The nurse is using critical thinking skills during the first phase of the nursing process. Which action indicates the nurse is in the first phase?

Determines whether outcomes have been achieved

Identifies pertinent nursing diagnoses

Completes a comprehensive database

Intervenes based on priorities of patient care

Answer and Explanation

The Correct Answer is C

A. Outcome evaluation is part of the final phase.

B. Nursing diagnoses come after assessment.

C. The first phase of the nursing process is assessment, which includes collecting a comprehensive database of patient information.

D. Interventions occur in the implementation phase.

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Correct Answer is C

Explanation

A. Collaborative problem. This is incorrect because a collaborative problem involves complications requiring both medical and nursing interventions. The statement is a nursing diagnosis, not a collaborative problem.

B. Nursing diagnosis. This is incorrect because "Impaired Physical Mobility" is an appropriate NANDA-I approved nursing diagnosis.

C. Etiology. This is correct because "tibial fracture" is a medical diagnosis, and nursing diagnoses should not include medical conditions as the etiology. Instead, the etiology should focus on the patient’s response, such as "pain and muscle weakness" related to the fracture.

D. Defining characteristic. This is incorrect because "patient's inability to ambulate" is an appropriate defining characteristic that supports the diagnosis of impaired mobility.

A. Review the patient's medication history for any potential drug interactions. B. Educate the patient about the potential side effects of the new medication. C. Document the patient's baseline blood pressure before starting the medication. D. Assess the patient's blood pressure to determine if the medication is effective.

Correct Answer is D

Explanation

A. Reviewing medication history is important before starting a medication, not during the evaluation phase.

B. While education is important, the priority in the evaluation phase is determining whether the medication is working.

C. Baseline data is collected before treatment begins. The evaluation phase focuses on assessing the effectiveness of treatment.

D. The evaluation phase of the nursing process focuses on determining if interventions (such as medications) have achieved the desired outcomes.

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The nurse is using critical thinking skills during the first phase of the nursing process. Which action indicates the nurse is in the first phase?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is reviewing a patient's plan of care, which includes the nursing diagnostic statement, Impaired physical mobility related to tibial fracture as evidenced by patient's inability to ambulate. Which part of the diagnostic statement does the nurse need to revise?

Correct Answer is C

Explanation

A 65-year-old male patient with hypertension was recently started on a new antihypertensive medication. During the evaluation phase of the nursing process, which action should the nurse prioritize?

Correct Answer is D

Explanation

A nurse reviews a patient's health record and finds the following data. Which example includes only subjective data?

The nurse is using critical thinking skills during the first phase of the nursing process. Which action indicates the nurse is in the first phase?

Which of the following is the most appropriate open-ended question to begin a nursing assessment?

A nurse is providing nursing care to a group of patients. Which actions are direct care interventions? (Select all that apply.)

The nurse is providing care to a client admitted with pressure injuries. The nurse develops a plan of care focusing on healing measures and prevention of further injury. Which task does the nurse delegate to the nursing assistive personnel (NAP)?

A patient who recently underwent abdominal surgery is complaining of severe abdominal pain and has a distended abdomen. Which of the following interventions should the nurse do first?

The nurse is evaluating whether patient goals and outcomes have been met for a patient with physical mobility problems due to a fractured leg. Which finding indicates the patient has met an expected outcome?