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2. A nurse is using the problem-oriented approach to data collection. Which action will the
nurse take first?
3. After reviewing the database, the nurse discovers that the patient’s vital signs have not
been recorded by the nursing assistive personnel (NAP). Which clinical decision should the
nurse make?
a. Administer scheduled medications assuming that the NAP would have reported abnormal
vital signs.
b. Have the patient transported to the radiology department for a scheduled x-ray, and review
vital signs upo
c. Ask the NAP to record the patient’s vital signs before administering medications.
b. Reports a headache
c. Respirations 16
d. Nauseated
5. A patient expresses fear of going home and being alone. Vital signs are stable and the
incision is nearly completely healed. What can the nurse infer from the subjective data?
a. The patient can now perform the dressing changes without help.
6. Which method of data collection will the nurse use to establish a patient’s database?
d. Ordering medications
7. A nurse is gathering information about a patient’s habits and lifestyle patterns. Which
method of data collection will the nurse use that will best obtain this information?
8. While interviewing an older female patient of Asian descent, the nurse notices that the
patient looks at the ground when answering questions. What should the nurse do?
a. Consider cultural differences during this assessment.
c. Continue with the interview and document that the patient is depressed.
9. A nurse has already set the agenda during a patient-centered interview. What will the nurse
do next?
10. The nurse is attempting to prompt the patient to elaborate on the reports of daytime
fatigue. Which question should the nurse ask?
a. “Is there anything that you are stressed about right now that I should know?”
11. A nurse is conducting a nursing health history. Which component will the nurse address?
a. Nurse’s concerns
b. Patient expectations
12. While the patient’s lower extremity, which is in a cast, is assessed, the patient tells the
nurse about an inability to rest at night. The nurse disregards this information, thinking that
no correlation has been noted between having a leg cast and developing restless sleep. Which
action would have been best for the nurse to take?
a. Tell the patient to just focus on the leg and cast right now.
d. Ask the patient about usual sleep patterns and the onset of having difficulty resting.
13. The nurse begins a shift assessment by examining a surgical dressing that is saturated
with serosanguineous drainage on a patient who had open abdominal surgery yesterday (or 1
day ago). Which type of assessment approach is the nurse using?
14. Which statement by a nurse indicates a good understanding about the differences between
data validation and data interpretation?
15. Which scenario best illustrates the nurse using data validation when making a nursing
clinical decision for a patient?
The nurse determines to remove a wound dressing when the patient reveals the time of the
last dressing ch
a. and notices old and new drainage.
The nurse administers pain medicine due at 1700 at
1600 because the patient reports increased pain and th
d. The nurse elevates a leg cast when the patient reports decreased mobility.
16. While completing an admission database, the nurse is interviewing a patient who states “I
am allergic to latex.” Which action will the nurse take first?
17. A patient verbalizes a low pain level of 2 out of 10 but exhibits extreme facial grimacing
while moving around in bed. What is the nurse’s initial action in response to these
observations?
18. The nurse is interviewing a patient with a hearing deficit. Which area should the nurse use
to conduct this interview?
d. The waiting room while the occupational therapist is working on leg exercises
19. A new nurse is completing an assessment on an 80-year-old patient who is alert and
oriented. The patient’s daughter is present in the room. Which action by the nurse will require
follow-up by the charge nurse?
The nurse makes eye contact with the patient. Answers available at http://bit.ly/2wduMPJ
a.
b. The nurse speaks only to the patient’s daughter.
MULTIPLE RESPONSE
1. A nurse is completing an assessment. Which findings will the nurse report as subjective
data? (Select all that apply.)
a. Patient’s temperature
MATCHING
A nurse is completing an assessment using the PQRST to obtain data about the patient’s
chest pain. Match the questions to the components of the PQRST that the nurse will be using.
1. Provokes
1. After assessing a patient, a nurse develops a standard formal nursing diagnosis. What is the
rationale for the nurse’s actions? Answers available at http://bit.ly/2wduMPJ
a. To form a language that can be encoded only by nurses
2. Which diagnosis will the nurse document in a patient’s care plan that is NANDA-I
approved?
a. b. c. d.
