Correct Answer: B

Rationale: Using the nursing process: The nursing process (assessment, diagnosis, planning, implementation, evaluation) is a structured approach that guides clinical decision-making and ensures patient-centered care. Relying on recall of information from past lectures and textbooks: Critical thinking involves applying knowledge, not just recalling it. Nurses must analyze patient-specific data and adapt care accordingly. Drawing on past clinical experiences to formulate standardized care plans: Past experiences can inform decision-making, but care plans must be individualized to the patient’s current condition rather than relying solely on standardization. Depending on the charge nurse to determine priorities of care: While charge nurses provide leadership, each nurse is responsible for critical thinking and independent decision-making based on their assessment.

Correct Answer: C

Rationale: Uses critical thinking for the highest level of quality nursing care: Professional standards provide guidelines for best practices, ensuring nurses apply critical thinking and clinical judgment to improve patient outcomes. Utilizing evidence-based practice based on nurses' needs: Professional standards focus on patient-centered care, not the nurse's needs. Evidence-based practice should prioritize patient safety and effectiveness. Establishes minimal passing standards for testing: While professional standards guide nursing education and testing, their primary role is to guide clinical decision-making for patient care. Bypasses the patient's feelings to promote ethical standards: Ethical nursing practice includes patient advocacy, not bypassing patient emotions or concerns.

Correct Answer: A

Rationale: Pressure points: Pressure points (e.g., sacrum, heels, elbows, shoulders, hips) are at the highest risk for breakdown, ulcers, and impaired circulation. This makes them the priority assessment for skin integrity. Pulse points: While checking pulses is important for circulatory assessment, it is not directly related to skin integrity assessment. Breath sounds: Breath sounds assess respiratory function and are not a direct indicator of skin integrity. Bowel sounds: Bowel sounds assess gastrointestinal function and are not relevant in a skin integrity assessment.

Correct Answer: D

Rationale: Aortic and Pulmonic: The second heart sound (S2) is produced by the closure of the aortic and pulmonic valves at the beginning of diastole. This marks the end of systole. Aortic and Mitral: The mitral valve is associated with the S1 sound, not S2. S2 occurs when the semilunar valves (aortic and pulmonic) close. Mitral and Pulmonic: The mitral valve closure is heard in S1, while the pulmonic valve closure is part of S2. However, the mitral valve is not involved in S2. Mitral and Tricuspid: The mitral and tricuspid valves close during S1, not S2. These valves are atrioventricular (AV) valves, not semilunar valves.

Correct Answer: B

Rationale: Asking the patient what pain-relief methods, pharmacological and nonpharmacological, have worked best in the past: This approach assesses the patient’s individual experience and applies personalized care, which is a hallmark of critical thinking. Explaining to the patient that self-reporting of severe pain is not consistent with the minor procedure that was performed: Pain is subjective and should always be believed and assessed rather than dismissed based on procedure type. This does not demonstrate critical thinking. Administering pain-relief medication according to what was given last shift: Pain levels fluctuate, and medication effectiveness must be reassessed each time. Simply repeating the previous shift’s orders does not involve critical thinking. Offering pain-relief medications based on the provider’s orders: While following orders is necessary, critical thinking involves assessing the patient’s pain level and determining the most appropriate intervention rather than blindly administering medication.