Exam 2: Critical Thinking and Nursing Process

The RN has chosen the nursing diagnosis of Risk for impaired skin integrity related to immobility.The correct goal/outcome statement for the diagnosis would be:

The nurse is caring for a patient diagnosed with pneumonia.The patient has a BP 160/94,P 102,R 28,crackles in posterior lower lobes bilaterally,oxygen saturation 89%,and complains of shortness of breath upon exertion.The highest priority nursing diagnosis for this patient is:

Matching Place the steps of the nursing process in their proper sequence. -Step: 4

Matching Place the steps of the nursing process in their proper sequence. -Step: 1

To assess skin turgor,the nurse would:

Matching Place the steps of the nursing process in their proper sequence. -Step: 5

Shortness of breath due to emphysema would be a major component of the _________ care plan.

The nurse demonstrates application of the nursing process by: (Select all that apply.)

During the admission process,the nurse receives orders for the patient to have arterial blood gases (ABGs)drawn.Which finding from the patient's history may cause concern?

The nursing student demonstrates knowledge of the proper use of the ___________ when determining that it is safe to administer meperidine (Demerol)and promethazine (Phenergan)together.

The diabetic patient who had blood drawn for an HbA?c level says,"I don't know why they want to look at my hemoglobin." The most helpful reply by the nurse would be:

The nurse explains to the nursing student that the application of critical thinking to patient care involves: (Select all that apply.)

The nurse's assessment reveals edema of both feet and ankles.The best documentation of these findings is:

The nurse adds a nursing order to the care plan related to a patient with a nursing diagnosis of Nutrition: less than body requirement related to nausea and vomiting.The statement that is a nursing order is:

The nurse performing an intake interview on a new resident to the long-term care facility detects the odor of acetone from the patient's breath.The assessment is done by:

The nurse explains that,in addition to the NANDA stem and etiology,the complete nursing diagnosis should include:

The LPN/LVN adheres to facility policy regarding core measures by performing which interventions during patient care?

Because the evaluation of the nursing care plan reflects lack of progress toward the goal,the nurse will confer with the patient to plan a:

During the admission interview,when asked about pain,the patient responds,"No.I'm pretty wobbly." Which action by the nurse would be most appropriate?

Matching Place the steps of the nursing process in their proper sequence. -Step: 2