3. A nurse develops a nursing diagnostic statement for a patient with a medical diagnosis of
pneumonia with chest x-ray results of lower lobe infiltrates. Which nursing diagnosis did the
nurse write?
4. The nurse is reviewing a patient’s plan of care, which includes the nursing
diagnostic
statement, Impaired physical mobility related to tibial fracture as evidenced by
patient’s inability to ambulate. Which part of the diagnostic statement does the nurse need to
revise?
a. Etiology
b. Nursing diagnosis
c. Collaborative problem
d. Defining characteristic
5. A nurse is using assessment data gathered about a patient and combining critical thinking
to develop a nursing diagnosis. What is the nurse doing?
c. Diagnostic reasoning
d. Diagnostic labeling
6. A patient presents to the emergency department following a motor vehicle crash and
suffers a right femur fracture. The leg is stabilized in a full leg cast. Otherwise, the patient has
no other major injuries, is in good health, and reports only moderate discomfort. Which is the
most pertinent nursing diagnosis the nurse will include in the plan of care?
7. The nurse is reviewing a patient’s database for significant changes and discovers that the
patient has not voided in over 8 hours. The patient’s kidney function lab results are abnormal,
and the
patient’s oral intake has significantly decreased since previous shifts. Which step of the
nursing process should the nurse proceed to after this review?
a. Diagnosis
b. Planning
c. Implementation
d. Evaluation
8. A patient with a spinal cord injury is seeking to enhance urinary elimination abilities by
learning self-catheterization versus assisted catheterization by home health nurses and family
members. The nurse adds Readiness for enhanced urinary elimination in the care plan.
Which type of diagnosis did the nurse write?
a. Risk
b. Problem focused
c. Health promotion
d. Collaborative problem
a. Assessment
b. Implementation
c. Evaluation
10. A nurse adds the following diagnosis to a patient’s care plan: Constipation related to
decreased gastrointestinal motility secondary to pain medication administration as evidenced
by the patient reporting no bowel movement in seven days, abdominal distention, and
abdominal pain. Which element did the nurse write as the defining characteristic?
b. Pain medication
c. Abdominal distention
d. Constipation
11. The patient database reveals that a patient has decreased oral intake, decreased oxygen
saturation when ambulating, reports of shortness of breath when getting out of bed, and a
productive cough. Which elements will the nurse identify as defining characteristics for the
diagnostic label of Activity intolerance?
b. Decreased oxygen saturation when ambulating and reports of shortness of breath when
getting out of bed
c. Reports of shortness of breath when getting out of bed and a productive cough
12. A nurse performs an assessment on a patient. Which assessment data will the nurse use as
an etiology for Acute pain?
13. A new nurse writes the following nursing diagnoses on a patient’s care plan. Which
nursing diagnosis will cause the nurse manager to intervene?
a. b. c. d.
14. A patient has a bacterial infection in left lower leg. Which nursing diagnosis will the
nurse add to the patient’s care plan?
a.
Infection
b.
d.
ANS: C
Impaired skin integrity is the only nursing diagnosis listed that will correlate to the patient
information. While risk for infection is a nursing diagnosis, the patient is not at risk; the
patient has an actual infection. Infection can be a medical diagnosis as well as a collaborative
problem. Staphylococcal leg infection is a medical diagnosis.
DIF:Apply (application)REF:225
OBJ: Differentiate among a nursing diagnosis, medical diagnosis, and collaborative problem.
15. A nurse adds a nursing diagnosis to a patient’s care plan. Which information did the nurse
document?
16. A charge nurse is evaluating a new nurse’s plan of care. Which finding will cause the
charge nurse to follow up?
a.
17. A patient exhibits the following symptoms: tachycardia, increased thirst, headache,
decreased urine output, and increased body temperature. The nurse analyzes the data. Which
nursing diagnosis will the nurse assign to the patient?
