goal met: Patient voices understanding of treatment therapy. D. 04/03/2018: Goal unmet: Patient demonstrates use of insulin injection successfully.

A Once the nurse determines if a goal has been met, the nurse writes an evaluation statement on the plan of care. Evaluation statements must contain the date and time of evaluation, and they must state whether the goal was met, partially met, or not met. The option stating the goal is met indicates that the plan of care is finished and that new diagnoses and interventions should be developed. The fact that the patient can self-inject insulin is fully met, not partially met. The use of oxygen therapy is unrelated to diabetes mellitus self-care, and it should be documented as the goal is fully met, not partially met.

The nurse is creating a concept map for a patient. Which guideline should be followed when preparing a concept map? A. Following the sequence of the nursing process B. Individualizing the care by using checklists and blank lines C. Highlighting medical treatments provided by other providers D. Including the rationales for each nursing intervention

A One guideline to follow when creating a concept map is to follow the sequence of the nursing process. Individualizing the plan of care by using provided checklists and blank lines is a feature of a standardized care plan. A multidisciplinary clinical pathway includes medical treatments provided by other healthcare providers. Including the rationale for each nursing intervention is an expectation of nursing students when creating a column plan of care.

The nurse identifies the diagnosis Imbalanced Nutrition: Less than Body Requirements related to poor nutrition, as evidenced by low serum albumin level, for a 65-year-old patient with osteoporosis. Which format should the nurse use to write goals for this patient? A. SMART B. CBE C. SBAR D. PIE

A SMART charting is used to write a goal statement and stands for specific single action, measurable, attainable, relevant, and time-limited. SBAR, PIE, and CBE are all forms of charting, not goal setting. SBAR stands for situation, background, assessment, and recommendations. PIE stands for problem, intervention, and evaluation. CBE stands for charting by exception and is used to document only abnormal findings.

The nurse is caring for a 3-year-old and an 8-year-old patient who are sharing the same room. Which intervention is appropriate for the 8-year-old but not the toddler? A. Allowing the child to help the care provider whenever possible B. Providing age-appropriate explanations C. Using play therapy and dolls and toys to explain treatments D. Giving options when appropriate

A School-aged children benefit from hands-on exploration of equipment and materials and can help the care provider whenever possible, which can help to reduce anxiety. Both age groups can benefit from age-appropriate explanations and options when appropriate. Toddlers can use play therapy to better understand medical treatments, but this is not a good intervention for a school-aged child.

The nurse works on a cardiopulmonary stepdown unit that uses standardized care plans for patients. In which patient scenario would a standardized plan of care be most appropriate? A. A patient 2 days post-stroke, with vital signs within normal limits, has begun the rehabilitation program. B. The family of a patient with chronic obstructive pulmonary disease (COPD) exacerbation indicates they are tired of dealing with the patient's issues because the patient refuses to quit smoking. C. A patient 1 week post-stroke, tearful and depressed, is not participating actively in rehabilitation efforts and is refusing to eat. D. A patient with recently diagnosed inoperable lung cancer has been homeless for the past 7 years.

A Standardized care plans are used for predictable, commonly occurring problems for a specific diagnosis. In this case, a patient post-stroke who has begun the rehabilitation program would fit these criteria. Standardized care plans are not appropriate for patients with issues not common to all patients with a similar diagnosis, such as a post-stroke patient refusing to eat or participate in rehabilitation efforts, a COPD patient with family issues, and a patient with lung cancer who is homeless.

The nurse manager is preparing an annual performance appraisal for a staff nurse who has worked on a medical-surgical care area for 2 years. The manager determines that the staff nurse's level of proficiency is competent. Which action by the staff nurse prompts the manager to make this decision? A. Focused on a specific patient problem when planning care B. Referred to the procedure manual to change the dressing at an intravenous (IV) site C. Determined how a new medication would impact a patient's other health problems D. Waited for direction from charge nurse before providing care

A The competent practitioner focuses on a specific problem when planning patient care. The novice nurse has no experience and uses rules and needs direction when providing care. The novice nurse would refer to the procedure manual to change an IV dressing and wait for direction from the charge nurse before providing care. The proficient nurse can see the whole picture. The nurse who is proficient would determine how a new medication impacts a patient's other health problems.

The nurse is working on a concept map for a patient with multiple health problems. Which noncomputerized method should the nurse consider that would most easily allow the nurse to move data around until the concept map is finished? A. Different colored sticky notes B. Formatted concept-map template C. Pencil and paper D. Different colored ink pens and paper

A The easiest noncomputerized way to make a concept map with the ability to move data around is sticky notes because they come in a variety of shapes and colors. A pencil and paper, different colored pens and paper, and a concept-map template can also be used but would not provide the ability to easily move data around.

The nurse is planning interventions for a patient with a nursing diagnosis of Activity Intolerance related to weakness, as evidenced by inability to walk two steps. Which part of the nursing diagnosis statement is used as the framework for planning nursing interventions? A. Weakness B. Previous health history C. Inability to walk two steps D. Activity Intolerance

A The framework for selecting nursing interventions is created when the correct problem is identified during the assessment and nursing diagnosis phases. In this instance, it is the weakness. The diagnostic label, Activity Intolerance, may have several etiologies, such as pain or sedentary lifestyle, so it is important to define the cause of the problem so that interventions are appropriate. A patient's previous health history is not used as the framework for identifying nursing interventions. A sign of not being able to walk two steps helps explain how a problem is affecting a patient.

The nurse is caring for a patient with an electrolyte disturbance. The healthcare provider asks the nurse to draw an arterial blood gas (ABG), but the nurse has never performed the procedure and asks a more senior nurse to assist. Which critical thinking attitude is exemplified by the nurse's action? A. Awareness of self-limits B. Perseverance C. Approaching situations objectively D. Differentiating fact from fiction

A The nurse has demonstrated an awareness of self-limits and recognizes that the lack of experience in performing this procedure requires that the nurse asks for help. Differentiating fact from fiction and approaching situations objectively are aspects of intellect, not an attitude of critical thinking as used by the nurse in this scenario. The nurse is not demonstrating perseverance (the ability to stick with it) in this clinical situation.

The nurse with 15 years of obstetric experience is caring for a patient in labor who is reporting extreme pain. The nurse knows that the patient is likely getting very close to delivery but asks the provider to come and evaluate the patient. Which decision-making process is reflected in this situation? A. Intuition B. Trial and error C. The scientific method D. The nursing process

A The nurse is relying on intuition from the 15 years of previous experience. Intuition is relying on subconscious clues and previous experience to find patterns in patient behavior. Trial and error is the process of trying different options to see what works and what does not, such as trying different positions to find one that is comfortable for the patient. The scientific process is a formal, investigative approach to problem solving, which is not the process used by this nurse. The nursing process uses five defined steps (assessment, diagnosis, planning, implementation, and evaluation) to solve a problem.

The nurse is implementing care for patients in an acute care facility and asks a patient about dietary restrictions related to religion or ethnicity. Which nursing goal is the nurse meeting with this question? A. Provide culturally competent care. B. Determine need for special services. C. Follow prescribed dietary needs. D. Promote contentment in the patient.

A The nurse should ask about dietary preferences related to religion and ethnicity to provide culturally competent care. The nurse would discuss dietary needs that relate to disease processes with the healthcare provider. The nurse would communicate the needs for special services through the healthcare provider. The nurse would ask the patient about food preferences to promote contentment in the patient.

