A nurse is using critical thinking skills to analyze data during the assessment phase of the nursing process. Which of the following actions should the nurse take?(Select all that apply).

Compare data with normal values and standards.

Organize data into clusters that have similar underlying causes.

Validate data by using multiple sources of information.

Document data using standardized terminology and abbreviations.

Prioritize data according to urgency and importance.

Answer and Explanation

Correct Answer : A,B,C,E

Choice A reason:

Comparing data with normal values and standards is an important action for the nurse to take during the assessment phase of the nursing process. This helps the nurse to identify any deviations from normal and potential problems that need further investigation or intervention.

Choice B reason:

Organizing data into clusters that have similar underlying causes is another action that the nurse should take during the assessment phase. This helps the nurse to recognize patterns and relationships among the data and to formulate nursing diagnoses.

Choice C reason:

Validating data by using multiple sources of information is also an action that the nurse should take during the assessment phase. This helps the nurse to ensure that the data are accurate, complete, and factual, and to avoid making assumptions or errors.

Choice D reason:

Documenting data using standardized terminology and abbreviations is not an action that the nurse should take during the assessment phase of the nursing process. Although documentation is an essential part of nursing practice, it is not specific to the assessment phase. Moreover, standardized terminology and abbreviations are not always appropriate or clear for documenting data.

Choice E reason:

Prioritizing data according to urgency and importance is another action that the nurse should take during the assessment phase of the nursing process. This helps the nurse to focus on the most relevant and significant data and to plan for further assessment or intervention based on the patient's needs and priorities.

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Correct Answer is B

Explanation

Choice A reason:

Independent nursing interventions are actions that nurses can perform by themselves, without any management from a doctor or another discipline. For example, checking vital signs, repositioning a patient, or providing patient education are independent nursing interventions. These interventions do not require a health care provider's order.

Choice B reason:

Dependent nursing interventions are actions that nurses perform under the direction of a physician or as part of a care plan. For example, administering medications, performing diagnostic tests, or inserting an intravenous line are dependent nursing interventions. These interventions require a health care provider's order.

Choice C reason:

Collaborative nursing interventions are actions that nurses perform in coordination with other health care professionals, such as physicians, pharmacists, dietitians, or physical therapists. For example, developing a discharge plan, implementing a wound care protocol, or providing nutritional counseling are collaborative nursing interventions. These interventions may or may not require a health care provider's order, depending on the situation and the scope of practice of the nurse.

Choice D reason:

Evaluative nursing interventions are not a type of intervention, but rather a step in the nursing process. Evaluative nursing interventions are actions that nurses take to assess the outcomes of their care and the effectiveness of their interventions. For example, measuring pain levels, monitoring wound healing, or evaluating patient satisfaction are evaluative nursing interventions. These interventions do not require a health care provider's order.

A. Positioning the patient in high Fowler's position. B. Encouraging deep breathing and coughing exercises. C. Administering bronchodilators and corticosteroids as ordered. D. Providing supplemental oxygen via nasal cannula as ordered. E. Restricting fluid intake to prevent fluid overload.

Correct Answer is ["A","C","D"]

Explanation

Choice A:

Positioning the patient in high Fowler's position. This is a correct intervention because it allows for optimal chest expansion and lung ventilation, reducing dyspnea and work of breathing.

Choice B:

Encouraging deep breathing and coughing exercises. This is an incorrect intervention because it may increase dyspnea and fatigue in a patient with COPD who already has difficulty breathing. Instead, the nurse should teach pursed-lip breathing and diaphragmatic breathing techniques to improve gas exchange and reduce air trapping.

Choice C:

Administering bronchodilators and corticosteroids as ordered. This is a correct intervention because these medications help to relax the smooth muscles of the airways, reduce inflammation, and improve airflow in a patient with COPD.

Choice D:

Providing supplemental oxygen via nasal cannula as ordered. This is a correct intervention because oxygen therapy helps to correct hypoxemia, reduce pulmonary hypertension, and improve exercise tolerance and quality of life in a patient with COPD. The nurse should monitor the oxygen saturation and adjust the flow rate according to the prescription and the patient's response.

Choice E:

Restricting fluid intake to prevent fluid overload. This is an incorrect intervention because fluid restriction is not indicated for a patient with COPD unless there is evidence of heart failure or renal impairment. Adequate hydration helps to thin the secretions and facilitate expectoration in a patient with COPD. The nurse should encourage oral fluids unless contraindicated and monitor the fluid balance and electrolytes of the patient.

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A nurse is using critical thinking skills to analyze data during the assessment phase of the nursing process. Which of the following actions should the nurse take?(Select all that apply).

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which type of intervention requires a health care provider's order?

Correct Answer is B

Explanation

A nurse is planning care for a patient who has chronic obstructive pulmonary disease (COPD) and is experiencing dyspnea at rest. Which of the following interventions should be included in the plan of care?(Select all that apply.).

Correct Answer is ["A","C","D"]

Explanation

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