Fundamentals of Nursing: Applying the Nursing
Process
This section explores the fundamental principles of nursing, focusing on the
nursing process and its application to patient care.
1. Phase of Nursing Process During Vital Signs Assessment: When a nurse
takes a client's vital signs who reports abdominal pain and diarrhea, the
nurse is in the Assessment phase.
o Rationale: Assessment is the initial step, involving data collection.
Accurate data is crucial for subsequent phases.
2. Objective Data in Urine Output Assessment: When measuring urine
output and straining urine, the objective data to record is:
o B. The client's urine output was 450 mL.
Rationale: Objective data is measurable and verifiable. Urine
output is a quantifiable measurement.
3. Evaluating Elderly Client's Blood Pressure: Before determining if an
elderly client's BP of 146/78 mmHg is normal, the nurse should:
o A. Compare this reading against defined standards.
Rationale: Analyzing BP requires knowledge of normal ranges
for older adults.
4. Demonstrating Critical Thinking: Behaviors that demonstrate critical
thinking include:
o A. Admitting not knowing how to do a procedure and requesting
help.
o E. Gathering three assistants to transfer the client to a stretcher
after noting the client weighs 300 lbs.
, Rationale: Critical thinking involves self-awareness of
knowledge and utilizing resources for safe care.
5. Completing an Outcome Goal: The missing component in the outcome
goal "The client will transfer from bed to chair with two-person assist" is:
o D. Target time.
Rationale: An effective goal needs a timeframe for
achievement.
6. Nursing Process Step for Documenting Outcome Goal: Documenting the
outcome goal "Anxiety will be relieved within 20 to 40 minutes following
administration of lorazepam (Ativan)" is part of the Planning step.
o Rationale: Planning involves setting goals and interventions.
7. Critical Thinking When Client Resists Medication: If a client resists
essential liquid medication, the nurse should first:
o B. Suggesting the medication can be diluted in a beverage.
Rationale: Problem-solving and finding alternative solutions
are key.
8. Response to a More Stringent Restraint Policy: When a new restraint
policy is introduced, the professionally appropriate response is to:
o C. Ask for the rationale behind the new policy.
Rationale: Understanding the rationale aids in analyzing and
understanding the change.
9. Action Before Delegating Ambulation to UAP: Before delegating
ambulation, the nurse must:
o A. Assess the client to be sure ambulation with assistance is an
appropriate care measure.
Rationale: The nurse must ensure delegation is safe and
appropriate for the client.
Process
This section explores the fundamental principles of nursing, focusing on the
nursing process and its application to patient care.
1. Phase of Nursing Process During Vital Signs Assessment: When a nurse
takes a client's vital signs who reports abdominal pain and diarrhea, the
nurse is in the Assessment phase.
o Rationale: Assessment is the initial step, involving data collection.
Accurate data is crucial for subsequent phases.
2. Objective Data in Urine Output Assessment: When measuring urine
output and straining urine, the objective data to record is:
o B. The client's urine output was 450 mL.
Rationale: Objective data is measurable and verifiable. Urine
output is a quantifiable measurement.
3. Evaluating Elderly Client's Blood Pressure: Before determining if an
elderly client's BP of 146/78 mmHg is normal, the nurse should:
o A. Compare this reading against defined standards.
Rationale: Analyzing BP requires knowledge of normal ranges
for older adults.
4. Demonstrating Critical Thinking: Behaviors that demonstrate critical
thinking include:
o A. Admitting not knowing how to do a procedure and requesting
help.
o E. Gathering three assistants to transfer the client to a stretcher
after noting the client weighs 300 lbs.
, Rationale: Critical thinking involves self-awareness of
knowledge and utilizing resources for safe care.
5. Completing an Outcome Goal: The missing component in the outcome
goal "The client will transfer from bed to chair with two-person assist" is:
o D. Target time.
Rationale: An effective goal needs a timeframe for
achievement.
6. Nursing Process Step for Documenting Outcome Goal: Documenting the
outcome goal "Anxiety will be relieved within 20 to 40 minutes following
administration of lorazepam (Ativan)" is part of the Planning step.
o Rationale: Planning involves setting goals and interventions.
7. Critical Thinking When Client Resists Medication: If a client resists
essential liquid medication, the nurse should first:
o B. Suggesting the medication can be diluted in a beverage.
Rationale: Problem-solving and finding alternative solutions
are key.
8. Response to a More Stringent Restraint Policy: When a new restraint
policy is introduced, the professionally appropriate response is to:
o C. Ask for the rationale behind the new policy.
Rationale: Understanding the rationale aids in analyzing and
understanding the change.
9. Action Before Delegating Ambulation to UAP: Before delegating
ambulation, the nurse must:
o A. Assess the client to be sure ambulation with assistance is an
appropriate care measure.
Rationale: The nurse must ensure delegation is safe and
appropriate for the client.
