ATI LPN
Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
Chapter 3 : Critical Thinking, Ethical Decision Making and the Nursing Process Questions
Question 1 of 5
A nurse has begun creating a patients plan of care shortly after the patients admission. It is important that the wording of the chosen nursing diagnoses falls within the taxonomy of nursing. Which organization is responsible for developing the taxonomy of a nursing diagnosis?
Correct Answer: B
Rationale: NANDA International is the official organization responsible for developing the taxonomy of nursing diagnoses and formulating nursing diagnoses acceptable for study. The ANA, NLN, and Joint Commission are not charged with the task of developing the taxonomy of nursing diagnoses.
Question 2 of 5
In response to a patients complaint of pain, the nurse administered a PRN dose of hydromorphone (Dilaudid). In what phase of the nursing process will the nurse determine whether this medication has had the desired effect?
Correct Answer: B
Rationale: Evaluation, the final step of the nursing process, allows the nurse to determine the patients response to nursing interventions and the extent to which the objectives have been achieved.
Question 3 of 5
A medical nurse has obtained a new patients health history and completed the admission assessment. The nurse has followed this by documenting the results and creating a care plan for the patient. Which of the following is most important rationale for documenting the patients care?
Correct Answer: A
Rationale: This record provides a means of communication among members of the health care team and facilitates coordinated planning and continuity of care. It serves as the legal and business record for a health care agency and for the professional staff members who are responsible for the patients care. Documentation is not primarily a teaching log; it does not verify staffing; and it is not intended to provide the patient with information about treatments.
Question 4 of 5
The nurse is caring for a patient who is withdrawing from heavy alcohol use and who is consequently combative and confused, despite the administration of benzodiazepines. The patient has a fractured hip that he suffered in a traumatic accident and is trying to get out of bed. What is the most appropriate action for the nurse to take?
Correct Answer: B
Rationale: It is mandatory in most settings to have a physicians order before restraining a patient. Before restraints are used, other strategies, such as asking family members to sit with the patient, or utilizing a specially trained sitter, should be tried. A patient should never be left alone while the nurse summons assistance.
Question 5 of 5
A patient admitted with right leg thrombophlebitis is to be discharged from an acute-care facility. Following treatment with a heparin infusion, the nurse notes that the patients leg is pain-free, without redness or edema. Which step of the nursing process does this reflect?
Correct Answer: D
Rationale: The nursing actions described constitute evaluation of the expected outcomes. The findings show that the expected outcomes have been achieved. Analysis consists of considering assessment information to derive the appropriate nursing diagnosis. Implementation is the phase of the nursing process where the nurse puts the care plan into action. This nurses actions do not constitute diagnosis.