NURX104 Essentials of Nursing Care
Health Safety Exam
Nursing process, Documentation, Reporting
During the implementation of a patient care plan, an RN needs to consider which of the
following actions?
(Select all that apply.)
Directing care to other personnel
Providing appropriate patient teaching as needed
Providing direct patient care according to the plan
Focusing on traditional health care practices
Implementing the plan in a safe, timely fashion with the patient only - Answer *1)
Implementation of the care plan involves directing the care of other personnel.
*2) Patient teaching is a component of care plan implementation.
*3) The RN is responsible for direct care of the patient during implementation.
4) The RN incorporates traditional and complementary health practices as appropriate.
5) The RN partners with the family, significant others, and caregivers as well as with the
patient.
,Nursing process, Documentation, Reporting
According to the ANA Standards of Practice, in which phase of the nursing process
does the RN determine patient-centered goals and the ways to achieve them?
Analysis
Assessment
Evaluation
Planning - Answer 1) Analysis is synthesizing data to identify the patient's actual or
potential health problems (nursing diagnosis).
2) Assessment is gathering and organizing data in relation to the patient's health status.
3) Evaluation is assessing the patient's response to nursing care, including progress
toward the expected outcome (patient-centered goal).
*4) Planning is determining the expected outcomes (patient-centered goals) and
formulating specific strategies to achieve the expected outcomes.
Nursing process, Documentation, Reporting
The ANA Standards of Practice state that the evaluation phase of the nursing process
involves which nursing activity?
Asking patients for feedback about their hospital stay
Determining achievement of expected outcomes
Documenting care given to the patient
Supervising NAP activities - Answer 1) Asking the patient for feedback is not an
application of the nursing process.
,*2) Evaluation is assessing the patient's response to nursing care, including progress
toward the expected outcome (patient-centered goal).
3) Documenting care is an ongoing task of the assessment phase of the nursing
process.
4) Assigning and supervising patient care to other members of the health care team is
part of the planning phase.
Nursing process, Documentation, Reporting
Posting pictures or descriptions of patient information on social media represents a
significant risk to the RN because of which legal violation?
Federal privacy laws
Personal privacy laws
Nursing ethics
Standards of practice - Answer *1) Federal privacy laws are violated under the Health
Insurance Portability and Accountability Act.
2) See 1).
3) See 1).
4) See 1).
Nursing process, Documentation, Reporting
, An RN is instructing a student on the process of developing a care plan for a patient.
Which statement by the student indicates to the RN that further instruction is needed on
writing outcomes based on ANA Standards of Nursing Practice?
"I need to base outcomes on my patient's acuity level."
"I should consider the patient's ethical, cultural, and spiritual values."
"I should involve the patient, family, and health care providers."
"I need to include a time estimate for attainment of expected outcomes." - Answer *1)
The answer is incorrect, since the patient's acuity is not related to goals developed is a
care plan.
2) See 1).
3) See 1).
4) See 1).
Nursing process, Documentation, Reporting
An RN teaches a patient who is diabetic how to assess the skin on the bottom of the feet
for open wounds, using a lighted mirror. Which element of nursing informatics has the
RN used with this intervention?
Data
Information
Knowledge
Wisdom - Answer 1) The data element would be that the skin is either intact or broken.
2) The information element would be that this patient has diabetes.
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