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

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.

The nurse administers pain medicine due at 1700 at 1600 because the patient reports increased pain and the family wants something done.

The nurse immediately asks the health care provider for an order of potassium when a patient reports leg cramps.

The nurse elevates a leg cast when the patient reports decreased mobility.

Answer and Explanation

The Correct Answer is A

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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Correct Answer is ["D","E","F"]

Explanation

A. The patient will be educated about the signs of infection. This is incorrect because it is not specific or measurable. The statement does not describe how the nurse will evaluate whether the patient has understood the information.

B. The patient will know how to manage diabetes effectively. This is incorrect because "know" is not measurable. A better outcome statement would describe a specific action the patient will perform to demonstrate their understanding of diabetes management.

C. The patient will understand the importance of medication adherence. This is incorrect because "understand" is not an observable or measurable behavior. Instead, an outcome should describe an action the patient will take, such as demonstrating how to take medication correctly.

D. The patient will walk 50 feet with a walker unassisted by the end of the week. This is correct because it is specific, measurable, and time-bound. It describes a clear action that the nurse can assess.

E. The patient will demonstrate correct use of an inhaler by the end of the teaching session. This is correct because it is measurable and observable. The nurse can directly assess whether the patient correctly uses the inhaler.

F. The patient will report a pain level of less than 4 on a scale of 0 to 10 within 24 hours of receiving pain medication. This is correct because it is specific, includes a measurable criterion (pain scale), and has a clear timeframe.

A. Review the patient's activity orders. B. Medicate the patient to alleviate discomfort while ambulating. C. Ask for at least two other assistive personnel to come to the room. D. Offer the patient a walker.

Correct Answer is A

Explanation

A. Before assisting a patient, especially one with mobility concerns, the nurse must verify provider orders to determine any restrictions or special considerations.

B. Administering pain medication before knowing activity restrictions could lead to falls or complications.

C. While assistance may be needed, the first priority is to check the patient's activity orders to determine the safest way to proceed.

D. Providing a walker might help, but the nurse must first confirm whether assistive devices are appropriate for the patient.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse educator is reviewing guidelines for writing an outcome statement. Which examples best indicate a correct outcome statement? (Select All that Apply.)

Correct Answer is ["D","E","F"]

Explanation

A newly admitted patient who is morbidly obese asks the nurse for assistance to the bathroom for the first time. Which action should the nurse take initially?

Correct Answer is A

Explanation

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

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