NR 226 Exam 1 - Review Questions/Answers well elaborated A+ GRADED
While assessing a patient, the nurse observes that the patient's intravenous (IV) line is not
infusing at the ordered rate. The nurse assesses the patient for pain at the IV site, checks the flow
regulator on the tubing, looks to see if the patient is lying on the tubing, checks the point of
connection between the tubing and the IV catheter, and then checks the condition of the site
where the intravenous catheter enters the patient's skin. After the nurse readjusts the flow rate,
the infusion begins at the correct rate. This is an example of:
A. Inference.
B. Diagnostic reasoning.
C. Competency.
D. Problem solving. - -D. Problem solving
-This is an example of problem solving. The nurse collects information and tries options until she
is able to find a solution to the slowed infusion rate. The focus is on solving the problem with the
patient's IV and not on solving the patient's health problem; thus this is not the diagnostic
reasoning process.
The nurse sits down to talk with a patient who lost her sister 2 weeks ago. The patient reports she
is unable to sleep, feels very fatigued during the day, and is having trouble at work. The nurse
asks her to clarify the type of trouble. The patient explains she can't concentrate or even solve
simple problems. The nurse records the results of the assessment, describing the patient as
having ineffective coping. This is an example of:
A. Diagnostic reasoning.
B. Competency.
C. Inference.
D. Problem solving. - -A. Diagnostic reasoning
,-In this example the nurse collects information about the patient, sees patterns in the data
collected, and makes a nursing diagnosis. This is an example of the diagnostic process.
A nurse has worked on an oncology unit for 3 years. One patient has become visibly weaker and
states, "I feel funny." The nurse knows how patients often have behavior changes before
developing sepsis when they have cancer. The nurse asks the patient questions to assess thinking
skills and notices the patient shivering. The nurse goes to the phone, calls the physician, and
begins the conversation by saying, "I believe that your patient is developing sepsis. I want to
report symptoms I'm seeing." What examples of critical thinking concepts does the nurse show?
(Select all that apply.)
A. Experience
B. Ethical
C. Analyticity
D. Self-confidence
E. Risk taking - -C & D.
-Among critical thinking concepts, the nurse shows analyticity (analyzing information, gathering
additional findings, and sensing a problem), and self-confidence (calling the physician, which
shows trust in his own reasoning). The nurse's experience would have influenced the familiarity
of patient symptoms, but in this text experience is considered a component of the critical
thinking model and not a concept. Acting ethically is a critical thinking standard.
.A nurse who is working on a surgical unit is caring for four different patients. Patient A will be
discharged home and is in need of instruction about wound care. Patients B and C have returned
from the operating room within an hour of each other, and both require vital signs and
monitoring of their intravenous (IV) lines. Patient D is resting following a visit by physical
therapy. Which of the following activities by the nurse represent(s) use of clinical decision
making for groups of patients? (Select all that apply.)
,A. Consider how to involve patient A in deciding whether to involve the family caregiver in
wound care instruction.
B. Think about past experience with patients who develop postoperative complications.
C. Decide which activities can be combined for patients B and C.
D. Carefully gather any assessment information and identify patient problems. - -A & C
-Considering how to involve patients in decisions and how to combine nursing activities to be
more organized and allow for resolving more than one problem at a time are examples of clinical
decision making for groups of patients. Thinking about past experience with patients is an
example of reflection, an approach to strengthen critical thinking skills. Gathering assessment
information is part of the process of diagnostic reasoning, which should be applied to each
patient.
The surgical unit has initiated the use of a pain-rating scale to assess patients' pain severity
during their postoperative recovery. The registered nurse (RN) looks at the pain flow sheet to see
the pain scores recorded for a patient over the last 24 hours. Use of the pain scale is an example
of which intellectual standard?
A. Deep
B. Relevant
C. Consistent
D. Significant - -C. Consistent
-Use of the same pain scale for assessing pain acuity is an example of being consistent.
