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. Skipping breaks can lead to burnout.

B. Taking on another nurse’s task may cause delays in primary responsibilities.

C. Planning for interruptions improves efficiency and prioritization.

D. Completing the easiest tasks first may not be the most efficient approach.

A. The nurse determines to remove a wound dressing when the patient reveals the time of the last dressing change and notices old and new drainage. B. The nurse administers pain medicine due at 1700 at 1600 because the patient reports increased pain and the family wants something done. C. The nurse immediately asks the health care provider for an order of potassium when a patient reports leg cramps. D. The nurse elevates a leg cast when the patient reports decreased mobility.

Correct Answer is A

Explanation

A. The nurse determines to remove a wound dressing when the patient reveals the time of the last dressing change and notices old and new drainage. This is correct because data validation involves verifying information before taking action. The nurse gathers subjective data from the patient (time of last dressing change) and objective data (drainage) before making a clinical decision.

B. The nurse administers pain medicine due at 1700 at 1600 because the patient reports increased pain and the family wants something done. This is incorrect because the nurse has not validated whether the pain medication can be given early or if other interventions should be attempted first.

C. The nurse immediately asks the health care provider for an order of potassium when a patient reports leg cramps. This is incorrect because the nurse has not validated whether the leg cramps are due to low potassium. Leg cramps can result from multiple causes, including dehydration or circulatory issues. Lab values should be checked first.

D. The nurse elevates a leg cast when the patient reports decreased mobility. This is incorrect because decreased mobility does not necessarily indicate the need for elevation. Data validation should include assessing for swelling, circulation, and pain before making a decision.

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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

A nurse is discussing time management strategies with another nurse. The nurse should include which of the following as an example of a time management strategy?

Correct Answer is C

Explanation

Which scenario best illustrates the nurse using data validation when making a nursing clinical decision for a patient?

Correct Answer is A

Explanation

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After receiving change of shift report, the nurse delegates hygiene care for the caseload of patients. Which patient should the nurse delegate to the nursing assistive personnel (NAP)?

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A nurse formulates several nursing diagnoses then prioritizes using Maslow's hierarchy. What nursing diagnosis should have the highest priority?

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

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