Rationale #1 Fundamentals of Nursing
1. D. Evaluation
Rationale: The nursing actions described constitute evaluation of expected outcomes. The findings show that the expected outcomes have been achieved. Assessment consists of the client's history, physical examination, and laboratory studies. 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 plan of care into action.
2. B. Analysis
Rationale: The nurse identifies human responses to actual or potential health problems during the analysis step of the nursing process, which encompasses the ability of the nurse to formulate a nursing diagnosis. During the assessment step the nurse systematically collects data about the client or family. During the planning step the nurse develops strategies to resolve or decrease the client's problem. During the evaluation step the nurse determines the effectiveness of the plan of care.
3. A. Formative
Rationale: Formative (or concurrent) evaluation occurs continuously throughout the teaching and learning process. One benefit is that the nurse can adjust teaching strategies as necessary to enhance learning. Retrospective or summative evaluation occurs at the conclusion of teaching and learning sessions. Informative isn't a type of evaluation.
4. A. pH
Rationale: The pH in an ABG report reflects the acid concentration in the blood. The partial pressure of arterial oxygen (Pao2) value indicates the amount of oxygen dissolved in the blood; the partial pressure of arterial carbon dioxide (Paco2) value represents the amount of carbon dioxide dissolved in the blood. The bicarbonate (HCO3_) value indicates the amount of bicarbonate or base in the blood.
5. C. walk from his room to the end of the hall and back before discharge.
Rationale: Walking from his room to the end of the hall and back before discharge is a specific measurable, attainable, and timed goal as well as a client oriented outcome goal. Having the client change his own dressing is incomplete and not as significant. Just walking in the hall isn't measurable. The need for a special diet isn't evident in this case.
6. D. Risk for aspiration related to anesthesia
Rationale: Risk for aspiration related to anesthesia takes priority for this client because general anesthesia may impair the gag and swallowing reflexes, possibly leading to aspiration. The other options, although important, are secondary.
7. B. Risk for injury
Rationale: A sensory deficit such as blindness puts the client at risk for injury from the environment. To prevent an injury that could further complicate the client's stay, the nurse should assign highest priority to this nursing diagnosis. Although Anxiety, Activity intolerance, or Impaired physical mobility also may be relevant, these nursing diagnoses don't take precedence over client safety.
8. B. documenting drugs given.
Rationale: Although documentation isn't a step in the nursing process, the nurse is legally required to document activities related to drug therapy, including the time of administration, the quantity, and the client's reaction. Developing a content outline, establishing outcome criteria, and setting realistic client goals are parts of planning rather than implementation.
9. A. By discharge, the client correctly identifies three potassium-rich foods.
Rationale: A client outcome must be measurable, concise, realistic for the client, and obtainable through nursing management. For each client outcome, the nurse should include only one client behavior, should express that behavior in terms of client expectations, and should indicate a time frame. Knowing the importance of consuming potassium-rich foods and knowing which foods are high in potassium aren't measurable. Understanding all complications isn't measurable or specific to the nursing diagnosis listed.
10. D. Acute pain
Rationale: The nursing diagnosis of Acute pain takes highest priority because pain increases the client's pulse and blood pressure. During an acute phase of an MI, low-grade fever is an expected result of the body's response to the myocardial tissue necrosis. This makes Risk for imbalanced body temperature an incorrect answer. The client's blood pressure and heart rate don't suggest a nursing diagnosis of Decreased cardiac output. Anxiety could be an appropriate nursing diagnosis but it may be corrected by addressing the priority concern — pain.
11. B. "Infuse I.V. fluids at 83 ml/hr"
Rationale: Because shock signals a severe fluid volume loss (700 to 1300 ml) its treatment includes rapid I.V. fluid replacement to sustain homeostasis and prevent death. The nurse should expect to administer three times the estimated fluid loss to increase the circulating volume. An I.V. infusion rate of 83 ml/hour wouldn't begin to replace the necessary fluids and reverse the problem. The other options are appropriate for this client.
12. A. Risk for impaired skin integrity related to immobility
Rationale: The information documented in the client's chart reflects the risk for impaired skin integrity. Because the client's skin is intact the problem is only a potential one, not an actual one, making the nursing diagnosis of Impaired skin integrity inappropriate. If constipation were a problem, interventions would focus on diet and activity. If disturbed body image were a problem, interventions would focus on the client's feelings about himself and the disease.
