Med surg Chapter 1 critical thinking and the
nursing process
A nurse approaches a person in a restaurant who appears to be experiencing
respiratory distress. Which action should the nurse perform first? - ANS - Collect
data about the person's condition
\A patient with a family history of diabetes is experiencing high blood glucose
levels, confusion, and unsteady gait, and dehydration. Which nursing diagnoses
should the nurse identify as appropriate for this patient's care? - ANS - Risk for
falls
Deficient fluid volume
\A patient with a newly fractured femur reports a pain level of 8/10 and analgesic
medication is not due for another 50 minutes. Which action should the nurse take
first? - ANS - Notify the registered nurse (RN) or physician
\After collecting data, the nurse identifies diagnoses to guide the patient's care.
Which diagnoses did the nurse document correctly?(Select all that apply) - ANS -
Acute pain
Activity intolerance
Impaired physical mobility
\After identifying nursing diagnoses the nurse plans outcomes for a patient with
gastroesophageal reflex disease. Which outcome should the nurse use to
evaluate this patient's care? - ANS - The patient's esophageal burning will resolve
30 minutes after taking oral antacids
\An RN delegates a patient care assignment to the LPN/LVN. Which phase of the
nursing process should the LPN/LVN perform independently? - ANS -
Implementation
\During morning report, the LPN/LVN is assigned a group of patients. Which
patient should LPN/LVN see first? - ANS - A patient with pneumonia who is short
of breath and anxious
\The LPN/LVN ask a patient who received 2 mg of morphine IV 30 minutes ago to
rate his or her pain. This describes which step of the nursing process? - ANS -
Evaluation
\The LPN/LVN enters the room of a patient who is angry and yells, "I asked 5
minutes ago for my pain medication. I'm going to call the CEO of the hospital if
you don't get it for me now." Which statement by the nurse demonstrates
intellectual empathy? - ANS - "I am sorry you had to wait, I know you must be in a
lot of pain."
nursing process
A nurse approaches a person in a restaurant who appears to be experiencing
respiratory distress. Which action should the nurse perform first? - ANS - Collect
data about the person's condition
\A patient with a family history of diabetes is experiencing high blood glucose
levels, confusion, and unsteady gait, and dehydration. Which nursing diagnoses
should the nurse identify as appropriate for this patient's care? - ANS - Risk for
falls
Deficient fluid volume
\A patient with a newly fractured femur reports a pain level of 8/10 and analgesic
medication is not due for another 50 minutes. Which action should the nurse take
first? - ANS - Notify the registered nurse (RN) or physician
\After collecting data, the nurse identifies diagnoses to guide the patient's care.
Which diagnoses did the nurse document correctly?(Select all that apply) - ANS -
Acute pain
Activity intolerance
Impaired physical mobility
\After identifying nursing diagnoses the nurse plans outcomes for a patient with
gastroesophageal reflex disease. Which outcome should the nurse use to
evaluate this patient's care? - ANS - The patient's esophageal burning will resolve
30 minutes after taking oral antacids
\An RN delegates a patient care assignment to the LPN/LVN. Which phase of the
nursing process should the LPN/LVN perform independently? - ANS -
Implementation
\During morning report, the LPN/LVN is assigned a group of patients. Which
patient should LPN/LVN see first? - ANS - A patient with pneumonia who is short
of breath and anxious
\The LPN/LVN ask a patient who received 2 mg of morphine IV 30 minutes ago to
rate his or her pain. This describes which step of the nursing process? - ANS -
Evaluation
\The LPN/LVN enters the room of a patient who is angry and yells, "I asked 5
minutes ago for my pain medication. I'm going to call the CEO of the hospital if
you don't get it for me now." Which statement by the nurse demonstrates
intellectual empathy? - ANS - "I am sorry you had to wait, I know you must be in a
lot of pain."
