Chapter 10 fundamentals
A nurse has come on day shift and is assessing the client's intravenous setup. The nurse notes that there is a mini-bag of the client's antibiotic hanging as a piggyback, but that the bag is still full. The nurse examines the patient's medication administration record (MAR) and concludes that the night nurse likely hung the antibiotic but failed to start the infusion. As a result, the antibiotic is three hours late and the nurse has consequently filled out an incident report. In doing so, the nurse has exhibited which of the following? A) Ethical/legal skills B) Technical skills C) Interpersonal skills D) Cognitive skills
Ans: A Feedback: Reporting problems and unacceptable practices is an aspect of ethical/legal skills. Technical skills enable the safe performance of kinesthetic tasks while interpersonal skills are the manifestations of caring. Cognitive skills encompass knowledge and critical thinking.
A client comes to the emergency department complaining of severe chest pain. The nurse asks the client questions and takes vital signs. Which step of the nursing process is the nurse demonstrating? A) Assessing B) Diagnosing C) Planning D) Implementing
Ans: A Feedback: Assessing is the step in which nurses assess the client to determine the need for nursing care. When assessing, the nurse systematically collects client data.
What is a systematic way to form and shape one's thinking? A) Critical thinking B) Intuitive thinking C) Trial-and-error D) Interpersonal values
Ans: A Feedback: Critical thinking is defined as "a systematic way to form and shape one's thinking. It functions purposefully and exactingly. It is thought that is disciplined, comprehensive, based on intellectual standards, and, as a result, well-reasoned" (Paul, 1993, p. 20).
Self-evaluation is a method that nurses use to promote their own development, and to grow in confidence in their nursing roles. This process is referred to as what? A) Promoting the nurse's self-esteem. B) Reflective practice. C) Assessment of oneself. D) Learning from mistakes.
Ans: B Feedback: Reflective practice is the use of self-evaluation by nurses committed to quality nursing practice. The others may be additional gains but are not descriptive of self-evaluation.
A client who has been admitted to the hospital for the treatment of a gastrointestinal bleed requires a transfusion of packed red blood cells. Which of the following aspects of the nurse's execution of this order demonstrates technical skill? A) Starting a new, large-gauge intravenous site on the client, and priming the infusion tubing B) Understanding the Rh system that underlies the client's blood type C) Ensuring that informed consent has been obtained and properly filed in the client's chart D) Explaining the process that will be involved in preparing and administering the transfusion
Ans: A Feedback: Performing tasks that require manual dexterity is a manifestation of technical skills. Explaining the transfusion process is largely dependent on interpersonal skills while understanding the theory behind blood types is indicative of cognitive skills. Informed consent lies within the domain of legal/ethical skills.
What name is given to standardized plans of care? A) Critical pathways B) Computer databases C) Nursing problems D) Care plan templates
Ans: A Feedback: Standardized care plans include critical pathways, which target desired outcomes for particular illnesses, procedures, or conditions along a timeline. Critical pathways are used in many health care settings.
The nurse is providing care for a pediatric client on night shift. At 0400, the nurse notes that the child has a high fever but does not have an order for an antipyretic. What nursing action represents a good example of teamwork and collaboration as defined by the Quality and Safety Education for Nurses (QSEN) competencies? The nurse: A) calls the health care practitioner, reports her findings, and requests an order for an antipyretic. B) gives the child a common over-the-counter antipyretic based on dosing recommendations and reports this to the oncoming nurse. C) reports to the oncoming nurse at 0700 that the child has a fever so that when the healthcare provider comes in, she can obtain an order for an antipyretic. D) requests that the child 's mother give the child something for the fever that she brought from home.
Ans: A Feedback: Teamwork and collaboration as defined by QSEN indicates the need to recognize practice boundaries at the same time as functioning within the inter-professional team to accomplish shared decision making. It is the nurses responsibility to report altered client status that may require collaborative interventions, irregardless of time of day. For the nurse to administer a medication, there must be a written order for the medication, and it is outside of the scope of practice to prescribe medications. Waiting to report the assessment to an oncoming nurse may delay client care and effect client outcomes. It would be inappropriate to require the mother take care of this with medications brought from home.
When the nurse assesses the client's blood sugar, what is the term for the type of skill the nurse is using? A) Technical B) Therapeutic C) Interactional D) Adaptive
Ans: A Feedback: Technical skills are used to carry out treatments and procedures.