13. A. Deficient fluid volume
Rationale: Clients with acute pancreatitis commonly experience deficient fluid volume, which can lead to hypovolemic shock. The volume deficit may be caused by vomiting, hemorrhage (in hemorrhagic pancreatitis), and plasma leaking into the peritoneal cavity. Hypovolemic shock would cause a decrease in cardiac output. Tissue perfusion would be altered if hypovolemic shock occurred, but this wouldn't be the primary nursing diagnosis.
14. D. Inability to speak clearly
Rationale: Aphasia is the complete or partial loss of language skills caused by damage to cortical areas of the brain's left hemisphere. The client may have arm and leg weakness or an absent gag reflex after a CVA, but these findings aren't related to aphasia. Difficulty swallowing is called dysphagia.
15. B. Administering a measles, mumps, and rubella immunization to an infant
Rationale: Immunizing an infant is an example of primary prevention, which aims to prevent health problems. Administering digoxin to treat heart failure and obtaining a Pap test for screening are examples of secondary prevention, which promotes early detection and treatment of disease. Using occupational therapy to help a client cope with arthritis is an example of tertiary prevention, which aims to help a client deal with the residual consequences of a problem or to prevent the problem from recurring.
16. A. Identifying one way to increase social interaction
Rationale: The goal of care for a client with a nursing diagnosis of Social isolation is to identify at least one way to increase social interaction or to participate in social activities at least weekly. The other options aren't goals that address this nursing diagnosis.
17. C. Failure to progress
Rationale: Failure to progress is an example of noncompliance. Undesirable drug action indicates adverse drug reaction. Multiple questions show a client's lack of knowledge about the drug. Resolved symptoms indicate that drug therapy was successful.
18. D. Evaluation
Rationale: During the evaluation step of the nursing process the nurse determines whether the goals established in the plan of care have been achieved and evaluates the success of the plan. If a goal is unmet or partially met the nurse reexamines the data and revises the plan. Assessment involves data collection. Planning involves setting priorities, establishing goals, and selecting appropriate interventions. Implementation involves providing actual nursing care.
19. B. Current health promotion activities
Rationale: Recognizing an individual's positive health measures is very useful. General health in the previous 10 years is important; however, current activities of an 85-year-old client are most significant in planning care. Family history of diseases for a client in later years is of minor significance. Marital status information may be important for discharge planning but isn't as significant for addressing the immediate medical problem.
20. C. Nurse-client relationship
Rationale: Two major clinical characteristics affect client compliance: the nurse-client relationship and the therapeutic regimen. The client's drug knowledge, psychosocial factors, and disease duration and severity are client characteristics, not clinical ones.
21. D. 5 cm H20.
Rationale: Usually CVP ranges from 4 to 10 cm H20 or 3 to 7 mm Hg. The other options are outside this range.
22. C. Man, environment, health, and nursing
Rationale: Most nursing theories deal with the key concepts of man (or person — the individual), the environment (external conditions affecting life and development), health (optimal functioning), and nursing. Illness, health care, health restoration, caring, disease, and treatment are concepts addressed by specific theorists.
23. B. Elimination
Rationale: According to Maslow, elimination is a first-level or physiological need and therefore takes priority over all other needs. Security and safety are second-level needs; belonging is a third-level need. Second- and third-level needs can be met only after a client's first level needs have been satisfied.
24. B. keeping the bed at the lowest position possible.
Rationale: Keeping the bed at the lowest possible position is the first priority for clients at risk for falling. Keeping the call light easily accessible is important but isn't a top priority. Instructing the client not to get out of bed may not effectively prevent falls — for example, if the client is confused. Even when assistance is required, the bed must first be in the lowest position. The client may not require a bedpan.
25. C. "What were you doing when the pain started?"
Rationale: Subjective data (data from the client) about the chest pain help determine the specific health problem. For example, asking about the setting in which the pain developed can provide helpful information about its cause. Options A and D wouldn't elicit information related to a cardiac problem. Option B presumes a particular diagnosis and asks a "why" question, which is a nontherapeutic communication technique.
26. D. Adjusting to retirement, deaths of family members, and decreased physical strength
Rationale: Challenges faced in older adulthood include adjusting to retirement, deaths of family members, and decreased physical strength. Challenges faced in young adulthood include selecting a vocation, becoming financially independent, and managing a home. Challenges in middle adulthood include developing leisure activities, preparing for retirement, and resolving empty nest crisis.