During a home health visit the nurse prepares to instruct a patient in how to perform range-of-
motion (ROM) exercises for an injured shoulder. The nurse verifies that the patient took an
analgesic 30 minutes before arrival at the patient's home. After discussing the purpose for the
exercises and demonstrating each one, the nurse has the patient perform them. After two attempts
, with only the second of three exercises, the patient stops and says, "This hurts too much. I don't
see why I have to do this so many times." The nurse applies the critical thinking attitude of
integrity in which of the following actions?
A. "I understand your reluctance, but the exercises are necessary for you to regain function in
your shoulder. Let's go a bit more slowly and try to relax."
B. "I see that you're uncomfortable. I'll call your doctor to decide the next step."
C. "Show me exactly where your pain is and rate it for me on a scale of 0 to 10."
D. "Is anything else bothering you? Other than the pain, is there any other reason you might not
want to do the exercises?" - -A. "I understand your reluctance, but the exercises are necessary for
you to regain function in your shoulder. Let's go a bit more slowly and try to relax."
-The nurse reviews the position of requiring exercises to restore function and decides to try a
different approach to proceed, which is an example of integrity. In calling the doctor for the next
step, the nurse does not reinforce the importance of exercises, which is likely the standard of care
for this type of patient. In asking the location and strength of the pain the nurse is interpreting
further to determine if any other physical problems are developing. In attempting to learn if any
other underlying problems exist, the nurse is showing curiosity.
The nurse cared for a 14-year-old with renal failure who died near the end of the work shift. The
health care team tried for 45 minutes to resuscitate the child with no success. The family was
devastated by the loss, and, when the nurse tried to talk with them, the mother said, "You can't
make me feel better; you don't know what it's like to lose a child." Which of the following
examples of journal entries might best help the nurse reflect and think about this clinical
experience? (Select all that apply.)
A. Data entry of time of day, who was present, and condition of the child
B. Description of the efforts to restore the child's blood pressure, what was used, and questions
about the child's response
While assessing a patient, the nurse observes that the patient's intravenous (IV) line is not
infusing at the ordered rate. The nurse assesses the patient for pain at the IV site, checks the flow
regulator on the tubing, looks to see if the patient is lying on the tubing, checks the point of
connection between the tubing and the IV catheter, and then checks the condition of the site
where the intravenous catheter enters the patient's skin. After the nurse readjusts the flow rate,
the infusion begins at the correct rate. This is an example of:
A. Inference.
B. Diagnostic reasoning.
C. Competency.
D. Problem solving. - -D. Problem solving
-This is an example of problem solving. The nurse collects information and tries options until she
is able to find a solution to the slowed infusion rate. The focus is on solving the problem with the
patient's IV and not on solving the patient's health problem; thus this is not the diagnostic
reasoning process.
The nurse sits down to talk with a patient who lost her sister 2 weeks ago. The patient reports she
is unable to sleep, feels very fatigued during the day, and is having trouble at work. The nurse
asks her to clarify the type of trouble. The patient explains she can't concentrate or even solve
simple problems. The nurse records the results of the assessment, describing the patient as
having ineffective coping. This is an example of:
A. Diagnostic reasoning.
B. Competency.
C. Inference.
D. Problem solving. - -A. Diagnostic reasoning
,-In this example the nurse collects information about the patient, sees patterns in the data
collected, and makes a nursing diagnosis. This is an example of the diagnostic process.
A nurse has worked on an oncology unit for 3 years. One patient has become visibly weaker and
states, "I feel funny." The nurse knows how patients often have behavior changes before
developing sepsis when they have cancer. The nurse asks the patient questions to assess thinking
skills and notices the patient shivering. The nurse goes to the phone, calls the physician, and
begins the conversation by saying, "I believe that your patient is developing sepsis. I want to
report symptoms I'm seeing." What examples of critical thinking concepts does the nurse show?
(Select all that apply.)