Which of the following groups developed standard language to increase the visibility of nursing's contribution to client care by continuing to develop, refine, and classify phenomena of concern to nurses? A) NANDA B) NIC C) NOC D) HHCC (now CCC)
Ans: A Feedback: The North American Nursing Diagnosis Association (NANDA) International increased the visibility of nursing's contribution to client care by continuing to develop, refine, and classify phenomena of concern to nurses. The Nursing Interventions Classification (NIC) works to identify, label, validate, and classify actions nurses perform, including direct and indirect care interventions. The Nursing-Sensitive Outcomes Classification (NOC) identifies, validates, and classifies nursing-sensitive client outcomes and indicators to evaluate the validity and usefulness of the classification. Home Health Care Classification (HHCC, now known as Clinical Care Classification (CCC) system) provides a structure for documenting and classifying home health and ambulatory care.
After completing an assessment of a client, the nurse uses critical thinking and clinical reasoning to prioritize the client's problems. Which of the following would the nurse determine is the highest priority? A) Severe bleeding from a wound B) History of asthma C) Diabetes D) Lack of family support
Ans: A Feedback: The client's problem is considered to be of high priority if it is life-threatening, requires more intervention time, and has serious consequences. The severe bleeding from a wound would be the highest priority. The client's history of asthma, diabetes, and lack of family support may be important but the bleeding is the priority.
A client age 50 years reports to a primary care unit with an open wound due to a fall in the bathroom. Which of the following nursing actions represents caring skills? A) The nurse cleans the wound and applies a dressing to it. B) The nurse inspects and examines the wound for swelling. C) The nurse tells the client to use caution while on slippery surfaces. D) The nurse informs the client that the wound is small and will heal easily.
Ans: A Feedback: The nursing action of cleaning the wound and applying a dressing indicates caring skills. The nurse implements assessment skills while inspecting and examining the wound. The nurse counsels the client to use caution when walking on slippery surfaces. By informing the client about the wound's condition, the nurse uses comforting skills.
The nursing student uses evidence-based practice findings in the development of a care plan. This is an example of which type of nursing skill? A) Cognitive skill B) Technical skill C) Interpersonal skill D) Ethical/legal skill
Ans: A Feedback: The student is demonstrating the use of cognitive skills, which is characterized by identifying scientific rationales for the client's plan of care, selecting nursing interventions that are most likely to yield the desired outcomes, and using critical thinking to solve problems. Technical skills focus on manipulating equipment skillfully to produce a desired outcome. Interpersonal skills are used to establish and maintain a caring relationship. Ethically and legally skilled nurses conduct themselves in a manner consistent with their personal moral code and professional role responsibilities.
A student is asked to perform a skill for which he is not prepared. When using the method of critical thinking, what would be the first step to resolve the situation? A) Purpose of thinking B) Adequacy of knowledge C) Potential problems D) Helpful resources
Ans: A Feedback: The student's first step when thinking critically about a situation is to identify the purpose or goal of the thinking. This helps to discipline thinking by directing all thoughts toward the goal.
In which of the following situations would the nurse be most justified in implementing trial-and-error problem solving? A) The nurse is attempting to landmark an obese client's apical pulse. B) The nurse is attempting to determine the range of motion of a client's hip joint following hip surgery. C) The nurse is attempting to determine which PRN (as needed) analgesic to offer a client who is in pain. D) The nurse is attempting to determine whether a poststroke client has a swallowing deficit.
Ans: A Feedback: Trial-and-error problem solving can be dangerous to the client. Testing range of motion by trial-and-error could result in dislocation; trial-and-error drug administration could result in over- or under-medicating; trial-and-error assessment of a potential swallowing deficit could result in aspiration. Each of these situations warrants more systematic problem-solving. Trial-and-error landmarking of an anatomically difficult point, such as the apex of an obese client's heart, does not pose a threat to the client and a reasonable amount of "hunting" for the apical pulse may be necessary.
Nurses apply critical thinking to clinical reasoning and judgment in their nursing practice every day. Which of the following are characteristics of this practice? Select all that apply. A) It is guided by standards, policies and procedures, ethics codes, and laws. B) It is based on principles of nursing process, problem solving, and the scientific method. C) It carefully identifies the key problems, issues, and risks involved. D) It is driven by the nurse's need to document competent, efficient care. E) It calls for strategies that make the most of human potential.
Ans: A, B, C, E Feedback: Critical thinking is guided by standards, policies and procedures, ethics codes, and laws; is based on principles of nursing process, problem-solving, and the scientific method; and carefully identifies the key problems, issues, and risks involved. It is driven by client, family, and community needs, as well as nurses' needs to give competent, efficient care (e.g., streamlining paperwork to free nurses for client care). It calls for strategies that make the most of human potential and compensate for problems created by human nature. It is constantly re-evaluating, self-correcting, and striving to improve.