Rationale: The nursing actions described constitute evaluation of expected outcomes. The findings show that the expected outcomes have been achieved. Assessment consists of the client's history, physical examination, and laboratory studies. 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 plan of care into action.
2. B. Analysis
Rationale: The nurse identifies human responses to actual or potential health problems during the analysis step of the nursing process, which encompasses the ability of the nurse to formulate a nursing diagnosis. During the assessment step the nurse systematically collects data about the client or family. During the planning step the nurse develops strategies to resolve or decrease the client's problem. During the evaluation step the nurse determines the effectiveness of the plan of care.
3. A. Formative
Rationale: Formative (or concurrent) evaluation occurs continuously throughout the teaching and learning process. One benefit is that the nurse can adjust teaching strategies as necessary to enhance learning. Retrospective or summative evaluation occurs at the conclusion of teaching and learning sessions. Informative isn't a type of evaluation.
4. A. pH
Rationale: The pH in an ABG report reflects the acid concentration in the blood. The partial pressure of arterial oxygen (Pao2) value indicates the amount of oxygen dissolved in the blood; the partial pressure of arterial carbon dioxide (Paco2) value represents the amount of carbon dioxide dissolved in the blood. The bicarbonate (HCO3_) value indicates the amount of bicarbonate or base in the blood.
5. C. walk from his room to the end of the hall and back before discharge.
Rationale: Walking from his room to the end of the hall and back before discharge is a specific measurable, attainable, and timed goal as well as a client oriented outcome goal. Having the client change his own dressing is incomplete and not as significant. Just walking in the hall isn't measurable. The need for a special diet isn't evident in this case.
6. D. Risk for aspiration related to anesthesia
Rationale: Risk for aspiration related to anesthesia takes priority for this client because general anesthesia may impair the gag and swallowing reflexes, possibly leading to aspiration. The other options, although important, are secondary.
7. B. Risk for injury
Rationale: A sensory deficit such as blindness puts the client at risk for injury from the environment. To prevent an injury that could further complicate the client's stay, the nurse should assign highest priority to this nursing diagnosis. Although Anxiety, Activity intolerance, or Impaired physical mobility also may be relevant, these nursing diagnoses don't take precedence over client safety.
8. B. documenting drugs given.
Rationale: Although documentation isn't a step in the nursing process, the nurse is legally required to document activities related to drug therapy, including the time of administration, the quantity, and the client's reaction. Developing a content outline, establishing outcome criteria, and setting realistic client goals are parts of planning rather than implementation.
9. A. By discharge, the client correctly identifies three potassium-rich foods.
Rationale: A client outcome must be measurable, concise, realistic for the client, and obtainable through nursing management. For each client outcome, the nurse should include only one client behavior, should express that behavior in terms of client expectations, and should indicate a time frame. Knowing the importance of consuming potassium-rich foods and knowing which foods are high in potassium aren't measurable. Understanding all complications isn't measurable or specific to the nursing diagnosis listed.
10. D. Acute pain
Rationale: The nursing diagnosis of Acute pain takes highest priority because pain increases the client's pulse and blood pressure. During an acute phase of an MI, low-grade fever is an expected result of the body's response to the myocardial tissue necrosis. This makes Risk for imbalanced body temperature an incorrect answer. The client's blood pressure and heart rate don't suggest a nursing diagnosis of Decreased cardiac output. Anxiety could be an appropriate nursing diagnosis but it may be corrected by addressing the priority concern — pain.
11. B. "Infuse I.V. fluids at 83 ml/hr"
Rationale: Because shock signals a severe fluid volume loss (700 to 1300 ml) its treatment includes rapid I.V. fluid replacement to sustain homeostasis and prevent death. The nurse should expect to administer three times the estimated fluid loss to increase the circulating volume. An I.V. infusion rate of 83 ml/hour wouldn't begin to replace the necessary fluids and reverse the problem. The other options are appropriate for this client.
12. A. Risk for impaired skin integrity related to immobility
Rationale: The information documented in the client's chart reflects the risk for impaired skin integrity. Because the client's skin is intact the problem is only a potential one, not an actual one, making the nursing diagnosis of Impaired skin integrity inappropriate. If constipation were a problem, interventions would focus on diet and activity. If disturbed body image were a problem, interventions would focus on the client's feelings about himself and the disease.