Assigning a documented nursing diagnosis of Risk for infection for a patient on intravenous
(IV) antibioti
ANS: C
The signs the patient is exhibiting are consistent with deficient fluid volume (dehydration).
Even without knowing the clinical manifestations of dehydration, the question can be
answered by the process of elimination. Adult failure to thrive, hypothermia, and nausea are
not appropriate diagnoses because data are insufficient to support these diagnoses.
MSC:Management of Care
18. Which question would be most appropriate for a nurse to ask a patient to assist in
establishing a nursing diagnosis of Diarrhea?
“When was the last time you took your medicine?”
Answers available at
http://bit.ly/2wduMPJ
c.
20. A nurse is developing nursing diagnoses for a patient. Beginning with the first step, place
in order the steps the nurse will use.
1. Observes the patient having dyspnea (shortness of breath) and a diagnosis of asthma 2.
Writes a diagnostic label of impaired gas exchange
3. Organizes data into meaningful
clusters
4. Interprets information from patient
5. Writes an etiology
a. 1, 3, 4, 2, 5
b. 1, 3, 4, 5, 2
c. 1, 4, 3, 5, 2
d. 1, 4, 3, 2, 5
MULTIPLE RESPONSE
1. A nurse is developing nursing diagnoses for a group of patients. Which nursing diagnoses
will the nurse use? (Select all that apply.)
a.
b.
c.
d.
e.
Impaired physical mobility related to incisional pain
Risk for falls related to nursing assistive personnel leaving bedrail down ANS: C, D
Impaired physical mobility and Nausea are the only correctly written nursing diagnoses. All
the rest are incorrectly written. Anxiety lists a diagnostic test as the etiology. Impaired gas
exchange lists a medical diagnosis as the etiology. Risk for falls has a legally inadvisable
statement for an etiology.
1. The nurse completes a thorough assessment of a patient and analyzes the data to identify
nursing diagnoses. Which step will the nurse take next in the nursing process?
a. Assessment
b.
c. Planning
d. Implementation
2. A patient’s plan of care includes the goal of increasing mobility this shift. As the patient is
ambulating to the bathroom at the beginning of the shift, the patient suffers a fall.
Which
initial action will the nurse take next to revise the plan of care?
4. A nurse is developing a care plan for a patient with a pelvic fracture on bed rest. Which
goal statement is realistic for the nurse to assign to this patient?
b. Patient will turn side to back to side with assistance every 2 hours.
c. Patient will use the walker correctly to ambulate to the bathroom as needed.
d. Patient will use a sliding board correctly to transfer to the bedside commode as needed.
5. The following statements are on a patient’s nursing care plan. Which statement will the
nurse use as an outcome for a goal of care?
a. The patient will verbalize a decreased pain level less than 3 on a 0 to 10 scale by the end of
this shift.
b. The patient will demonstrate increased tolerance to activity over the next month.
6. A charge nurse is reviewing outcome statements using the SMART approach. Which
patient outcome statement will the charge nurse praise to the new nurse?
b. The nurse will monitor the patient’s heart rhythm continuously this shift.
c. The patient will feed self at all mealtimes today without reports of shortness of breath.
d. The nurse will administer pain medication every 4 hours to keep the patient free from
discomfort.
7. A nursing assessment for a patient with a spinal cord injury leads to several pertinent
nursing diagnoses. Which nursing diagnosis is the highest priority for this patient?
b.
c. Answers available at http://bit.ly/2wduMPJ
d.
8. The new nurse is caring for six patients in this shift. After completing their assessments,
the nurse asks where to begin in developing care plans for these patients. Which statement is
an appropriate suggestion by another nurse?
a. “Choose all the interventions and perform them in order of time needed for each one.”
b. “Make sure you identify the scientific rationale for each intervention first.”
c. “Decide on goals and outcomes you have chosen for the patients.”
d. “Begin with the highest priority diagnoses, then select appropriate interventions.”
9. A patient’s son decides to stay at the bedside while his father is confused. When
developing the plan of care for this patient, what should the nurse do?
b. Request that the son leave at bedtime, so the patient can rest.
c. Suggest that a female member of the family stay with the patient.
