Fundamentals of Nursing Thinking Doing and Caring
4th Edition Volume 2 Wilkinson Treas Questions &
Answers with rationales Chapter 1-8
The nurse has written this diagnosis for a patient: Ineffective Airway Clearance related to weak
cough secondary to incisional pain. Which of the following outcomes is essential for the nurse to
include in the care plan?
1) Effective cough
2) Airways clear to auscultation
3) Pain less than 4 on a scale of 1 to 10
4) Demonstrates splinting of incision - verified answer 2) Airways clear to auscultation
For every nursing diagnosis, it is essential to have one goal that, if achieved, would show resolution
of the problem. If the airways were clear to auscultation that would show resolution of Ineffective
Airway Clearance. Effective cough, reduced pain, and splinting of incision would help to resolve the
problem, but they are aimed at the etiology side of the diagnostic statement. Even if pain is reduced,
for example, the airways still might not be clear.
See page 85 in the textbook, BASIC NURSING by Leslie Treas and Judith Wilkinson.
What is wrong with this goal statement? "The patient will walk to the doorway with the help of one
person."
1) Action verb
2) Special conditions
3) Target time
4) Nothing is wrong with it. - verified answer 3) Target time
The goal does not have a target time. Its action verb is "patient." Its special conditions are "with the
help of one person."
See page 92 in the textbook, BASIC NURSING by Leslie Treas and Judith Wilkinson.
Which of the following is a collaborative intervention?
1) Rubbing patient's back to facilitate relaxation
,2) Measuring the patient's blood pressure
3) Assessing the patient's educational needs related to discharge
4) Administering prescribed medications to a patient - verified answer 4) Administering prescribed
medications to a patient
Administering medications requires a physician's order and pharmacist to dispense; it is therefore a
collaborative intervention for the nurse. The other options are independent nursing actions.
See page 103 in the textbook, BASIC NURSING by Leslie Treas and Judith Wilkinson.
Which nurse is most clearly using evidence-based practice? One who uses an intervention:
1) He read about in a study in a nursing research journal
2) From the agency's critical pathway
3) Published in the clinical practice guidelines of a national group
4) That is individualized to meet a specific patient need - verified answer 3) Published in the clinical
practice guidelines of a national group
Clinical practice guidelines provide the best evidence because they are usually developed by
scientists and qualified medical professionals after a thorough review and evaluation of the available
evidence for an intervention. An individual study published in a nursing journal can provide some
applicable evidence; however, it might not be as reliable as a body of studies of the same
intervention. Critical pathways are not always evidence based. The nurse should always individualize
interventions, as needed, to meet specific patient needs; however, this answer does not state that
the intervention being individualized has any basis at all in evidence.
See page 105 in the textbook, BASIC NURSING by Leslie Treas and Judith Wilkinson.
How is a critical pathway different from a standardized care plan? A critical pathway:
1) Does not include medical orders
2) Provides individualized goals and interventions
3) Specifies patient outcomes and interventions for each day, or other period of time
4) Is usually a preprinted document for a particular diagnosis or condition - verified answer 3)
Specifies patient outcomes and interventions for each day, or other period of time
, A critical pathway specifies patient outcomes and interventions for each day, and in some situations
(such as labor and delivery) for each hour. Critical pathways do include medical orders, so that
statement is not true of critical pathways. Critical pathways are standardized, not individualized, so
this is not true of critical pathways. Both critical pathways and standardized care plans are
preprinted documents for a particular diagnosis or condition, so that statement cannot be used to
differentiate them.
See page 87 in the textbook, BASIC NURSING by Leslie Treas and Judith Wilkinson.
A facility is using ___________ nursing care when scientifically sound research data are used to
make nursing care decisions.
1) Evidence-based
2) Standardized
3) Individualized
4) Theoretical - verified answer 1) Evidence-based
Evidence-based nursing care uses solid, scientific data to make decisions about nursing practice.
See page 104 in the textbook, BASIC NURSING by Leslie Treas and Judith Wilkinson.
The nurse has developed and implemented a care plan for a patient. Evaluation of the patient's
responses ends the nursing process for this patient.
1) True
2) False - verified answer 2) False
Evaluation does not end the nursing process. The nursing process is continuous; evaluation provides
information to begin another cycle of care.
Which is the best example of a well-stated desired outcome? The patient will:
1) Use the incentive spirometer while awake
2) State pain < 4 on a scale of 1 to 10 within 1 hour after receiving pain medication
3) Increase the distance he walks each time he ambulates
4) Verbalize the side effects of his new medication - verified answer 2) State pain <4 on a scale of 1
to 10 within 1 hour after receiving pain medication
4th Edition Volume 2 Wilkinson Treas Questions &
Answers with rationales Chapter 1-8
The nurse has written this diagnosis for a patient: Ineffective Airway Clearance related to weak
cough secondary to incisional pain. Which of the following outcomes is essential for the nurse to
include in the care plan?