13. A. Deficient fluid volume
Rationale: Clients with acute pancreatitis commonly experience deficient fluid volume, which can lead to hypovolemic shock. The volume deficit may be caused by vomiting, hemorrhage (in hemorrhagic pancreatitis), and plasma leaking into the peritoneal cavity. Hypovolemic shock would cause a decrease in cardiac output. Tissue perfusion would be altered if hypovolemic shock occurred, but this wouldn't be the primary nursing diagnosis.
14. D. Inability to speak clearly
Rationale: Aphasia is the complete or partial loss of language skills caused by damage to cortical areas of the brain's left hemisphere. The client may have arm and leg weakness or an absent gag reflex after a CVA, but these findings aren't related to aphasia. Difficulty swallowing is called dysphagia.
15. B. Administering a measles, mumps, and rubella immunization to an infant
Rationale: Immunizing an infant is an example of primary prevention, which aims to prevent health problems. Administering digoxin to treat heart failure and obtaining a Pap test for screening are examples of secondary prevention, which promotes early detection and treatment of disease. Using occupational therapy to help a client cope with arthritis is an example of tertiary prevention, which aims to help a client deal with the residual consequences of a problem or to prevent the problem from recurring.
16. A. Identifying one way to increase social interaction
Rationale: The goal of care for a client with a nursing diagnosis of Social isolation is to identify at least one way to increase social interaction or to participate in social activities at least weekly. The other options aren't goals that address this nursing diagnosis.
17. C. Failure to progress
Rationale: Failure to progress is an example of noncompliance. Undesirable drug action indicates adverse drug reaction. Multiple questions show a client's lack of knowledge about the drug. Resolved symptoms indicate that drug therapy was successful.
18. D. Evaluation
Rationale: During the evaluation step of the nursing process the nurse determines whether the goals established in the plan of care have been achieved and evaluates the success of the plan. If a goal is unmet or partially met the nurse reexamines the data and revises the plan. Assessment involves data collection. Planning involves setting priorities, establishing goals, and selecting appropriate interventions. Implementation involves providing actual nursing care.
19. B. Current health promotion activities
Rationale: Recognizing an individual's positive health measures is very useful. General health in the previous 10 years is important; however, current activities of an 85-year-old client are most significant in planning care. Family history of diseases for a client in later years is of minor significance. Marital status information may be important for discharge planning but isn't as significant for addressing the immediate medical problem.
20. C. Nurse-client relationship
Rationale: Two major clinical characteristics affect client compliance: the nurse-client relationship and the therapeutic regimen. The client's drug knowledge, psychosocial factors, and disease duration and severity are client characteristics, not clinical ones.
21. D. 5 cm H20.
Rationale: Usually CVP ranges from 4 to 10 cm H20 or 3 to 7 mm Hg. The other options are outside this range.
22. C. Man, environment, health, and nursing
Rationale: Most nursing theories deal with the key concepts of man (or person — the individual), the environment (external conditions affecting life and development), health (optimal functioning), and nursing. Illness, health care, health restoration, caring, disease, and treatment are concepts addressed by specific theorists.
23. B. Elimination
Rationale: According to Maslow, elimination is a first-level or physiological need and therefore takes priority over all other needs. Security and safety are second-level needs; belonging is a third-level need. Second- and third-level needs can be met only after a client's first level needs have been satisfied.
24. B. keeping the bed at the lowest position possible.
Rationale: Keeping the bed at the lowest possible position is the first priority for clients at risk for falling. Keeping the call light easily accessible is important but isn't a top priority. Instructing the client not to get out of bed may not effectively prevent falls — for example, if the client is confused. Even when assistance is required, the bed must first be in the lowest position. The client may not require a bedpan.
25. C. "What were you doing when the pain started?"
Rationale: Subjective data (data from the client) about the chest pain help determine the specific health problem. For example, asking about the setting in which the pain developed can provide helpful information about its cause. Options A and D wouldn't elicit information related to a cardiac problem. Option B presumes a particular diagnosis and asks a "why" question, which is a nontherapeutic communication technique.
26. D. Adjusting to retirement, deaths of family members, and decreased physical strength
Rationale: Challenges faced in older adulthood include adjusting to retirement, deaths of family members, and decreased physical strength. Challenges faced in young adulthood include selecting a vocation, becoming financially independent, and managing a home. Challenges in middle adulthood include developing leisure activities, preparing for retirement, and resolving empty nest crisis.