The nurse has created a nursing plan of care for a patient with an intellectual disability who is hospitalized for a surgical procedure. Which nursing intervention reinforces the patient's individuality and sense of control? A. Allow the patient to wear pajamas from home as per patient request. B. Assess the patient's ability to independently complete activities of daily living (ADLs). C. Encourage the patient to discuss any fears related to the surgery. D. Teach the patient how to turn and reposition self every 2 hours after surgery.

A The nurse should customize the plan to include patient choices, including preferences about the times of care and methods used. In this situation, allowing the patient to wear pajamas from home would help to reinforce the patient's individuality and sense of control. Assessing the patient's ability to complete ADLs, encouraging the patient to discuss fears, and teaching the patient how to turn and reposition postoperatively would not be customizations of the plan using patient preferences or choices.

The nurse is evaluating the current plan of care for a patient who is receiving care in a long-term healthcare facility. The evaluation indicates that the patient is not meeting goals related to mobility. Which is an appropriate nursing action at this time? A. Revising the plan of care B. Concluding that the problem is resolved C. Determining that the patient does not have any risk factors D. Asking the patient to try harder

A The patient is not meeting goals related to mobility, so the plan of care must be revised. The nurse will work with the patient to determine how the plan might be revised. Perhaps assessment data were not fully considered, or goals were not within reasonable expectations for what the patient is able to accomplish. Concluding that the problem is resolved would be inaccurate. The nurse would be wise to reassess risk factors as part of reassessment before revising the plan of care. Asking the patient to try harder is not appropriate.

The nurse is providing care for a new patient admitted with heart failure (HF). The facility in which the nurse works has purchased a set of standardized plans for use. Which is a benefit of using a standardized plan for this patient versus generating an individual plan? A. A standardized plan is more time efficient and includes a common set of interventions for a patient with HF. B. A standardized plan uses evidence to account for all possibilities related to the diagnosis, eliminating the need for individualization. C. A standardized plan can be used to address both predictable and unpredictable problems that occur with HF, thus ensuring flexibility for many patient variations. D. A standardized plan is a multidisciplinary plan that becomes a part of the permanent patient record, thus making documentation easier.

A The use of standardized plans is more time efficient than generating a single plan for patients with the same diagnosis. Standardized plans include a common set of interventions for the specified diagnosis. They do not account for all possibilities and should only be used for predictable, commonly occurring problems. An individual plan would need to be created to address unpredictable problems. A clinical pathway, not a standardized plan, is a multidisciplinary plan that becomes a part of the patient's permanent record.

The nurse is creating a concept map to guide a plan of care for a patient with multiple health problems. The nurse is using paper and pencil to create the map because the nurse is not comfortable with using the computer for this activity. How could the nurse easily improve the readability of the map? A. Use colored pencils or markers. B. Use a concept-map template. C. Make sure to match colors and shapes and coordinate patterns. D. Find a software program that the nurse is comfortable with.

A There are a variety of methods and tools that can be used to create concept maps. Using just pencil and paper can make it difficult to understand the visual depiction of the plan of care. In this situation, because the nurse is not comfortable using a computer, use of different colored pencils is appropriate to help to delineate specific areas of the map. Expecting a nurse who has indicated difficulty using electronic software to do so would not be expected or necessary. Using a concept-map template would not necessarily be the best way to improve the nurse's preferred method of developing a concept map. Spending a great deal of time matching colors and shapes and coordinating patterns is not a good use of time and does not necessarily enhance the process.

The nurse is sitting with a laboring patient who is requesting intermittent fetal monitoring. The nurse is explaining the risks, benefits, and evidence to support the different types of monitoring. Which type of decision making is the nurse demonstrating? A. Mutualism B. Maternalism C. Consumerism D. Paternalism

A This is an example of mutualism, which is a process of shared decision making between both the patient and the provider. Paternalism is where the provider has the education and experience to make the best decision for the mom and baby. The consumerism model is a hands-off approach to healthcare where the provider provides the scientific information and allows the patient to make the best decision. There is no maternalism model of decision making.

Which statement describes the evaluation phase of the nursing process? A. Evaluation is performed only after nursing interventions are performed. B. Evaluation is performed throughout all phases of the nursing process. C. Evaluation focuses on determining changes and preventing complications. D. Evaluation is determined based on gathering subjective and objective data.

B Evaluation is performed throughout all phases of the nursing process. It is a constant, fluid process that is used to determine the effectiveness of planned interventions and includes reassessment of the patient. It is not only performed after nursing interventions. Implementation focuses on determining changes and preventing complications. Assessment is based on gathering subjective and objective data.

A facility has decided to use clinical pathways to guide multidisciplinary care for patients on the cardiac unit. This decision was made due to the multidisciplinary nature of clinical pathways. Which information included in the pathway best supports multidisciplinary use? A. Inclusion of projected length of stay and daily sequence of care by providers B. Inclusion of medical treatments to be performed by different providers C. Inclusion of clinical interventions and time frames for completion D. Inclusion of usual expectations of response and expected outcomes

B A clinical pathway is a standardized, evidence-based, multidisciplinary plan that outlines care for patients with common, predictable health problems. It is multidisciplinary because it includes medical treatments to be performed by different types of healthcare providers. Clinical interventions and time frames for completion, projected length of stay, daily sequence of care by providers, and usual expectations of response and expected outcomes are aspects of the clinical pathway but do not best indicate why the clinical pathway is considered multidisciplinary.

A healthcare team on an orthopedic unit is discussing ways to reduce cost, increase efficiency, and improve patient outcomes while collaboratively providing care. Which approach to care would be most useful in guiding daily, multidisciplinary care for the patient population on this unit? A. Standardized care plan B. Clinical pathway C. Concept map D. Column or care

B A clinical pathway is a standardized, evidence-based, multidisciplinary plan that outlines care for patients with common, predictable health problems; thus, the team would select this approach. A standardized care plan is specific to nursing interventions and would not necessarily be multidisciplinary in focus. Column care plans and concept maps are both ways to develop a care plan and would not be indicated for this use.

The nurse admitting a patient asks the family if they would be available to help provide information to support the development of the nursing plan of care. The family asks the nurse what a nursing plan of care is. Which response by the nurse answers this question? A. "It will provide daily information about when the patient will be bathed, taken to the dining room for meals, and so forth." B "The nursing plan of care helps to organize information about the patient's nursing care and ensures appropriate, individualized treatment." C. "A nursing plan of care just refers to the daily medications and labs that the patient will be receiving." D. "A nursing plan of care helps us to organize and coordinate all of the provider's orders in one place for easy reference."

B A nursing plan of care organizes information about a patient's or family's care. It may include multiple nursing diagnoses (three to five are recommended), which helps the nurse to focus on nursing care that provides the best patient outcomes. It is not used to provide a daily schedule of times for bathing and eating. Although the nursing plan of care may be informed by the provider's orders, it is not a tool to organize all of the provider's orders in one place, nor is it used to list all medications or labs in one place.

A new nurse is speaking with a mentor about a mistake made the day before. The mentor encourages the nurse to review the situation and make a mental note to respond differently the next time the situation occurs. Which process is the mentor encouraging? A. Interpreting B. Reflecting C. Responding D. Noticing

B According to Tanner's clinical judgment model, this is an example of reflecting because the nurse is reviewing the previous clinical actions. Noticing is the recognition of the presence or absence of expected significant cues from the patient's response to an illness or medical condition. Interpreting involves using logical reasoning to determine appropriate action after noticing a clinical finding. Responding occurs when the nurse acts based on what is found and interpreted.