10. A nurse is caring for a patient with a nursing diagnosis of Constipation related to slowed
gastrointestinal motility secondary to pain medications. Which outcome is most appropriate
for the nurse to include in the plan of care?
a. Patient will have one soft, formed bowel movement by end of shift.
11. The nurse performs an intervention for a collaborative problem. Which type of
intervention did the nurse perform?
a. Dependent
b. Independent
c. Interdependent
d. Physician-initiated
12. A registered nurse administers pain medication to a patient suffering from fractured ribs.
Which type of nursing intervention is this nurse implementing?
a. Collaborative
b. Independent
c. Interdependent
d. Dependent
13. Which action indicates the nurse is using a PICOT question to improve care for a patient?
14. A nurse is developing a care plan. Which intervention is most appropriate for the nursing
diagnostic statementRisk for loneliness related to impaired verbal communication?
d. Ask the family to provide a sitter to remain with the patient at all times.
15. A nurse is completing a care plan. Which intervention is most appropriate for the nursing
diagnostic statementImpaired skin integrity related to shearing forces?
16. A patient has reduced muscle strength following a left-sided stroke and is at risk for
falling. Which intervention ismost appropriate for the nursing diagnostic statement Risk for
falls?
17. Which action will the nurse take after the plan of care for a patient is developed?
a. Place the original copy in the chart, so it cannot be tampered with or revised.
b. Communicate the plan to all health care professionals involved in the patient’s care.
c. File the plan of care in the administration office for legal examination.
18. A nurse is preparing to make a consult. In which order, beginning with the first step, will
the nurse take?
1. Identify the problem.
2. Discuss the findings and recommendation.
3. Provide the
consultant with relevant information about the problem.
4. Contact the right professional,
with the appropriate knowledge and expertise.
5. Avoid bias by not providing a lot of
information based on opinion to the consultant.
19. A hospital’s wound nurse consultant made a recommendation for nurses on the unit about
how to care for the patient’s dressing changes. Which action should the nurses take next?
b. Assume that the wound nurse will perform all dressing changes.
1. A nurse is planning care for a patient with a nursing diagnosis of Impaired skin integrity.
The patient needs many nursing interventions, including a dressing change, several
intravenous antibiotics, and a walk. Which factors does the nurse consider when prioritizing
interventions? (Select all that apply.)
e.
2. A nurse is teaching the staff about the benefits of Nursing Outcomes Classification. Which
information should the nurse include in the teaching session? (Select all that apply.)
1. A nurse is providing nursing care to patients after completing a care plan from nursing
diagnoses. In which step of the nursing process is the nurse?
a. Assessment
b. Planning
c. Implementation
d. Evaluation
2. The nurse is teaching a new nurse about protocols. Which information from the new nurse
indicates a correct understanding of the teaching?
a. Protocols are guidelines to follow that replace the nursing care plan.
Protocols assist the
clinician in making decisions and choosing interventions for specific health care probl
b. conditions.
c. Protocols are policies designating each nurse’s duty according to standards of care and a
code of ethics.
d. Protocols are prescriptive order forms that help individualize the plan of care.
3. The standing orders for a patient include acetaminophen 650 mg every 4 hours prn for
headache. After assessing the patient, the nurse identifies the need for headache relief and
determines that the patient has not had acetaminophen in the past 4 hours. Which action will
the nurse take next?
a.
4. Which action indicates a nurse is using critical thinking for implementation of nursing care
to patients?
a. Determines whether an intervention is correct and appropriate for the given situation
b. Reads over the steps and performs a procedure despite lack of clinical competency
5. A nurse is reviewing a patient’s care plan. Which information will the nurse identify as a
nursing intervention?
a. The patient will ambulate in the hallway twice this shift using crutches correctly.
c. Provide assistance while the patient walks in the hallway twice this shift with crutches.
6. A patient recovering from a leg fracture after a fall reports having dull pain in the affected
leg and rates it as a 7 on a 0 to 10 scale. The patient is not able to walk around in the room
with crutches because of leg discomfort. Which nursing intervention is priority?
