Situation 1. The nursing process provides a framework for a nurse's responsibility and accountability. It requires critical thinking. 1. The patient states, “My chest hurts and my left arm feels numb.” What is the type and source of this data? A. Subjective data from a primary source B. Subjective data from a secondary source C. Objective data from a primary source D. Objective data from a secondary source Answer: A Rationale: Subjective data is apparent only to the person affected and cannot be measured, seen, felt, or heard by the nurse. It may be called “covert data.” It includes the patient's thoughts, beliefs, feelings, perceptions, and sensations. The patient is always considered the primary source. (Hogan et. al., Prentice Hall Reviews and Rationales Series for Nursing: Fundamentals of Nursing) 2. The nurse is measuring the patient's urine output and straining the urine to assess for stones. Which of the following should the nurse record as objective data? A. The patient stated, “I feel like I have passed a stone.” B. The patient's urine output was 550 mL C. The patient is complaining of abdominal pain D. The patient stated, “I didn't see any stones in my urine.” Answer: B Rationale: Measurable data is objective data. (Hogan et. al., Prentice Hall Reviews and Rationales Series for Nursing: Fundamentals of Nursing) 3. Which of the following demonstrates that the nurse is participating critical thinking? A. The nurse admits she does not know how to do a procedure and requests help B. The nurse makes her point with clever and persuasive remarks to win an argument C. The nurse accepts without question the values acquired in nursing school D. The nurse finds a quick and logical answer, even to complex questions Answer: A Rationale: Critical thinking is self-directed and supports what an individual knows and makes clear what she does not know. It is important for nurses to recognize when they lack the knowledge they need to provide safe care for a client. Nurses must utilize their resources to acquire the knowledge and support they need to fulfill a nursing responsibility safely. . (Hogan et. al., Prentice Hall Reviews and Rationales Series for Nursing: Fundamentals of Nursing) 4. What is the problem with the following outcome goal, “Patient will state pain is less than or equal to 3 on a 0 to 10 pain scale”? A. None, goal is written correctly B. It is not measurable C. No target time is given D. Patient behavior is missing Answer: C Rationale: Outcome goals should be SMART (specific, measurable, appropriate, realistic, and timely). There is no time estimate for goal attainment. Thus, option A is incorrect. (Hogan et. al., Prentice Hall Reviews and Rationales Series for Nursing: Fundamentals of Nursing) 5. When evaluating an adult patient's blood pressure reading. The nurse considers the patient's age. This is an example of which of the following? A. Comparing data against standards B. Clustering data C. Determining gaps in the data D. Differentiating cues and inferences Answer: A Rationale: Analysis of the client data (blood pressure reading) requires knowledge of the normal blood pressure range for an adult. The nurse compares client data against standards to identify significant cues. (Hogan et. al., Prentice Hall Reviews and Rationales Series for Nursing: Fundamentals of Nursing) Situation 2. Jason has a nursing diagnosis of ineffective airway clearance related to excessive secretions and is at risk for infection because of retained secretions. Part of Nurse Melai’s nursing care plan isto loosen and remove excessive secretions in the airway. 6. Nurse Melai listens to Jason’s bilateral sounds and finds that congestion is in the upper lobes of the lungs. The appropriate position to drain the anterior and posterior apical segment of the lungs when the nurse does percussion would be: A. Patient lying on his back then flat on his abdomen on Trendelenburg position B. Patient seated upright in bed or on a chair then leaning forward in sitting position then flat on his back and on his abdomen C. Patient lying flat in his back and then flat on his abdomen D. Patient lying on his right then leftside on Trendelenburg position Answer: B