Which of the following is an essential feature of professional nursing? Select all that apply. A) Providing a caring relationship to facilitate health and healing B) Attention to a range of human experiences and responses to health and illness C) Use of objective data to negate the client's subjective experience D) Use of judgment and critical thinking to form a medical diagnosis E) Advancement of professional nursing knowledge through scholarly inquiry
Ans: A, B, E Feedback: As the role has changed, definitions of nursing have evolved to acknowledge the following essential features of professional nursing: (1) providing a caring relationship that facilitates health and healing, (2) attention to the range of human experiences and responses to health and illness within the physical and social environments, (3) integration of objective data with knowledge gained from an appreciation of the client's or group's subjective experience, (4) application of scientific knowledge to the processes of diagnosis and treatment through the use of judgment and critical thinking, (5) advancement of professional nursing knowledge through scholarly inquiry, and (6) influence on social and public policy to promote social justice.
A nurse is examining a child two years of age. Based on her findings, she initiates a care plan for a potential problem with normal growth and development. Which step of the nursing process identifies actual and potential problems? A) Assessing B) Diagnosing C) Planning D) Implementing
Ans: B Feedback: After assessing the need for nursing care, the nurse clearly identifies client strengths, and actual and potential problems in diagnoses.
A nurse interviews a pregnant teenager and documents her answers on the client record. At the same time, the nurse responds to the client's concerns and makes a referral for counseling and maternity care. This scenario is an example of which of the descriptors of the nursing process? A) Systematic B) Dynamic C) Outcome oriented D) Universally applicable
Ans: B Feedback: Although the nursing process is presented as an orderly progression of steps, in reality there is great interaction and overlapping among the five steps. No one step in the nursing process is a one-time phenomenon; each step flows into the next step. In some nursing situations, all five stages occur almost simultaneously.
What nursing organization first legitimized the use of the nursing process? A) National League for Nursing B) American Nurses Association C) International Council of Nursing D) State Board of Nursing
Ans: B Feedback: Although the term "nursing process" was first used by Lydia Hall in 1955 and nursing theorists delineated specific steps in a process approach to nursing, use of the nursing process was legitimized in 1973, when the American Nurses Association's Congress for Nursing Practice developed Standards of Practice to guide nursing performance.
A home health nurse reviews the nursing care with the client and family and then mutually discusses the expected outcomes of the nursing care to be provided. Which step of the nursing process is the nurse illustrating? A) Diagnosing B) Planning C) Implementing D) Evaluating
Ans: B Feedback: During the planning step, the nurse identifies expected outcomes of the plan of care. The plan of care should be holistic and individualized, specify desired client goals and related outcomes, and identify the nursing interventions most likely to meet those expected outcomes.
A nurse asks a multidisciplinary team to collaborate in developing the most appropriate plan of care to meet the needs of an adolescent with a severe head injury. Which of the blended skills essential to nursing practice is the nurse using? A) Cognitive skills B) Interpersonal skills C) Technical skills D) Ethical/legal skills
Ans: B Feedback: Interpersonally skilled nurses establish and maintain caring relationships that facilitate the achievement of valued goals, and simultaneously affirm the worth of those in the relationship. They are, among other things, able to work collaboratively with the health care team to reach valued goals.
An experienced ICU nurse is mentoring a student. The nurse tells the student, "I think something is going wrong with your client." What type of clinical decision making is the experienced nurse demonstrating? A) Trial-and-error problem solving B) Intuitive thinking C) Scientific problem solving D) Methodical reasoning
Ans: B Feedback: Nurses today acknowledge the role of intuitive thinking in clinical decision making. Many veteran nurses can describe situations in which an "inner prompting" led to a quick nursing intervention that saved a client's life. However, intuitive problem solving comes with years of practice and observation.
A nurse is caring for a client in the ER who was injured in a snowmobile accident. The nurse documents the following client data: uncontrollable shivering, weakness, pale and cold skin. Th nurse suspects the client is experiencing hypothermia. Upon further assessment, the nurse notes a heart rate of 53 BPM and core internal temperature of 90°F, which confirms the initial diagnosis. The nurse then devises a plan of care and continues to monitor the client to evaluate the outcomes. This nurse is using which of the following types of problem solving in her care of this client? A) Trial-and-error B) Scientific C) Intuitive D) Critical thinking
Ans: B Feedback: Scientific problem solving is a systematic, seven-step, problem-solving process that involves (1) problem identification, (2) data collection, (3) hypothesis formulation, (4) plan of action, (5) hypothesis testing, (6) interpretation of results, and (7) evaluation, resulting in conclusion or revision of the study. This method is used most correctly in a controlled laboratory setting but is closely related to the more general problem-solving processes commonly used by health care professionals as they work with clients, such as the nursing process.
The nurse, after gathering data, analyzes the information to derive meaning. The nurse is involved in which phase of the nursing process? A) Planning B) Diagnosis C) Implementation D) Outcome identification
Ans: B Feedback: The diagnosis phase involves the analysis of information and deriving the meaning from the analysis. The planning phase involves preparing a care plan and directing the nursing staff in providing care. The implementation phase involves initiation, evaluation of response to the plan, record of nursing actions, and client response to actions. Outcome identification involves formulating and documenting measurable, realistic, client-focused goals.