7. The nurse is caring for a patient who requires a complex dressing change. While in the
patient’s room, the nurse decides to change the dressing. Which action will the nurse take just
before changing the dressing?
8. A patient visiting with family members in the waiting area tells the nurse “I don’t feel
good, especially in the stomach.” What should the nurse do?
b. Ask the patient to return to the room, so the nurse can inspect the abdomen.
c. Ask the patient when the last bowel movement was and to lie down on the sofa.
d. Tell the patient that the dinner tray will be ready in 15 minutes and that may help the
stomach feel better.
9. A newly admitted patient who is morbidly obese asks the nurse for assistance to the
bathroom for the first time. Which action should the nurse take initially?
a. Ask for at least two other assistive personnel to come to the room.
10. A new nurse is working in a unit that uses interdisciplinary collaboration. Which action
will the nurse take?
d. Avoid conflict.
11. Which action should the nurse take first during the initial phase of implementation?
c. Evaluate interventions.
d.
12. Vital signs for a patient reveal a high blood pressure of 187/100. Orders state to notify the
health care provider for diastolic blood pressure greater than 90. What is the nurse’s first
action?
b. Review the most recent lab results for the patient’s potassium level.
c. Assess the patient for other symptoms or problems, and then notify the health care
provider.
d. Administer an antihypertensive medication from the stock supply, and then notify the
health care provide
13. Which initial intervention is most appropriate for a patient who has a new onset of chest
pain?
14. A nurse is making initial rounds on patients. Which intervention for a patient with poor
wound healing should the nurse perform first?
a.
15. The nurse establishes trust and talks with a school-aged patient before administering an
injection. Which type of implementation skill is the nurse using?
a. Cognitive
b. Interpersonal
c. Psychomotor
d. Judgmental
16. The nurse inserts an intravenous (IV) catheter using the correct technique and following
the recommended steps according to standards of care and hospital policy. Which type of
implementation skill is the nurse using?
a. Cognitive
b. Interpersonal
c. Psychomotor
d. Judgmental
17. A staff development nurse is providing an inservice for other nurses to educate them
about the Nursing Interventions Classification (NIC) system. During the inservice, which
statement made by one of the nurses in the room requires the staff development nurse to
clarify the information provided?
a. “This system can help medical students determine the cost of the care they provide to
patients.”
“If the nursing department uses this system, communication among
nurses who work throughout the hosp
b. be enhanced.”
“We could use this system to help organize orientation for new nursing
employees because we can better e
c. the nursing interventions we use most frequently on our unit.”
“The NIC system
provides one way to improve safe and effective documentation in the hospital’s
electron
d. record.”
18. The nurse is intervening for a family member with role strain. Which direct care nursing
intervention is mostappropriate?
19. The nurse is intervening for a patient that has a risk for a urinary infection. Which direct
care nursing intervention is most appropriate?
20. The nurse is revising the care plan. In which order will the nurse perform the tasks,
beginning with the first step?
ULTIPLE RESPONSE
1. A nurse is implementing interventions for a group of patients. Which actions are nursing
interventions? (Select all that apply.)
2. A nurse is providing nursing care to a group of patients. Which actions are direct care
interventions? (Select all that apply.)
a. Ambulating a patient
c. Performing resuscitation
3. A nurse is preparing to carry out interventions. Which resources will the nurse make sure
are available? (Select all that apply.)
a. Equipment
b. Safe environment
c. Confidence
d. Assistive personnel
e. Creativity
4. Which interventions are appropriate for a patient with diabetes and poor wound healing?
(Select all that apply.)
1. A nurse determines that the patient’s condition has improved and has met expected
outcomes. Which step of the nursing process is the nurse exhibiting?
a. Assessment
b. Planning
c. Implementation
d. Evaluation
2. A nurse completes a thorough database and carries out nursing interventions based on
priority diagnoses. Which action will the nurse take next?
a. Assessment
b. Planning
c. Implementation
d. Evaluation
3. A new nurse asks the preceptor to describe the primary purpose of evaluation. Which
statement made by the nursing preceptor is most accurate?
a. “An evaluation helps you determine whether all nursing interventions were completed.”
d.
