Hesi Q's: Nursing Process

Which nursing process involves delegation and verbal discussion with the healthcare team?

A. Planning B. Evaluation C. Assessment D. Implementation Correct: D

The nurse applies the nursing process while caring for clients. What is the correct order of steps of the nursing process?

Assessment Diagnosis Planning Implementation Evaluation

A nursing student is learning about the nursing process, which consists of four components. Which scenarios should the nursing student consider as the 'input' component? Select all that apply.

A. "The nurse checks the client's health history for allergy to iodine before inserting a urinary catheter." B. "The nurse finds that the client's urine has presence of blood after the urinary catheter is removed." C. "The nurse checks if the client has a history of substance abuse before administering nasal medications." D. "The nurse finds that the client's skin color has changed to bluish purple after cold therapy is applied to reduce swelling." E. "The nurse checks the medical records of the client to know if he/she has had a rectal surgery in the past year before placing an internal fecal catheter." Correct: A,C,E

A nursing student is learning about the nursing process, which consists of four components. Which scenarios would be considered output components? Select all that apply.

A. "While assessing a client, the nurse finds a history of mental illness." B. "While assessing an obese client, the nurse finds a history of asthma." C. "The nurse notices that the client's wounds have healed after performing regular wound debridement." D. "The nurse notices that the client has developed an infection at the surgical site after the dressing has been changed." E. "The nurse finds that the client's blood pressure has increased even though medication is administered on a timely basis." Correct: C,D,E

What is the difference between risk nursing diagnoses and actual nursing diagnoses?

A. Actual nursing diagnoses have related factors; risk nursing diagnoses do not have related factors. B. Actual nursing diagnoses are present in NANDA-I classification; risk nursing diagnoses are absent in NANDA-I classification. C. Actual nursing diagnoses are associated with environmental and physiological factors; risk nursing diagnoses are not associated with these factors. D. Actual nursing diagnoses are least likely to be established in a vulnerable population; risk nursing diagnoses are established in vulnerable population. Correct: A

Which step in the research process is similar to the assessment step of the nursing process?

A. Analyzing the results B. Conducting the study C. Developing hypothesis D. Identifying the problem Correct: D

A doctor asks a nurse to collect the medical history of a client. What nursing process should the nurse undertake?

A. Diagnosis B. Evaluation C. Assessment D. Implementation Correct: C

An injured client with an open wound is brought to the hospital. The doctor asks the nurse to administer a tetanus toxoid injection. Which step of the nursing process does the nurse follow next?

A. Diagnosis B. Evaluation C. Assessment D. Implementation Correct: D

Which action of the leader signifies the implementation phase of the nursing process to teaching?

A. Establishing expectations B. Sequencing different tasks C. Comparing progress to plan D. Assessing the needed performance level Correct: B

A nurse is explaining the nursing process to a nursing assistant. Which step of the nursing process should include interpretation of data collected about the client?

A. Evaluation B. Assessment C. Nursing interventions D. Proposed nursing care Correct: B

The nurse is aware that the nursing diagnosis should follow the North American Nursing Diagnosis Association International (NANDA-I) label. How should the nurse document the nursing diagnosis in a three-part format?

A. NANDA-I label, related factor, and etiologies B. NANDA-I label, risk factor, and nursing interventions C. NANDA-I label, related factor, and nursing interventions D. NANDA-I label, related factor, and defining characteristics Correct: D

Which features distinguish nursing diagnoses from medical diagnoses? Select all that apply.

A. Nursing diagnoses involve the client when possible. B. Nursing diagnoses are based on results of diagnostic tests and procedures. C. Nursing diagnoses are the identification of a disease condition in the client. D. Nursing diagnoses involve the sorting of health problems within the nursing domain. E. Nursing diagnoses involve clinical judgment about the client's response to health problems. Correct: A,D,E

While entering data for a client in the electronic health record (EHR), the nurse uses North American Nursing Diagnosis Association (NANDA) International terminology to document which part of the nursing process?

A. Planning B. Diagnosis C. Outcomes D. Intervention Correct: B

Which step of the nursing process is directly affected if the nurse does not make a nursing diagnosis?

A. Planning B. Evaluation C. Assessment D. Implementation Correct: A

A nurse revises the care plan when the client's responses indicate that goals have not been met. What phase of the nursing process is being applied?

A. Planning B. Evaluation C. Assessment D. Implementation Correct: B

The nurse is verbally interviewing and taking a history of a client who was admitted to the hospital. Which phase of the nursing process is being used in this situation?

A. Planning B. Evaluation C. Assessment D. Implementation Correct: C

Which step in the nursing process would involve promoting a safe environment for the client?

A. Planning B. Evaluation C. Assessment D. Implementation Correct: D

Which client is likely to have a health promotion nursing diagnosis?

A. The client with acute pain due to appendicitis. B. The client who is willing to take a 30-minute walk daily. C. The elderly client with dementia admitted to the healthcare facility. D. The client with reduced cognitive ability while recovering from surgery. Correct: B

Which feature is characteristic of a risk nursing diagnosis?

A. The diagnosis does not have related factors. B. The diagnosis can be used in any health state. C. The defining characteristics support the diagnostic judgment. D. The defining characteristics are supported by a client's readiness. Correct: A