The nurse manager is looking at models of clinical judgment to use as an employee assessment tool. The nurse manager wishes to use a model that can evaluate clinical competence in the workplace. Which is best suited for the job? A. Guided reflection B. Benner's skill acquisition model C. Lasater's clinical judgment rubric D. Tanner's clinical judgment model

B Benner's skill acquisition model looks at clinical competence at five different levels and would be best suited for an employee evaluation tool. Tanner's clinical judgment model looks at the different cognitive skills needed in effective nursing practice. Lasater's clinical judgment rubric builds off Tanner's model to evaluate learners in a simulated environment. Guided reflection helps the nurse reflect on a given situation and is not suited as an employee evaluation tool.

The nurse is struggling to see the "whole picture" when caring for a patient with very complex needs. Which method for developing the plan of care should the nurse consider? A. Standardized plan B. Concept map C. Column plan D. Clinical pathway

B Concept maps can help the nurse to visualize and analyze relationships among clinical data, thus helping them view patient problems holistically. This would be the best development method for a nurse who is having difficulty seeing the "big picture." A column plan of care uses columns to categorize data for each phase of the nursing process, but it would not necessarily help a nurse better understand the "big picture." A standardized care plan specifies the nursing care for groups of patients with common needs, such as all patients with diabetes; this is not something which the nurse would develop. A clinical pathway is a standardized, evidence-based, multidisciplinary plan that outlines the expected care required for patients with common, predictable health conditions; it requires a physician's order and is not something the nurse would develop.

During a discussion of clinical pathways with a recent nursing graduate, the nurse preceptor mentions the use of diagnosis-related groups (DRGs) as the basis for clinical pathways. The new nurse asks what the DRGs are used for. Which information should the nurse preceptor provide to the new nurse? A. DRGs are used to group conditions that are often comorbid together into one diagnosis-related group to account for the contribution of each diagnosis to days needed for care. B. DRGs determine the number of preset days allowed for care for patients with that specific medical diagnosis. C. DRGs are used by hospitals to provide effective patient care while remaining profitable. D. DRGs are used to determine the detailed nursing interventions to include in the clinical pathway.

B DRGs determine the preset number of days allowed for the patient's diagnosis. They are not used to determine specific nursing interventions; specific nursing interventions are not included in clinical pathways. DRGs divide possible diagnoses into body systems, then into almost 500 groups. They do not group comorbid conditions together. Although a hospital can make a profit if the patient stays shorter than the preset number of days, it also can lose money if the patient stays longer than the preset number of days. This is not the main purpose of DRGs.

The nurse is caring for a teenager who requires surgery to repair a broken femur after a motor vehicle crash. Which statement about patient consent is correct? A. The teenager must sign the consent form. B. The parents must provide consent. C. The parents must provide consent, and the teen must sign an assent form. D. The teenager must sign the consent form, and the parents must also provide assent.

B Even though teenagers should be involved in healthcare decisions whenever possible, the parents must provide consent. Whenever possible, the teenager should also assent to the procedure, although no formal form is required. Unless the teenager was given autonomous and legal decision-making power, the teen does not sign the consent form.

The nurse is developing a plan of care for a patient with the nursing diagnosis Impaired Physical Mobility related to inactivity secondary to arthritis. The nurse and patient develop a goal of ambulating the hall three times a day with a wheeled walker. Which purpose should this goal help achieve? A. Evaluate the patient's response to the plan of care. B. Provide direction for nursing interventions. C. Measure the end result of nursing action. D. Identify a time frame for an action to occur.

B Goals provide direction when selecting nursing interventions. Therefore, the nurse and patient develop the goal of ambulating the hallways three times a day to help provide guidance for improving mobility. Outcomes are used to evaluate the patient's response to the plan of care and to measure the end result of the nursing action. Identifying a time frame for an action to occur is part of the goal statement; however, it is not the purpose of a goal.

The nurse is creating a nursing plan of care for a patient admitted for surgery. Which headings should the nurse use as the pre- and postoperative nursing plan of care is created? A. Medical and nursing diagnoses, goals/outcomes, nursing interventions, evaluation B. Assessment, nursing diagnoses, goals/desired outcomes, nursing interventions, evaluation C. Demographic information, assessment data, nursing diagnoses, nursing interventions, outcomes D. List of medications, nursing diagnoses, goals/outcomes, nursing interventions, evaluation

B Headings for nursing care plans generally follow the nursing process phases and should include the following: "Assessment," "Nursing Diagnoses," "Goals/Desired Outcomes," "Nursing Interventions," and "Evaluation."

The nurse is working on the oncology floor of the hospital and notes that many of the patients request internet access so that they can communicate with loved ones more easily. Using this information, the nurse obtains a grant to purchase several laptops for the patients to share. Which type of reasoning did the nurse use to develop this protocol? A. Deductive reasoning B. Inductive reasoning C. Careful reasoning D. Clinical Reasoning

B Inductive reasoning uses a "bottom-up" approach that helps the nurse develop a theory or change in practice. In this example, the nurse observed a way to help some patients cope better with their diagnosis, then developed a protocol or practice to address their needs. The nurse may also be demonstrating clinical or careful reasoning, but these are not the best and most inclusive answers. Deductive reasoning uses a "top-down" approach and looks at a specific rule to see if examples apply to the rule.

The nurse is looking at ways to help infants in the healthcare process. Which intervention is appropriate for this age group? A. Allow for hands-on exploration of all equipment. B. Place cots for parents to stay over in all patient rooms. C. Encourage the use of play therapy and toys in the treatment rooms. D. Provide simple options when appropriate.

B Infants are not able to be involved in decision making but must be comforted and made to feel secure throughout the entire healthcare process. Placing cots in patient rooms to allow parents to sleep over helps infants feel more comfortable. Infants are not able to participate in play therapy, choose between options, or explore all equipment with their hands.

The nurse decides to take vital signs and draw morning blood work before the patient's family comes to visit. Which type of decision does the nurse's action reflect? A. Time-management decision B. Scheduling decision C. Value decision D. Priority decision

B Nurses make four types of decisions. A scheduling decision is made when the nurse decides take vital signs and draw blood before visiting hours. Value decisions are those regarding patient confidentiality. Time-management decisions are those made to help the nurse manage time better. A priority decision is deciding what needs to be completed first and what can be delegated to a nursing assistant.

The nurse educator is teaching student nurses about nursing judgment. Which statement by a student indicates effective learning? A. "Clinical decision making is scarcely used in nursing judgement." B. "Both clinical decision making and critical thinking are important parts of nursing judgment." C. "Students must be skilled at using clinical judgment while in nursing school." D. "Intuition is an important part of nursing judgment in the new nurse."

B Nursing judgment combines both critical thinking and clinical decision making when making decisions about patient care. Student nurses are not expected to have excellent clinical judgment because it is honed and improved over time. Clinical nursing judgment is frequently used by nurses. As new nurses become more experienced, they will increasingly be able to use their intuition to help in decision making.

The nurse is delegating assignments to unlicensed assistive personnel (UAPs) on a medical-surgical unit. When making assignments, which is the best resource for the nurse to use as a guide? A. Functional status of each patient B. Nursing plan of care for each patient C. Medical diagnosis of each patient D. Ages of the patients

B Nursing plans of care can provide the nurse with a guide when assigning nursing staff to care for each patient because they provide a plan to meet the unique needs of each patient. Medical diagnosis, age, and functional status would not provide an overall picture of patient needs such as that which is detailed in the nursing plan of care.

