Answer to Question 1
Correct Answer: 4
Rationale 1: Setting criteria is based on three questions: What is the desired outcome? What needs to be preserved? What needs to be avoided?
Rationale 2: Examining alternatives ensures that there is an objective rationale in relation to the established criteria for choosing one strategy over another.
Rationale 3: Implementation is putting a plan into action.
Rationale 4: In evaluating, the nurse determines the effectiveness of the plan and whether the initial purpose was achieved. In this situation, the nurse wants to determine what worked on the previous shift and what didn't. This will help with deciding on interventions for the client during the shift.
Answer to Question 2
Correct Answer: 2
Rationale 1: Identifying the purpose, in this case, would be determining that the client needs intervention to control the dysrhythmia.
Rationale 2: In this step, the decision maker (nurse) identifies possible ways to meet the criteria. Alternatives considered are which by route to give a certain medication: IV versus oral. The nurse is utilizing his experience, taking what he knows about cardiac problems and pharmacology, and will make a selection based on that information.
Rationale 3: Projecting is when the nurse applies creative thinking and skepticism to determine what might go wrong as a result of a decision and develops plans to prevent, minimize, or overcome any problems.
Rationale 4: Implementation is taking the plan into action.