4. After assessing the patient and identifying the need for headache relief, the nurse
administers acetaminophen for the patient’s headache. Which action by the nurse is priority
for this patient?
5. A nurse is getting ready to discharge a patient who has a problem with physical mobility.
What does the nurse need to do before discontinuing the patient’s plan of care?
d. Ensure that the patient’s prescriptions have been filled to take home.
6. The nurse is evaluating whether patient goals and outcomes have been met for a patient
with physical mobility problems due to a fractured leg. Which finding indicates the patient
has met an expected outcome?
a. The nurse provides assistance while the patient is walking in the hallways.
7. The nurse is evaluating whether a patient’s turning schedule was effective in preventing
the formation of pressure ulcers. Which finding indicates success of the turning schedule?
8. A nurse has instituted a turn schedule for a patient to prevent skin breakdown. Upon
evaluation, the nurse finds that the patient has a stage II pressure ulcer on the buttocks. Which
action will the nurse take next?
9. A new nurse is confused about using evaluative measures when caring for patients and
asks the charge nurse for an explanation. Which response by the charge nurse is most
accurate?
b. outcomes and goals.”
“Evaluative measures are used by quality assurance nurses to
determine the progress a nurse is making fro
10. The nurse is caring for a patient who has an open wound and is evaluating the progress of
wound healing. Whichpriority action will the nurse take?
d. Leave the dressing off the wound for easier access and more frequent assessments.
11. The nurse is caring for a patient who has an order to change a dressing twice a day, at
0600 and 1800. At 1400, the nurse notices that the dressing is saturated and leaking. What is
the
nurse’s next action?
12. A goal for a patient with diabetes is to demonstrate effective coping skills. Which patient
behavior will indicate to the nurse achievement of this outcome?
a. Health status
b. Health behavior
c. Psychological self-control
d. Health service utilization
14. A nurse is evaluating the goal of acceptance of body image in a young teenage girl.
Which statement made by the patient is the best indicator of progress toward the goal?
a. “I’m worried about what those other girls will think of me.”
15. A nurse is evaluating goals and expected outcomes for a confused patient. Which finding
indicates positive progress toward resolving the confusion?
16. A nurse identifies a fall risk when assessing a patient upon admission. The nurse and the
patient agree that the goal is for the patient to remain free from falls. However, the patient fell
just before shift change. Which action is the nurse’s priority when evaluating the patient?
b. Counsel the nursing assistive personnel on duty when the patient fell.
c. Remove the fall risk sign from the patient’s door because the patient has suffered a fall.
Request that the more experienced charge nurse complete the documentation about the fall.
Answers available at http://bit.ly/2wduMPJ
d.
17. A patient was recently diagnosed with pneumonia. The nurse and the patient have
established a goal that the patient will not experience shortness of breath with activity in 3
days with an expected outcome of having no secretions present in the lungs in 48 hours.
Which evaluative measure will the nurse use to demonstrate progress toward this goal?
a. No sputum or cough present in 4 days
18. A nurse is evaluating an expected outcome for a patient that states heart rate will be less
than 80 beats/min by 12/3. Which finding will alert the nurse that the goal has been met?
d.
19. A nurse is modifying a patient’s care plan after evaluation of patient care. In which order,
starting with the first step, will the nurse perform the tasks?
1. Revise nursing diagnosis.
2. Reassess blood pressure reading.
3. Retake blood pressure
after medication.
4. Administer new blood pressure medication.
5. Change goal to blood
pressure less than 140/90.
MULTIPLE RESPONSE
1. A nurse is caring for a group of patients. Which evaluative measures will the nurse use to
determine a patient’s responses to nursing care? (Select all that apply.)
2. Which nursing actions will the nurse perform in the evaluation phase of the nursing
process? (Select all that apply.)