The nurse is creating a plan of care for a patient with complex health problems, including sepsis. Which action should the nurse take to focus nursing care and support the best patient outcomes? A. List all applicable nursing diagnoses, highlighting those that have highest priority. B. Prioritize three to five nursing diagnoses. C. Focus nursing diagnoses only on those issues caused by the sepsis. D. Create two to three general categories of nursing diagnosis.

B When creating a nursing care plan, it is important to list only three to five nursing diagnoses to help the nurse focus on nursing care that provides the best outcomes. It would not be appropriate to create general categories of nursing diagnosis, to focus only on those related to the sepsis, or to list all applicable nursing diagnoses because this may lead to difficulties in focusing nursing care, ultimately affecting patient outcomes.

The nurse is preparing to discharge a patient after a hospital stay. Which task should the nurse perform to determine if goals have been met? A. Collect data to provide discharge instructions to follow when at home. B. Collect data related to the goal and make decisions about nursing care effectiveness. C. Collect data to develop new nursing diagnoses for the home health nurse to follow. D. Collect data related to patient-specific outcomes for accrediting bodies.

B Outcomes are evaluated to determine if the patient's goals have been met and for the effectiveness of the plan of care. Based on the evaluation, the plan of care is continued, modified, or terminated. The nurse will collect data at discharge to determine if the goals have been met and make decisions about nursing care effectiveness. If home health care is ordered at discharge, the home health nurse will develop a plan of care pertinent to self-care. The nurse provides discharge instructions based on healthcare provider orders, but this is not related to nursing diagnoses. The hospital will collect data for accrediting agencies, but this is not related to the nursing diagnoses and goal attainment.

The nurse made a medication error while caring for a patient. Which statement by the nurse indicates that the nurse is interpreting the situation using guided reflection? A. "I was so busy giving medication that I misread the order and gave the wrong one to the wrong patient." B. "I should have remembered to check the patient's wristband even though I've been taking care of this patient for several days." C. "I had to tell the patient and doctor that I gave the wrong medication. It was very embarrassing." D. "The medication didn't harm the patient, but I need to be more careful whenever I give medication."

B Stating that the nurse should have remembered to check the wristband is an example of interpreting the situation and what went wrong. The nurse is showing the process of observing after making the statement about being busy and misreading the order. Stating that it was embarrassing to make the mistake is an example of responding, and understanding the need to be more careful in the future is an example of reflecting.

A patient reports hematuria along with the pain. After reviewing the patient's chart and assessing the patient, the nurse documented the following nursing diagnosis: Acute Pain related to urinary obstruction secondary to prostate cancer. Which part of the nursing diagnosis statement reflects the etiology? A. Prostate cancer B. Urinary obstruction C. Acute Pain D. Hematuria

B The etiology of the nursing diagnosis statement is the urinary obstruction because this is leading to the acute pain due to bladder enlargement. The nursing diagnosis is Acute Pain. "Hematuria" is the assessment data. The medical diagnosis is prostate cancer.

The nurse is caring for a patient with malnutrition and identifies a nursing diagnosis of Imbalanced Nutrition: Less than Body Requirements related to poor oral intake secondary to cancer treatment. Which goal set by the nurse is an example of a specific and measurable goal? A. The patient will verbalize foods that are needed to gain weight. B. The patient will take in 80 grams of protein per day. C. The patient will gain weight over the next few months. D. The patient will experience no further nausea and vomiting.

B The goal of consuming 80 mg of protein per day is a specific, measurable goal with a time frame. It is also relevant and attainable. Verbalizing foods needed to gain weight, experiencing no further nausea and vomiting, and gaining weight over the next few months are not specific nor are they measurable.

The nurse is creating a legend for a concept map. At which point in the development of the concept map should this activity occur? A. When the number of necessary data clusters has been determined B. At the beginning of the concept-map development C. After data clusters, nursing diagnoses, and nursing interventions have been created D. At the end when the concept map is complete

B The legend for the concept map is the first step in the process of developing a concept map. It is not done at the end; after determination of the number of data clusters needed; or once data clusters, nursing diagnoses, and nursing interventions have been created.

Which clinical situation best exemplifies the nurse who is choosing between alternatives when making a clinical decision? A. The nurse has a "gut reaction" to the patient's pain and calls the patient's physician. B. The nurse administers an intravenous (IV) narcotic instead of an oral narcotic. C. The nurse determines that the patient's nursing diagnosis is Pain, Acute. D. The nurse changes the patient's position numerous times until the patient appears in less pain.

B The nurse who administers an IV narcotic instead of an oral narcotic is choosing between alternatives. The nurse who helps the patient change position numerous times is using trial and error. The nurse acting on a "gut reaction" is using intuition. The nurse determining the nursing diagnosis is utilizing the nursing process.

The nurse is caring for a patient with schizophrenia. The patient is at risk for disturbed thought process. Which nursing intervention could the nurse implement without an order from the healthcare provider? A. Placing the client in a seclusion room for a time-out B. Explaining that the nurse does not hear the voices C. Complying with taking all medications as prescribed D. Referring the patient to an outpatient program on discharge

B The nursing intervention that can be implemented without a prescription from the health care provider is to provide reality testing and explain to the patient that the nurse does not hear the voices that the patient hears. Setting the patient up with services after discharge, promoting medication compliance, and placing the patient in a seclusion room for a time-out all require healthcare provider intervention.

A pregnant patient presents with rising blood pressure and protein in her urine. After testing, the provider diagnoses the patient with preeclampsia and informs her that they are taking her to the operating room to deliver the baby through cesarean delivery immediately. Which decision-making model is displayed? A. Maternalism B. Paternalism C. Mutualism D. Consumerism

B This is an example of paternalism, where the provider has the education and experience to make the best decision for the mom and baby. The consumerism model is a hands-off approach to healthcare where the provider provides the scientific information and allows the patient to make the best decision. Mutualism is a process of shared decision making between both the patient and the provider. There is no maternalism model of decision making.

The nurse is using a clinical pathway to provide care to a patient hospitalized with pneumonia. While reviewing the clinical pathway, the nurse would note that the columns organize care in which manner? A. Each column represents a different nursing diagnosis. B. Each column represents an expected patient response. C. Each column represents a day of care. D. Each column represent a different health discipline.

C A clinical pathway is usually organized with a column for each day, listing the interventions that should be carried out and the patient outcomes that should be achieved on that day. There are as many columns on the multidisciplinary care plan as the preset number of days allowed for the patient's diagnosis-related group (DRG). The columns do not represent different health disciplines, nursing diagnoses, or expected patient responses.

The nurse is describing the three-column plan of care. Which description by the nurse provides an accurate description? A. "The three-column plan only has nursing diagnosis, nursing interventions, and goals/desired outcomes." B. "The three-column plan combines assessment with nursing diagnosis and combines goals/desired outcomes with evaluation." C. "The three-column plan has no assessment column and combines goals/desired outcomes and evaluation into one columns." D. "In the three-column plan, nursing diagnosis and evaluation are stand-alone columns, whereas interventions and goals/desired outcomes are combined."

C A column plan of care generally has four columns: nursing diagnosis, goals/desired outcomes, nursing interventions, and evaluation. Some agencies may also add an assessment column, whereas others may collapse it to three columns and combine the evaluation with the goals column.

