The nurse is charting on the patient who is status post-surgery for an abdominal abscess and notes: "Pt's temperature has not exceeded $37°C this shift." This is an example of a(n)

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Question 1 of 5

The nurse is charting on the patient who is status post-surgery for an abdominal abscess and notes: "Pt's temperature has not exceeded $37°C this shift." This is an example of a(n)

Correct Answer: B

Rationale: An outcome measures care plan effectiveness (B), like temperature stability post-surgery. An intervention (A) is an action (e.g., administering medication), a plan (C) outlines intended actions, and a diagnosis (D) identifies a problem, none of which fit this evaluative statement, making B correct.

Question 2 of 5

A patient with pneumonia has been using the incentive spirometer four times daily while awake during his 3-day hospitalization. How would the nurse explore the effectiveness of this intervention?

Correct Answer: D

Rationale: Effectiveness is evaluated objectively by auscultating lungs (D) for reduced adventitious sounds, indicating spirometer success. A (subjective), B (new intervention), and C (observation) don’t assess outcomes, making D the best method.

Question 3 of 5

The nurse is listening to a lecture on collaborative problems. Which statement indicates that teaching has been effective?

Correct Answer: C

Rationale: Collaborative problems involve nurse monitoring for complications (C), requiring teamwork with other providers, unlike nursing diagnoses (A). B is false (not two physicians), and D aligns with diagnoses, not collaborative issues, making C correct.

Question 4 of 5

A nurse is reinforcing discharge teaching with the parents of an infant who has a prescription for home oxygen and pulse oximetry monitoring. Which of the following statements by the parents indicates a need for further teaching?

Correct Answer: D

Rationale: A consistent reading of 100% is likely inaccurate, as it suggests potential equipment malfunction or improper placement, especially in a client requiring supplemental oxygen where saturation is rarely 100%. This indicates a need for further teaching as the parents should recognize this as abnormal and report it. Choices A, B, and C reflect correct understanding of pulse oximetry use.

Question 5 of 5

A nurse is caring for an older adult client. The client has an increased risk for dehydration due to which of the following physiological changes that can occur with aging?

Correct Answer: B

Rationale: Aging decreases kidney function, reducing the ability to concentrate urine and regulate fluid balance, increasing dehydration risk. Decreased systolic blood pressure (A) is incorrect as aging often increases it, increased body water (C) is false as it decreases with age, and increased saliva production (D) is incorrect as it typically reduces.

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