A patient had hip surgery 16 hours ago. During the previous
shift the patient had 40 mL of drainage in the surgical
drainage collection device for an 8-hour period. The nurse
refers to the written plan of care, noting that the health care
provider is to be notified when drainage in the device exceeds
100 mL for the day. On entering the room, the nurse looks at
the device and carefully notes the amount of drainage
currently in it. This is an example of:
A. Planning.
B. Evaluation.
C. Intervention.
D. Diagnosis. - ...ANSWER...B. Evaluation
RATIONALE -The patient's baseline for wound drainage
was 40 mL, representing the initial assessment of the patient's
wound condition. In this example the nurse is evaluating to
determine if there is a change in the amount of drainage,
which indicates the progress of wound healing.
In which of the following examples is the nurse not applying
critical thinking skills in practice?
A. The nurse considers personnel experience in performing
intravenous (IV) line insertion and ways to improve
performance.
B. The nurse uses a fall risk inventory scale to determine a
patient's fall risk.
C. The nurse observes a change in a patient's behavior and
considers which problem is likely developing.
D. The nurse explains the procedure for giving a tube feeding
to a second nurse who has floated to the unit to assist with
care. - ...ANSWER...D. The nurse explains the procedure for
giving a tube feeding to a second nurse who has floated to the
unit to assist with care.
RATIONALE-The nurse is explaining how to provide care
on the basis of knowledge. Considering personal experience is
self-regulation through reflection. Determining a patient's fall
risk is evaluation, using a criteria-based screening scale.
Observing a change in the patient's behavior and considering
likely developments is inference, in which the nurse looks for
a relationship in findings.
A nurse assesses a patient who comes to the pulmonary clinic.
"I see that it's been over 6 months since you've been in, but
your appointment was for every 2 months. Tell me about that.
Also I see from your last visit that the doctor recommended
routine exercise. Can you tell me how successful you have
been following his plan?" The nurse's assessment covers
which of Gordon's functional health patterns?
A. Value-belief pattern
B. Cognitive-perceptual pattern
C. Coping-stress-tolerance pattern
D. Health perception-health management pattern -
...ANSWER...D. Health perception-health management
pattern
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