Which short-term goal should the nurse view as appropriate for a patient with the nursing diagnosis Deficient Knowledge related to disease process secondary to diabetes? A. The patient will identify ways to prevent complications from diabetes within 2 months. B. The patient will maintain blood sugars between 80 and 120 mg/dL within 1 month. C. The patient will verbalize understanding of how insulin affects blood sugar by the end of the day. D. The patient will follow a diabetic diet with 90% compliance within 3 months.

C Goal statements include a time frame for completion. Short-term goals are useful for patients needing a limited amount of nursing care. These goals can be achieved in a few hours to a few days. Therefore, the goal of understanding how insulin affects blood sugar by the end of the day is an example of a short-term goal. The other goals have time frames of 1 month or longer, making them long-term goals.

The nurse decides to suction and perform tracheostomy care on a patient before sending the patient to a scheduled procedure. Which process does the nurse's action define? A. Choosing among alternatives B. Intuition C. Clinical decision making D. Trial and error

C Here, the nurse is relying on clinical judgment to perform respiratory care for the patient before sending the patient off the floor. This is to ensure that the patient does not need to be suctioned or cleaned up while at the procedure. The nurse is not relying on intuition to make the decision, using trial and error, or choosing among alternatives.

The nurse is examining the following nursing diagnosis statement: Risk for Impaired Skin Integrity related to decreased peripheral circulation secondary to diabetes. The use of "secondary to" in this diagnosis reflects which component? A. Subjective data obtained B. Axis 2 of the nursing diagnosis C. Pathophysiological disease process D. Primary identifiable nursing problem

C In this instance, the secondary clause reflects the pathophysiological disease process that caused the problem. The nursing diagnosis is the primary nursing problem. Axis 2 represents the patient or subject of the diagnosis. Subjective data lead the nurse to develop the nursing diagnosis.

The nurse is planning to transfer a 76-year-old patient to a long-term care facility. The patient wants to live close to family; however, the facility that would best meet the patient's needs is a few miles farther away. Which action should the nurse implement? A. Tell the patient that being near family is not always a good idea. B. List other facilities so that the patient can make a better decision. C. Discuss the advantages of the facility that is a bit farther away. D. Tell the patient that the facility that is closer to family is not accepting admissions.

C Nurses help patients make decisions by providing information or making referrals to resources. In this situation, the patient wants to be placed in a facility near family, but the best facility for the patient is farther away. The nurse needs to help the patient through the decision-making process by providing additional information about the facility that is more suited to the patient's needs. The nurse should not make up information so that the patient agrees to the facility that is farther away. Listing other facilities might confuse the issue. Telling the patient that being near family is not always a good idea is a judgment and does not take the patient's needs into consideration.

The nurse is beginning a new shift and is reviewing the report given by the previous nurse. Which decision by the nurse is an example of a scheduling decision? A. Deciding what can be completed by a nursing assistant B. Deciding what information to share with other healthcare providers C. Deciding to bathe the patient before therapy D. Deciding when to change a dressing

C Nurses make four types of decisions. A scheduling decision is made when the nurse decides what a patient needs before attending a therapy session. A value decision occurs when deciding which information to share with other healthcare providers. A time-management decision is made when deciding when to change a dressing. A priority decision is deciding what can be assigned to a nursing assistant to complete.

The nurse is creating a column plan of care. Which information should the nurse place in the intervention column for a diabetic patient with a slow-healing foot wound? A. Patient will list three high-protein foods to include in the diet by the end of hospitalization. B. Patient has a 1/2-inch by 1/2-inch open wound on the dorsal aspect of the right foot. C. Obtain a dietary consult for the patient. D. Patient named five foods high in protein prior to discharge.

C Obtaining a dietary consult for the patient would be considered a nursing intervention and would be placed in that column. The statement that the patient will list three high-protein foods prior to discharge would be a goal/desired outcome, not an intervention. Stating that the patient named five high-protein foods prior to discharge indicates an evaluation (in this case the patient met the goal). The wound description would be assessment data and would go in the assessment column.

Which action by the nurse indicates support for a preschooler's decision-making ability? A. Showing the child the materials that will be used to stitch up the wound in the child's knee B. Soothing the child by rocking the child until calm C. Asking if the child would like to have the scheduled snack before or after going for an x-ray D. Inviting the child to the interdisciplinary meeting

C Preschoolers are able to make some decisions related to preference when information is provided to them in a way that makes sense to them. Asking preschoolers if they would like a scheduled snack before or after a procedure is an example of assisting a preschool child in decision making. Because adolescents are capable of participating in making decisions on their own behalf, it would be appropriate to invite an adolescent patient to come to an interdisciplinary meeting. School-age children benefit from direct explanations and would likely be interested in seeing and handling materials that will be used in their own care. Although infants cannot make decisions, they need to feel secure during care; soothing and rocking the infant patient is appropriate.

The nurse has been using a standardized care plan to guide care for a patient hospitalized following open heart surgery. The patient is not married and lives with his 85-year-old mother who has unstable diabetes and congestive heart failure. Which nursing diagnosis would require the nurse to create an individual plan to supplement the standardized plan? A. Cardiac Output, Decreased, Risk for B. Self-care Deficit: Toileting C. Caregiver Role Strain, Risk for D. Tissue Integrity, Impaired

C Standardized care plans are used for predictable, commonly occurring problems related to a specific diagnosis. In this scenario, caregiver role strain due to age of mother and presence of multiple health issues would create potential problems that would not necessarily be common to all patients post-surgery and would require development of an individualized care plan. Self-care deficit, decreased cardiac output, and wound infections are complications that can commonly occur following heart surgery and would likely be included in the standardized care plan.

The nurse is reviewing assessment data collected from a patient with pneumonia. Which data should the nurse identify as subjective? A. Rapid breathing B. Presence of cough C. Report of difficulty breathing D. Observation of yellow sputum

C Subjective data are those that the patient feels, such as difficulty breathing. Objective data are those that the nurse can observe, measure, feel, hear, or smell.

The nurse forgets to provide the patient with discharge papers. When speaking with a coworker, the nurse states, "I should have remembered to bring the papers into the patient's room, but I got distracted with another task." Which guided reflection task is the nurse demonstrating? A. Reflecting B. Responding C. Interpreting D. Observing

C The nurse is interpreting the situation after thinking about the background information needed to understand the situation and making pertinent observations (observing) about what happened. Responding describes the nursing response to the situation. Reflecting describes an understanding of the "take-away" lesson from the experience or situation.

The nurse is caring for a patient with a history of diabetes mellitus. The nurse notices an upward trend to the patient's daily fasting serum blood glucose and notifies the patient's healthcare provider. Which level best describes this nurse according to Benner's skill acquisition model? A. Novice B. Advanced beginner C. Proficient D. Competent

C The nurse is proficient according to Benner's skill acquisition model. In this level of the model, nurses develop their own rules for actions by analyzing significant cues and are able to see the "big picture." The novice level includes those without any nursing experience who act only by rules, not cognition. The advanced beginner is typically a new graduate who begins to recognize significant cues using cognition but is unable to piece all clinical cues into a whole picture. The competent nurse, according to Benner, has 2-3 years of nursing experience. However, the competent nurse is still unable to see the "big picture."

The nurse determines that the patient has not met the plan of care for the nursing diagnosis Skin Integrity, Impaired because the wound has not healed within the time frame specified. The nurse chooses to revise the plan of care. Which step should the nurse perform first? A. Set a new, reachable goal. B. Talk to the healthcare provider. C. Reassess the wound. D. Change the interventions.

