ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 3 : The Nursing Process Questions
Question 1 of 5
The LPN states to an RN, 'I don't know why we have to follow a care plan. No one even uses it, and it just means more paperwork. What's the purpose?' What is the best response by the RN?
Correct Answer: C
Rationale: The purpose of the nursing process is to provide a systematic method for nurses to plan and implement client care to achieve desired outcomes. The nursing process cannot be eliminated from the paperwork because nurses use the process to evaluate and update a client's care. It is an integral part of nursing practice. Stating that the nursing process is something nurses have always done and must continue to do so is a vague and incomplete answer. It does not give a rationale for using the nursing process. Although health care providers may review a nurse's care plan to see what is being done for the client, that is not the reason nurses use the nursing process or create care plans. The client's plan of care guides nursing care and provides a vehicle for assessment, planning, implementation, evaluation, and, if needed, the revision of care.
Question 2 of 5
A client is admitted to the hospital for control of diabetes mellitus. When does the nurse understand the nursing process begins?
Correct Answer: A
Rationale: The nursing process begins when a client enters the healthcare system. Prior to being discharged, after the plan of care is initiated, and when the healthcare provider writes the first prescription for care all occur after the client is already in the healthcare system.
Question 3 of 5
The RN is obtaining a health history and performing a physical assessment for a client who is admitted to the hospital with complaints of chest pain. What part of the nursing process is the RN performing?
Correct Answer: D
Rationale: Assessment is the careful observation and evaluation of a client's health status. The nurse collects information to determine abnormal function and risk factors that contribute to health problems as well as client strengths. Planning is establishing the outcomes and actions that will help achieve the overall goals. Implementation is putting the plan into action. Evaluation is determining the client's responses to the care provided.
Question 4 of 5
The RN develops an outcome standard of 'client will ambulate with an assistive device 60 feet with assistance twice a day' for a client who had a hip replacement. What part of the nursing process is involved with this outcome statement?
Correct Answer: B
Rationale: Planning establishes the outcomes and actions that will help the client achieve the overall goals of care. Assessment is the careful observation and evaluation of a client's health status by the collection of data. Implementation is putting the plan into action, and evaluation is determining the client's responses to the care provided.
Question 5 of 5
A client has been admitted to the hospital with a large sacral pressure ulcer. The physician prescribes the wound care protocol to be performed twice a day. What would be a statement on the plan of care that would address the implementation phase of the nursing process for this client?
Correct Answer: D
Rationale: Turning the client every 2 hours is implementing care to allow the pressure ulcer to heal and prevent another formation of a wound. Recording the description of the wound would occur during the assessment phase of the nursing process. The prediction of how much and how soon the client's wound will heal would be made during the planning phase, while noting the amount the wound has healed on a given day is an example of a statement that would be made during the evaluation phase.