The nurse is caring for a trauma patient who has just arrived in the emergency room.
The nurse listens to the patient's lung sounds, palpates the patient's peripheral pulses, and obtains vital signs.
What is the best description of the nurse's actions?
Performing a physical examination.
Establishing priorities for outcomes.
Demonstrating diagnostic reasoning.
Setting time frames for interventions.
The Correct Answer is A
Choice A rationale
Performing a physical examination involves the systematic assessment of a patient's body to identify signs of health or illness. Listening to lung sounds, palpating peripheral pulses, and obtaining vital signs are all fundamental components of a physical examination aimed at gathering objective data about the patient's current condition.
Choice B rationale
Establishing priorities for outcomes involves setting goals for patient care based on identified nursing diagnoses and collaborative problems. While the nurse's assessment data will inform the development of outcomes, the initial actions described focus on data collection, not outcome identification.
Choice C rationale
Demonstrating diagnostic reasoning is the cognitive process of analyzing assessment data to arrive at a nursing diagnosis or identify a collaborative problem. While the nurse is gathering data that will contribute to diagnostic reasoning, the actions described are the data collection phase itself, not the analysis.
Choice D rationale
Setting time frames for interventions involves establishing specific schedules for nursing actions aimed at achieving patient outcomes. The nurse's immediate actions upon the patient's arrival are focused on rapid assessment to understand the patient's immediate needs, not on scheduling future interventions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["0.7"]
Explanation
Step 1 is: The desired dose is 7000 units and the available concentration is 10,000 units/mL.
Step 2 is: Divide the desired dose by the available concentration: 7000 units ÷ 10,000 units/mL = 0.7 mL. Final answer: The nurse will administer 0.7 mL.
Correct Answer is A
Explanation
Choice A rationale
The nursing process is a systematic, cyclical method used by nurses to identify and address patient health needs. It involves assessment, diagnosis, planning, implementation, and evaluation, providing a structured approach to problem-solving and the delivery of individualized care.
Choice B rationale
Standardized protocols offer guidelines for specific conditions but do not encompass the holistic and individualized nature of the entire nursing process. The nursing process allows for adaptation and critical thinking beyond pre-established routines to meet unique patient needs.
Choice C rationale
A legal document defining the scope of practice outlines what nurses are legally allowed to do. While the nursing process guides nursing actions, it is a framework for care delivery rather than a legal definition of professional boundaries.
Choice D rationale
While communication is integral to healthcare, the nursing process is more than just a communication tool. It is a comprehensive framework that guides all aspects of nursing care, from initial assessment to the evaluation of outcomes, involving critical thinking and clinical judgment.
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