C The nurse should always reassess the patient prior to changing the plan of care. This determines future needs. The nurse would not need to discuss this with the healthcare provider because these are nursing interventions. The nurse may need to change interventions or set new goals, but these are not the first steps.

The nurse is explaining how to develop an appropriate nursing diagnosis. Which participant statement indicates an appropriate understanding? A. "A nursing diagnosis is determined by the medical diagnosis and current patient needs." B. "A nursing diagnosis is derived after the nurse develops the plan of care for the patient." C. "A nursing diagnosis is based on clinical judgment that is derived from assessment data." D. "A nursing diagnosis is developed after the nurse evaluates the interventions provided."

C The nursing diagnosis is derived after collecting objective and subjective data from the patient and defining the patient problem. A nursing diagnosis is determined by using clinical judgment. The evaluation phase occurs after the interventions are provided. The nursing diagnosis is derived prior to developing the plan of care for the patient, not after. The nursing diagnosis is not necessarily based on the medical diagnosis. Nursing diagnoses may result from the complications that arise from medical problems.

The nurse is caring for a patient who is 8 weeks pregnant, reports never having been pregnant before, and does not know what to expect. The nurse instructs the patient to keep all scheduled prenatal clinical visits and states, "These classes will help you and your baby to stay healthy." Which is the reason for the nurse to make this statement? A. To develop a nursing diagnosis of Knowledge, Deficient for the patient B. To provide the patient a list of reasons why attending classes is important. C. To motivate the patient by associated a personal meaning with the goal D. To educate the patient on the importance of attending the classes

C The patient reports a knowledge deficit by stating that she does not know what to expect. Therefore, the nurse should encourage the patient to attend prenatal classes to learn what is expected and relate it to a personal goal. Educating the patient is important, but relating the goal to something with personal meaning would improve motivation. The nursing diagnosis set by the nurse does not help the patient understand why attendance at prenatal classes is important. Providing the patient a list of pros for attending will not be as successful as the patient relating the classes to something meaningful.

The school nurse is looking at the effects that increasing recess and recreation time has in the classroom. The nurse plans to assign some classes within the school an additional hour of recess each day, and the remaining classes will stay on the current schedule. Which concept of problem solving and critical thinking should be most useful in this situation? A. Intuition B. The nursing process C. The scientific method D. Trial and error

C The scientific method is a formalized and systematic approach to solving problems and is best used in this situation. Intuition is relying on subconscious clues and previous experience to find patterns in patient behaviors. The nursing process uses five defined steps (assessment, diagnosis, planning, implementation, and evaluation) to solve a problem. Trial and error is the process of trying different options to see what works and what does not, such as trying different positions to find one that is comfortable for the patient.

The nurse is sitting with the healthcare provider and a pregnant patient. The provider is explaining to the pregnant woman the various options for genetic testing that are currently available. The provider asks the patient which testing she would like to have done. The nurse understands that the provider is displaying which decision-making model? A. Maternalism B. Mutualism C. Consumerism D. Paternalism

C This is an example of the consumerism model, which is a hands-off approach to healthcare where the provider provides the scientific information and allows the patient to make the best decision. Mutualism is a process of shared decision making between both the patient and the provider. Paternalism is where the provider has the education and experience to make the best decision for the mom and baby. There is no maternalism model of decision making.

The nurse is caring for a patient who is having back discomfort. The nurse helps the patient change position several times until comfortable. Which process is defined by this action? A. The nursing process B. Clinical decision making C. Trial and error D. Intuition

C Trial and error is the process of trying different options to see what works and what does not, such as trying different positions to find one that is comfortable for the patient. Intuition is relying on subconscious clues and previous experience to find patterns in patient behavior. The nursing process uses five defined steps (assessment, diagnosis, planning, implementation, and evaluation) to solve a problem. Clinical decision making uses the nurse's skills, experience, and knowledge to make a decision.

The nurse is creating a patient concept map for a simulation scenario. Which should the nurse do first when creating the concept map? A. Put a shape with patient information and priority medical diagnosis in the middle of the paper. B. Look at the assessment data, including both subjective and objective data. C. Develop a legend for the concept map. D. Gather and sort significant clusters of assessment data.

C When creating a concept map, the nurse would first develop a legend by assigning shapes and colors for each nursing process phase and for the other categories of patient information. Gathering and sorting significant clusters of assessment data, looking at the assessment data (including both subjective and objective), and putting a shape with patient information and the priority medical diagnosis in the middle of the paper would follow development of the legend.

The nurse is providing care for a 3-year-old hospitalized child. As the nurse creates the nursing plan of care, the family informs the nurse that they usually give the toddler a warm bath every night before bed. How should the nurse best address this in the nursing plan of care? A. Discuss current plan of care with the family and include the family in planning care as is feasible. B. Teach the family the importance of helping the toddler adjust to hospital routines, including a morning bath. C. Allow the family to provide a warm bath in the evening as allowed by the provider. D. Instruct nursing assistive personnel to provide bath per unit guidelines every other day in the evening.

C When possible, the plan should be customized to include patient preferences and choices. This helps to reinforce the patient's individuality and sense of control. Teaching the family that the toddler must adjust to the hospital routine and providing the bath per unit protocol does not address the family's preferences and choices for their toddler. Discussing the current plan of care and including the family is important but does not directly address the issue in this situation.

The nurse is caring for a neonate who requires nasogastric (NG) tube feedings due to prematurity. The NG tube frequently slips out of position, and the nurse tries different approaches to prevent this from happening. Which critical thinking skill is the nurse demonstrating? A. Intellect B. Reflection C. Inquiry D. Reasoning

C When using inquiry, objective information is examined in order to clarify and find solutions to problems. Inquiry uses questions to find alternative approaches or solutions. Nurses use intellect to identify salient cues and group them into meaningful patterns. Clinical reasoning is the careful evaluation of information to improve patient care. Reflection is looking back at a situation to determine what worked, what did not work, or what could have been done better.

The nurse is working for a facility that requires the use of a column framework for planning care. Information in which column of the plan of care is best derived from and supported by research evidence? A. Nursing diagnosis B. Evaluation C. Goals/desired outcomes D. Nursing interventions

D A column plan of care uses columns to categorize data for each phase of the nursing process. When writing nursing interventions, the nurse may be required to write a rationale for selecting a particular nursing intervention. This generally requires citing research-based evidence. Research evidence is not necessarily required to support nursing diagnosis, goals and outcomes, or evaluation, although evidence could be used for these sections as well.

Which process can be used to visualize relationships among clinical data and help to prioritize meeting patient needs? A. Column plan of care B. Standardized plan of care C. Clinical pathway D. Concept map

D A concept map is a visual representation of a nursing plan of care in a patterned diagram with data and ideas; it helps to provide a visual guide for analyzing relationships among clinical data to help prioritize meeting patient needs. A column plan of care uses columns to categorize data for each phase of the nursing process, not a visual representation. A standardized plan of care specifies the nursing care for groups of patients with common needs, such as all patients with diabetes; this plan of care is not visually depicted. A clinical pathway is a standardized, evidence-based, multidisciplinary plan that outlines the expected care required for patients with common, predictable health conditions; it requires a physician's order and is not a visual depiction.