What step in the nursing process is most closely associated with cognitively skilled nurses? A) Assessing B) Planning C) Implementing D) Evaluating
Ans: B Feedback: Cognitively skilled nurses are critical thinkers and are able to select those nursing interventions that are most likely to yield the desired outcomes.
Nurses make decisions in their practice every day. Which of the following are potential errors in this decision-making process? Select all that apply. A) Placing emphasis on the last data received B) Avoiding information contrary to one's opinion C) Selecting alternatives to maintain status quo D) Being predisposed to multiple solutions E) Prioritizing problems in order of importance
Ans: B, C Feedback: Potential errors in decision making include bias: placing emphasis on the first data received, avoiding information contrary to one's opinion, selecting alternatives to maintain status quo, and being predisposed to a single solution. Failure to prioritize problems in order of importance is failure to consider the total situation. Failure to use appropriate resources is impatience. All these actions can lead to errors in decision making (Lipe & Beasley, 2004.)
As a beginning student in nursing, what is essential to the mastery of technical skills, such as giving an injection? A) Read the steps of the procedure before clinical assignments. B) Even if you do not know how to give an injection, act as if you do. C) Practice giving injections in the learning laboratory until you feel comfortable. D) Tell your instructor that you don't think you can ever give an injection.
Ans: C Feedback: Before attempting to perform a technical skill with or on a patient, it is necessary for the nurse to practice that skill until he or she feels confident in doing it.
Based on an established plan of care, a nurse turns a client every two hours. What part of the nursing process is the nurse using? A) Assessing B) Planning C) Implementing D) Evaluating
Ans: C Feedback: During the implementing step of the nursing process, the nurse carries out interventions that were developed during the planning step.
When the nurse is administering Lasix 20 mg to a client in congestive heart failure, what phase of the nursing process does this represent? A) Assessment B) Planning C) Implementation D) Evaluation
Ans: C Feedback: Implementation refers to the action phase of the nursing process, in which nursing care is provided.
Legally speaking, how would the nurse ensure that care was not negligent? A) Verbally reporting assessments to the client's physician B) Keeping private notes about the care given to each assigned client C) Documenting the nursing actions in the client's record D) Tape recording complete information for each oncoming shift
Ans: C Feedback: Legally speaking, a nursing action not documented in the client's record is a nursing action not performed. Unless the record contains written (not verbal, tape-recorded, or in private notes) documentation of care provided, the court would have no reason to accept a nurse's claim that the care was given.
Which of the following group of terms best describes the nursing process? A) nursing goals, medical terminology, linear B) nurse-centered, single focus, blended skills C) patient-centered, systematic, outcomes-oriented D) family-centered, single point in time, intuitive
Ans: C Feedback: The nursing process is a patient-centered, systematic, outcomes-oriented method of caring that provides a framework for nursing practice. It is nursing practice in action.
Which of the following is one example of a client benefit of using the nursing process? A) Greater personal satisfaction B) Decreased reliance on the nursing staff C) Continuity of care D) Decreased incidence of medical errors
Ans: C Feedback: When used well, the nursing process achieves for the client scientifically based, holistic, individualized care; the opportunity to work collaboratively with nurses; and continuity of care.
Members of the staff on a hospital unit are critical of a client's family, who has different cultural beliefs about health and illness. A student assigned to the patient does not agree, based on her care of the client and family. What critical-thinking attitude is the student demonstrating? A) Being curious and persevering B) Being creative C) Demonstrating confidence D) Thinking independently
Ans: D Feedback: Although all the attitudes listed are components of critical thinking, the student is thinking independently. Nurses who are independent thinkers are careful not to let the status quo or a persuasive individual control their thinking.
Which of the following interpersonal skills is essential to the practice of nursing? A) Performing technical skills knowledgeably and safely B) Maintaining emotional distance from clients and families C) Keeping personal information among shared clients confidential D) Promoting the dignity and respect of patients as people
Ans: D Feedback: Characteristics of interpersonal caring that are essential to the practice of nursing include promoting the dignity and respect of clients as people, the centrality of the caring relationship, and a mutual enrichment of both participants in the nurse-client relationship.
Nursing is a profession in a rapidly changing health care environment. What is the most important reason for the nurse to develop critical thinking and clinical reasoning? A) To be able to employ the nursing process in client care. B) The licensing examination requires nurses to be adept at critical thinking. C) Because clients deserve experts who know how to care for them. D) To provide quality care with nursing ability and knowledge.
Ans: D ack: The goal of all nursing is to meet the standard of quality care. Clinical reasoning and critical thinking may be applied in all of the answers but the most important goal in health care is to provide quality nursing care to clients.