A. Experience
B. Ethical
C. Analyticity
D. Self-confidence
E. Risk taking - -C & D.
-Among critical thinking concepts, the nurse shows analyticity (analyzing information, gathering
additional findings, and sensing a problem), and self-confidence (calling the physician, which
shows trust in his own reasoning). The nurse's experience would have influenced the familiarity
of patient symptoms, but in this text experience is considered a component of the critical
thinking model and not a concept. Acting ethically is a critical thinking standard.
.A nurse who is working on a surgical unit is caring for four different patients. Patient A will be
discharged home and is in need of instruction about wound care. Patients B and C have returned
from the operating room within an hour of each other, and both require vital signs and
monitoring of their intravenous (IV) lines. Patient D is resting following a visit by physical
therapy. Which of the following activities by the nurse represent(s) use of clinical decision
making for groups of patients? (Select all that apply.)
,A. Consider how to involve patient A in deciding whether to involve the family caregiver in
wound care instruction.
B. Think about past experience with patients who develop postoperative complications.
C. Decide which activities can be combined for patients B and C.
D. Carefully gather any assessment information and identify patient problems. - -A & C
-Considering how to involve patients in decisions and how to combine nursing activities to be
more organized and allow for resolving more than one problem at a time are examples of clinical
decision making for groups of patients. Thinking about past experience with patients is an
example of reflection, an approach to strengthen critical thinking skills. Gathering assessment
information is part of the process of diagnostic reasoning, which should be applied to each
patient.
The surgical unit has initiated the use of a pain-rating scale to assess patients' pain severity
during their postoperative recovery. The registered nurse (RN) looks at the pain flow sheet to see
the pain scores recorded for a patient over the last 24 hours. Use of the pain scale is an example
of which intellectual standard?
A. Deep
B. Relevant
C. Consistent
D. Significant - -C. Consistent
-Use of the same pain scale for assessing pain acuity is an example of being consistent.
During a home health visit the nurse prepares to instruct a patient in how to perform range-of-
motion (ROM) exercises for an injured shoulder. The nurse verifies that the patient took an
analgesic 30 minutes before arrival at the patient's home. After discussing the purpose for the
exercises and demonstrating each one, the nurse has the patient perform them. After two attempts
, with only the second of three exercises, the patient stops and says, "This hurts too much. I don't
see why I have to do this so many times." The nurse applies the critical thinking attitude of
integrity in which of the following actions?
A. "I understand your reluctance, but the exercises are necessary for you to regain function in
your shoulder. Let's go a bit more slowly and try to relax."
B. "I see that you're uncomfortable. I'll call your doctor to decide the next step."
C. "Show me exactly where your pain is and rate it for me on a scale of 0 to 10."
D. "Is anything else bothering you? Other than the pain, is there any other reason you might not
want to do the exercises?" - -A. "I understand your reluctance, but the exercises are necessary for
you to regain function in your shoulder. Let's go a bit more slowly and try to relax."
-The nurse reviews the position of requiring exercises to restore function and decides to try a
different approach to proceed, which is an example of integrity. In calling the doctor for the next
step, the nurse does not reinforce the importance of exercises, which is likely the standard of care
for this type of patient. In asking the location and strength of the pain the nurse is interpreting
further to determine if any other physical problems are developing. In attempting to learn if any
other underlying problems exist, the nurse is showing curiosity.
The nurse cared for a 14-year-old with renal failure who died near the end of the work shift. The
health care team tried for 45 minutes to resuscitate the child with no success. The family was
devastated by the loss, and, when the nurse tried to talk with them, the mother said, "You can't
make me feel better; you don't know what it's like to lose a child." Which of the following
examples of journal entries might best help the nurse reflect and think about this clinical
experience? (Select all that apply.)
A. Data entry of time of day, who was present, and condition of the child
B. Description of the efforts to restore the child's blood pressure, what was used, and questions
about the child's response