A peer tells a new nurse that there is a standardized plan that can be used for a patient diagnosed with diabetes. The nurse asks the peer how standards of care can be helpful in developing a plan of care for this patient. Which response by the peer best answers this question? A. "Standards of care and standardized care plans refer to the same thing; they are very helpful in supporting the provision of evidence-based care." B. "Standards of care underlie the development of standardized plans; they are used to determine which nursing interventions should be included in the standardized plan." C. "The standards of care can be very helpful in these situations because they set benchmarks for nursing performance expectations." D. "A standardized plan is a set of common interventions that can be individualized for patients with the same diagnosis, which is different from standards of care."

D A standardized plan specifies the nursing care for a group of patients with common needs, whereas standards of care set benchmarks for nursing performance expectations, including evidence of competent and effective clinical decision making that reflects professional behavior. Thus, stating that they are different would be the best response. Although the statement describing standards of care as benchmarks is accurate, it would not be very helpful when creating the plan of care for the patient (although it should always be kept in mind). Standards of care and standardized plans are not the same thing; thus, this is not an accurate statement. Standards of care do not underlie the development of standardized plans; standardized plan development is based on evidence. This is not an accurate statement.

The nurse is creating a concept map for a patient with multiple health problems. After creating clusters of assessment data, which should the nurse complete next to prioritize patient needs? A. Determine goals and outcomes that can be achieved through nursing care; use lines to connect these to relevant nursing diagnoses. B. Develop priority nursing interventions; use lines to connect them to the relevant nursing diagnoses. C. Develop appropriate goals and outcomes for care; use lines to connect these to the relevant clusters. D. Determine the priority nursing diagnosis for each cluster; use lines to connect them to the clusters

D After creation of clusters of the subjective and objective assessment data, the nurse determines priority nursing diagnoses that are relative to each of the clusters. The nurse then draws connecting lines between the diagnoses and assessment data, which helps to prioritize patient needs. Interventions and goals and outcomes cannot be created until after nursing diagnoses are developed; thus, these would not be valid answers.

A patient is admitted to the hospital with pneumonia. The nurse develops a plan of care with a nursing diagnosis of Impaired Gas Exchange related to inadequate ventilation secondary to atelectasis. Which goal includes all elements of a goal statement? A. The patient will be instructed in use of the incentive spirometer every hour. B. The patient will be given supplemental oxygen to use via nasal cannula. C. The patient will be given bronchodilators as prescribed. D. The patient will demonstrate correct use of the incentive spirometer after the teaching session.

D An appropriate goal for a patient with any nursing diagnosis includes a subject and verb and is both measurable and patient centered. The statement of the patient demonstrating the correct use of incentive spirometry after a teaching session meets these requirements. It is also realistic and relevant. Providing supplemental oxygen, administering bronchodilators, and instructing on the incentive spirometer are all nursing interventions, not goals.

The nurse is caring for a patient who is scheduled to have a chest x-ray at 9:00 a.m. and will be off the unit. The patient is also due to have medication at 9:00 a.m. Which action by the nurse is most appropriate? A. Administer the medication after the patient returns from x-ray. B. Administer the patient's medication at the start of shift. C. Wait to administer the medication at the next dosage time. D. Administer the patient's medication at 8:45 a.m.

D By administering the scheduled medication 15 minutes early, the nurse is using clinical decision making to ensure the patient receives all necessary care despite the apparent scheduling conflict. Because there is no way to tell how long the patient might be at x-ray, it might jeopardize the patient's dosing schedule to wait to administer the patient's medication. Administering medication at the start of shift may be inappropriate depending on the dosing schedule. Waiting until it is time for the next dose will result in the patient missing a dose, which is not an option.

The nurse has just admitted a 72-year-old patient for total hip replacement to a unit that utilizes clinical pathways. The patient is otherwise healthy, and recovery is expected to progress normally. How will the clinical pathway for this patient be initiated? A. The nurse will initiate the clinical pathway after verification of appropriateness by the nursing supervisor. B. The nurse will complete a patient assessment to determine if the patient meets the parameters for the clinical pathway, then initiate it. C. The physical therapist will initiate the clinical pathway for this patient if appropriate. D. The healthcare provider will write an order for the appropriate clinical pathway for this patient.

D Clinical pathways are initiated by healthcare provider order. They are not initiated by the physical therapist or the nurse independently.

The nurse is providing care to a patient who recently had back surgery. Which nursing action is a collaborative nursing activity? A. Assessing the patient's surgical wound site B. Assisting the patient with bathing C. Adjusting the head of the patient's bed for comfort D. Arranging for physical therapy to ambulate the patient

D Collaborative interventions encompass dependent interventions employed by the nurse under a physician's orders, under supervision, or according to specified routines and protocols, as well as actions the nurse carries out in collaboration with other healthcare team members, such as physical therapists, social workers, dietitians, and physicians. Collaborative nursing activities reflect the overlapping responsibilities of, and cooperative relationships among, healthcare personnel and demonstrate the benefits of multidisciplinary patient care. The other choices are independent nursing activities, which are those activities that nurses can do within their scope of practice.

The nurse is formulating a plan of care for a pregnant patient. One goal set by the nurse is that the patient should attend all prenatal classes. Which step should the nurse take to motivate the patient to attain the goal? A. Tell the patient that it is in her best interest to attend classes. B. Inform the patient that insurance will not pay for the hospital stay for nonattendance at prenatal classes. C. Attend the classes with the patient to ensure compliance. D. Associate the goal with a personal meaning for the patient.

D Goals are created from the patient's nursing diagnosis, specifically from the diagnostic label. Each nursing diagnosis has one goal. An appropriate goal statement to address the patient's insufficient knowledge about pregnancy is that the patient will attend prenatal classes. Therefore, the nurse should relate the classes to a personal meaning for the patient. Instructing the patient that it is in her best interest to attend or that insurance will not pay will not motivate the patient. The patient may see it as a threat. The nurse would not need to attend the classes.

The nurse is caring for a patient who has difficulty breathing. Which nursing action would be considered independent? A. Administering medication to relax breathing B. Ordering chest physiotherapy C. Prescribing oxygen therapy D. Sitting the patient up in bed

D Independent interventions are those activities that nurses are licensed to do within their scope of practice—in other words, areas of healthcare that are unique to nursing and separate and distinct from medical management. A nurse can independently make the decision to sit the patient up in bed to help with breathing. Collaborative interventions encompass dependent interventions employed by the nurse under a physician's orders, under supervision, or according to specified routines. Collaborative nursing activities reflect the overlapping responsibilities of, and cooperative relationships among, healthcare personnel and demonstrate the benefits of multidisciplinary patient care. Healthcare providers would prescribe medications, oxygen therapies, and specific therapies. The nurse would be responsible for implementing this care.

The nurse is caring for a newly admitted patient. Which skills should the nurse use to build rapport and trust with the patient? A. Multidisciplinary B. Cognitive C. Technical D. Interpersonal

D Interpersonal skills are verbal and nonverbal skills used to communicate with patients, their families, and all members of the healthcare team. The effectiveness of a nursing action often depends largely on the nurse's ability to use therapeutic communication to build trust and rapport. Cognitive skills are the problem-solving skills implemented by nurses. Multidisciplinary collaboration includes discussing patient care with members of the healthcare team, but it is not a skill. Technical skills are the hands-on skills used by nurses to provide care.

The nurse is developing a plan of care for a patient admitted to the hospital for pneumonia. Which phase of the nursing process will the nurse use to develop interventions? A. Implementation B. Nursing diagnosis C. Assessment D. Planning

D Nursing interventions are selected and written during the planning phase of the nursing process. The nursing process begins with assessment, which involves the collection, organization, and validation of data. These data are used to formulate a nursing diagnosis. During the implementation phase, interventions are prioritized and carried out.