1) Effective cough
2) Airways clear to auscultation
3) Pain less than 4 on a scale of 1 to 10
4) Demonstrates splinting of incision - verified answer 2) Airways clear to auscultation
For every nursing diagnosis, it is essential to have one goal that, if achieved, would show resolution
of the problem. If the airways were clear to auscultation that would show resolution of Ineffective
Airway Clearance. Effective cough, reduced pain, and splinting of incision would help to resolve the
problem, but they are aimed at the etiology side of the diagnostic statement. Even if pain is reduced,
for example, the airways still might not be clear.
See page 85 in the textbook, BASIC NURSING by Leslie Treas and Judith Wilkinson.
What is wrong with this goal statement? "The patient will walk to the doorway with the help of one
person."
1) Action verb
2) Special conditions
3) Target time
4) Nothing is wrong with it. - verified answer 3) Target time
The goal does not have a target time. Its action verb is "patient." Its special conditions are "with the
help of one person."
See page 92 in the textbook, BASIC NURSING by Leslie Treas and Judith Wilkinson.
Which of the following is a collaborative intervention?
1) Rubbing patient's back to facilitate relaxation
,2) Measuring the patient's blood pressure
3) Assessing the patient's educational needs related to discharge
4) Administering prescribed medications to a patient - verified answer 4) Administering prescribed
medications to a patient
Administering medications requires a physician's order and pharmacist to dispense; it is therefore a
collaborative intervention for the nurse. The other options are independent nursing actions.
See page 103 in the textbook, BASIC NURSING by Leslie Treas and Judith Wilkinson.
Which nurse is most clearly using evidence-based practice? One who uses an intervention:
1) He read about in a study in a nursing research journal
2) From the agency's critical pathway
3) Published in the clinical practice guidelines of a national group
4) That is individualized to meet a specific patient need - verified answer 3) Published in the clinical
practice guidelines of a national group
Clinical practice guidelines provide the best evidence because they are usually developed by
scientists and qualified medical professionals after a thorough review and evaluation of the available
evidence for an intervention. An individual study published in a nursing journal can provide some
applicable evidence; however, it might not be as reliable as a body of studies of the same
intervention. Critical pathways are not always evidence based. The nurse should always individualize
interventions, as needed, to meet specific patient needs; however, this answer does not state that
the intervention being individualized has any basis at all in evidence.
See page 105 in the textbook, BASIC NURSING by Leslie Treas and Judith Wilkinson.
How is a critical pathway different from a standardized care plan? A critical pathway:
1) Does not include medical orders
2) Provides individualized goals and interventions
3) Specifies patient outcomes and interventions for each day, or other period of time
4) Is usually a preprinted document for a particular diagnosis or condition - verified answer 3)
Specifies patient outcomes and interventions for each day, or other period of time
, A critical pathway specifies patient outcomes and interventions for each day, and in some situations
(such as labor and delivery) for each hour. Critical pathways do include medical orders, so that
statement is not true of critical pathways. Critical pathways are standardized, not individualized, so
this is not true of critical pathways. Both critical pathways and standardized care plans are
preprinted documents for a particular diagnosis or condition, so that statement cannot be used to
differentiate them.
See page 87 in the textbook, BASIC NURSING by Leslie Treas and Judith Wilkinson.
A facility is using ___________ nursing care when scientifically sound research data are used to
make nursing care decisions.
1) Evidence-based
2) Standardized
3) Individualized
4) Theoretical - verified answer 1) Evidence-based
Evidence-based nursing care uses solid, scientific data to make decisions about nursing practice.
See page 104 in the textbook, BASIC NURSING by Leslie Treas and Judith Wilkinson.
The nurse has developed and implemented a care plan for a patient. Evaluation of the patient's
responses ends the nursing process for this patient.
1) True
2) False - verified answer 2) False
Evaluation does not end the nursing process. The nursing process is continuous; evaluation provides
information to begin another cycle of care.
Which is the best example of a well-stated desired outcome? The patient will:
1) Use the incentive spirometer while awake
2) State pain < 4 on a scale of 1 to 10 within 1 hour after receiving pain medication
3) Increase the distance he walks each time he ambulates
4) Verbalize the side effects of his new medication - verified answer 2) State pain <4 on a scale of 1
to 10 within 1 hour after receiving pain medication
