FUNDAMENTALS OF NURSING, NURSING PROCESS QUESTIONS AND ANSWERS LATEST UPDATE
7 views 0 purchase
Course
FUNDAMENTALS OF NURSING
Institution
FUNDAMENTALS OF NURSING
FUNDAMENTALS OF NURSING, NURSING PROCESS QUESTIONS AND ANSWERS LATEST UPDATE
client comes to the walk-in clinic with reports of abdominal pain and diarrhea. While taking the client's vital signs, the nurse is implementing which phase of the nursing process?
A. Assessment
B. Diagnosis
C. ...
FUNDAMENTALS OF NURSING, NURSING PROCESS
QUESTIONS AND ANSWERS LATEST UPDATE
client comes to the walk-in clinic with reports of abdominal pain and diarrhea.
While taking the client's vital signs, the nurse is implementing which phase of the
nursing process?
A. Assessment
B. Diagnosis
C. Planning
D. Implementation
A. Assessment
Rationale: The first step in the nursing process is assessment, the process of collecting
data. All subsequent phases of the nursing process (options 2, 3, and 4) rely on
accurate and complete data.
The nurse is measuring the client's urine output and straining the urine to assess
for stones. Which of the following should the nurse record as objective data?
A. The client reports abdominal pain
B. The client's urine output was 450 mL
C. The client states, "I didn't see any stones in my urine."
D. The client states, "I feel like I have passed a stone."
B. The client's urine output was 450 mL.
Rationale: Objective data is measurable data that can be seen, heard, or verified by the
nurse. The objective data is the measurement of the urine output. A client's statements
and reports of symptoms are documented as subjective data, such as the data found in
options 1, 3, and 4.
When evaluating an elderly client's blood pressure (BP) of 146/78 mmHg, the
nurse does which of the following before determining whether the BP is normal
or represents hypertension?
,A. Compare this reading against defined standards
B. Compare the reading with one taken in the opposite arm
C. Determine gaps in the vital signs in the client record
D. Compare the current measurement with previous ones
A. Compare this reading against defined
Rationale: Analysis of the client's BP requires knowledge of the normal BP range for an
older adult. The nurse compares the client's data against identified standards to
determine whether this reading is normal or abnormal. Measuring the BP in the other
arm (option 2) and comparing the reading to previous ones (option 4) will give additional
client data, but the comparison alone will not determine whether the BP is normal. Gaps
in the record (option 3) will not aid in interpreting the current measurement.
Which of the following behaviors by the nurse demonstrates that the nurse is
participating in critical thinking? Select all that apply.
A. Admitting not knowing how to do a procedure and requesting help
B. Using clever and persuasive remarks to support an opinion or position
C. Accepting without question the values acquired in nursing school
D. Finding a quick and logical answer, even to complex questions
E. Gathering three assistants to transfer the client to a stretcher after noting the
client weighs 300 lbs.
A. Admitting not knowing how to do a procedure and requesting help
E. Gathering three assistants to transfer the client to a stretcher after noting the client
weighs 300 lbs.
Rationale: Critical thinking in nursing is self-directed, supporting what nurses know and
making clear what they do not know. It is important for nurses to recognize when they
lack the knowledge they need to provide safe care for a client (option 1). Nurses must
also utilize their resources to acquire the support they need to care for a client safely
(option 5). Options 2, 3, and 4 do not demonstrate critical thinking.
, The nurse has documented the following outcome goal in the care plan: "The
client will transfer from bed to chair with two-person assist." The charge nurse
tells the nurse to add which of the following to complete the goal?
A. Client behavior
B. Conditions or modifiers
C. Performance criteria
D. Target time
D. Target time
Rationale: The outcome goal does not state the target timeframe for when the nurse
should expect to see the client behavior ("transfer"). The condition or modifier is present
("with two assists"). The performance criterion is "from bed to chair."
The nurse who documents on the client's care plan the outcome goal "Anxiety
will be relieved within 20 to 40 minutes following administration of lorazepam
(Ativan)" is engaged in which step of the nursing process?
A. Assessment
B. Planning
C. Implementation
D. Evaluation
B. Planning
Rationale: The planning step of the nursing process involves formulating client goals
and designing the nursing interventions required to prevent, reduce, or eliminate the
client's health problems. Outcome goals are documented on the client's care plan.
Assessment data (option 1) is used to help identify a client's human response, and once
a plan is established, the interventions are implemented (option 3) and evaluated
(option 4).
When the client resists taking a liquid medication that is essential to treatment,
the nurse demonstrates critical thinking by doing which of the following first?
The benefits of buying summaries with Stuvia:
Guaranteed quality through customer reviews
Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.
Quick and easy check-out
You can quickly pay through credit card or Stuvia-credit for the summaries. There is no membership needed.
Focus on what matters
Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!
Frequently asked questions
What do I get when I buy this document?
You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.
Satisfaction guarantee: how does it work?
Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.
Who am I buying these notes from?
Stuvia is a marketplace, so you are not buying this document from us, but from seller SUPERGRADES01. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy these notes for $8.79. You're not tied to anything after your purchase.