The nurse is completing the admission process for a patient scheduled for a radical prostatectomy. Which should the nurse provide to the patient to help him best understand what to expect in terms of time frames, actions, and results related to this procedure? A. Concept map B. Clinical pathway C. Patient education pamphlet D. Patient-specific clinical pathway

D Patient-specific clinical pathways help patients understand what to expect in terms of time frames, actions, and results as related to diagnosis-related groups (DRGs). Concept maps are a visual depiction of a nursing care plan and would not provide this information. Clinical pathways are standardized, multidisciplinary care plans that outline expected care required for patients with common, predictable problems; they are intended for use by the healthcare team, not to provide information to patients. Patient education pamphlets can generally provide some of this information but are not generally specific in relation to time frames and actions; thus, they would not be the best at providing this information.

The nursing team is reviewing the possible use of clinical pathways to guide care for patients on the pulmonary care unit. One of the team members asks how the number of columns is determined for the clinical pathway. Which response by the team facilitator provides the best explanation? A. Each insurer determines the number of days it will cover for a patient related to the specific diagnosis, which determines the number of columns. B. Column numbers vary by each patient's diagnosis, patient age, and existence of comorbidities; thus, the number of columns can vary widely between patients. C. The number of columns is preset regardless of diagnosis and includes assessment, pretreatment, and treatment of the specified diagnosis. D. Preset diagnosis-related groups (DRGs) determine the number of days allowed for this diagnosis and thus the number of columns.

D Preset diagnosis-related groups (DRGs) determine the number of days allowed for a specific diagnosis. Each column represents a day; thus, this would be the best response to this question. Insurers generally also use the DRG preset number of days; thus, this would not be the best response. Information about assessment, pretreatment, and treatment of the specified diagnosis may be included in the clinical pathway but does not determine the number of columns. Clinical pathways do not vary by patient.

A healthcare team member accesses a patient's nursing plan of care because the nurse is currently unavailable. Which patient outcome is enhanced by this action? A. Establishment of a clinical pathway B. Adequate reimbursement for services provided C. Standardization of care D. Continuity of care

D The ability of all healthcare team members to access the nursing plan of care enhances communication, resulting in continuity of care. Adequate reimbursement by insurance companies for services provided is a purpose of the nursing plan of care, but it is not a patient outcome that is enhanced by healthcare team members having access to the nursing plan of care. Standardization of care is achieved with a standardized care plan, but it is not a patient outcome that is enhanced by the ability of the healthcare team member to access the nursing plan of care. A clinical pathway is a standardized, evidence-based, multidisciplinary plan—it is not a patient outcome that is enhanced by the ability of healthcare team members to access nursing plans of care.

The nurse is planning care for a patient based on the patient's established goals. Which characteristic should the nurse consider for nursing interventions? A. Can be interchangeable among patients for optimal applicability B. Identified with specific laws and regulations C. Can be performed with limited resources D. Consistent with the patients' values, beliefs, and culture

D The challenge is for the nurse to identify the best interventions to ensure goal achievement. Interventions should be consistent with patient values, beliefs, and culture; performed with available resources; consistent with other prescribed treatments and therapies for that patient; and provided within established standards of care. Established standards of care are determined by state laws (e.g. nurse practice act), professional associations (e.g., American Nurses Association), and the policies of the facility.

A patient who is recovering from a motor vehicle crash has been ordered complete bedrest for 3 months. The patient presents with skin breakdown. Which nursing diagnosis statement is correct? A. Impaired Skin Integrity related to skin breakdown B. Impaired Skin Integrity related to time in bed C. Impaired Skin Integrity related to motor vehicle crash D. Impaired Skin Integrity related to immobility

D The correct nursing diagnosis, Impaired Skin Integrity related to immobility, is a basic two-part statement that identifies the problem and the etiology. The motor vehicle is not the cause nor is the time in bed. Skin breakdown is the problem, so it would not be stated again in the diagnosis.

The nurse auditor is reviewing several patient charts to evaluate the effectiveness of the nursing care provided. Which information should the auditor look for that demonstrates nursing accountability and is essential for evaluation? A. Use of standardized nursing diagnoses B. Customization of the plan to include patient choices and preferences C. Use of the phases of the nursing process as category headings D. Date the plan was written and initiating nurse's signature

D The date the nursing plan of care was written is necessary for evaluation, review, and future planning. The nurse's signature indicates accountability for the plan. Use of standardized nursing diagnoses, phases of the nursing process as category headings, and customization of the plan to include patient choices/preferences do not indicate accountability for the plan.

The nurse working in the intensive care unit (ICU) has decided to attend a professional critical care conference. Which critical thinking attitude is exemplified by the nurse's actions? A. Integrity B. Independence C. Confidence D. Awareness of self-limits

D The nurse is demonstrating awareness of self-limits by seeking new knowledge or skills. Nurses exhibit independence when they think on their own. Confidence is exemplified by self-assurance. Integrity is displayed when the nurse chooses the right option, even if it is not the popular option.

The nurse is caring for a toddler who appears frightened by the nurse. To make the child more at ease, the nurse gives the toddler a disposable tape measure to play with. Which critical thinking concept is the nurse displaying? A. Independence B. Confidence C. Concreteness D. Creativity

D The nurse is using creativity, or finding a solution by using a method that is unconventional. In this case, the nurse is "thinking outside the box" to let the toddler play and put the child at ease. Concreteness is a concept of therapeutic communication, which is when the nurse is specific rather than general. Confidence is an attitude that nurses convey by acting on information and experience they know are correct. Nurses exhibit independence by looking at facts and not being easily influenced by opinion.

A patient presents to the emergency department with high fever and coughing. Which information should the nurse collect for analysis? A. Inferences B. Judgments C. Opinions D. Subjective data

D The nurse would obtain subjective and objective data in order to develop a nursing diagnosis. This information is analyzed by the nurse, and a plan of care is created. Judgments, opinions, and inferences can be biased and based on the nurse's beliefs rather than facts.

In which column in a plan of care should the nurse place this information: "Patient will walk 100 feet two times each shift"? A. Assessment B. Nursing interventions C. Evaluation D. Goals/desired outcomes

D The statement "Patient will walk 100 feet twice per shift" is a goal/desired outcome; thus, it would be placed in that column. This statement is not an intervention or evaluation. This statement does not include assessment data. A column plan of care generally has four columns: nursing diagnosis, goals/desired outcomes, nursing interventions, and evaluation. Some agencies may also add an assessment column, whereas others may collapse it to three columns and combine the evaluation with the goals column.

The nurse is caring for a patient with a nursing diagnosis of Ineffective Breathing Pattern related to diminished lung/chest wall expansion secondary to pneumonia. The current interventions of turning, coughing, deep breathing, and use of incentive spirometer have not improved the patient's breathing. Which independent nursing intervention should the nurse add to meet the patient's needs? A. Administering nebulized bronchodilators B. Increasing the amount of oxygen provided C. Providing chest physiotherapy for secretions D. Elevating the head of the bed to 45 degrees

D This patient has an ineffective breathing pattern related to diminished lung/chest wall expansion. Therefore, the nurse can include elevating the head of the bed in the plan of care. Administering nebulized bronchodilators, increasing oxygen, and chest physiotherapy all require an order from the healthcare provider.