Answer to Question 1
D
Taking appropriate action demonstrates the implementation step of the nursing process.
Assessment involves the gathering of data.
When formulating a nursing diagnosis, the nurse critically examines and analyzes the data and identifies the client's response to a problem. The nurse may then determine priorities.
Planning involves establishing goals and expected outcomes of care.
Answer to Question 2
A, B, D, E
To create a new nutritional plan of care, the nurse must utilize characteristics of a normal nutritional status to gauge effectiveness of the plan. The nurse must be aware of previous patient responses to nursing interventions for altered nutrition to determine the probability of success. The nurse must use established expected outcomes to evaluate the patient's response to care (e.g., patient's weight increases by 0.5 kg/week). The nurse must also be creative when designing innovative nursing interventions to meet the patient's nutritional needs and must demonstrate responsibility by following through with evaluation and counseling to successfully reach goals.
The nurse uses a noninvasive bladder ultrasound to measure the client’s bladder volume.
Application of an ostomy bag or pouch: B, An ostomy nurse applying an ostomy bag to a stoma;
nurse
Three different ginkgo formulations: tablets, tea bags, and liquid extract.
Spreads and soft-gel tablets containing plant sterols and stanols
Examples of Tablets