Foundations of Nursing Practice Flashcards

A nurse is documenting the care provided to a client. Which of the following documentation entries is most appropriate and legally sound?

Answer: "Client ambulated 50 feet down the hallway with steady gait, denies shortness of breath."

Legally sound documentation must be objective, specific, and factual. This option provides specific, measurable information about the client's activity ('ambulated 50 feet'), an objective observation of their stability ('steady gait'), and includes the client's subjective report ('denies shortness of breath'). The other options are either too vague, subjective, or incomplete.

A client with a terminal illness has a living will and has expressed a desire to refuse further life-prolonging treatments. The client's family, however, insists that the healthcare team do everything possible to keep the client alive. Which ethical principle should primarily guide the nurse's actions in this situation?

Answer: Autonomy

The principle of autonomy honors the client's right to make their own decisions about their healthcare, even if those decisions differ from the family's wishes or the healthcare team's recommendations. The nurse's role is to advocate for the client's wishes as expressed in their advance directive. Beneficence (acting for the patient's good), non-maleficence (do no harm), and justice (fairness) are also important, but autonomy is the guiding principle when a competent client has made their wishes known.

During the assessment phase of the nursing process, the nurse gathers both subjective and objective data. Which of the following is an example of subjective data?

Answer: The client's statement, "I have a pounding headache."

Subjective data is information provided by the client from their own perspective, such as their feelings, perceptions, and concerns. It cannot be directly measured by the healthcare provider. The statement "I have a pounding headache" is what the client is reporting. Blood pressure, heart rate, and observed grimacing are all forms of objective data that can be seen, measured, or observed by the nurse.

Which of the following tasks is appropriate for a Registered Nurse (RN) to delegate to a Licensed Practical Nurse (LPN)?

Answer: Administering a scheduled oral antibiotic to a stable patient.

The scope of practice for an LPN typically includes administering medications to stable patients with predictable outcomes. Initial assessments, developing the comprehensive nursing care plan, and providing complex patient education (like discharge teaching) are responsibilities of the RN and require a broader scope of knowledge and clinical judgment.

A nurse is preparing a plan of care for a client. Which step of the nursing process involves setting measurable and achievable short- and long-term goals?

Answer: Planning

The planning phase of the nursing process is where the nurse establishes priorities, sets client-centered goals and expected outcomes, and selects nursing interventions to achieve these goals. This involves creating a roadmap for the client's care with specific, measurable, achievable, realistic, and time-bound (SMART) goals.

A nurse administers an incorrect dose of medication to a patient. After assessing the patient and ensuring their immediate safety, what is the nurse's next priority action?

Answer: Notify the healthcare provider and the nurse manager.

After ensuring patient safety, the immediate priority is to communicate the error to the healthcare provider who can assess the patient and provide any necessary orders to counteract the error. The nurse manager also needs to be informed to follow organizational procedures. While documentation and completing an incident report are crucial, notification must happen first to ensure prompt medical intervention if needed.