THERA

19. A nurse assesses that a patient has not voided in 6 hours. Which question should the nurse ask to assist in establishing a nursing diagnosis of Urinary retention? a. "Do you feel like you need to go to the bathroom?" b. "Are you able to walk to the bathroom by yourself?" c. "When was the last time you took your medicine?" d. "Do you have a safety rail in your bathroom at home?"

a. "Do you feel like you need to go to the bathroom?"

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 hospital may be b. enhanced." "We could use this system to help organize orientation for new nursing employees because we can better explain the c. nursing interventions we use most frequently on our unit." d. "The NIC system provides one way to improve safe and effective documentation in the hospital's electronic health record."

a. "This system can help medical students determine the cost of the care they provide to patients."

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. Administer the acetaminophen. b. Notify the health care provider to obtain a verbal order. c. Direct the nursing assistive personnel to give the acetaminophen. d. Perform a pain assessment only after administering the acetaminophen.

a. Administer the acetaminophen.

9. A nurse administers an antihypertensive medication to a patient at the scheduled time of 0900. The nursing assistive personnel (NAP) then reports to the nurse that the patient's blood pressure was low when it was taken at 0830. The NAP states that was busy and had not had a chance to tell the nurse yet. The patient begins to complain of feeling dizzy and light-headed. The blood pressure is rechecked and it has dropped even lower. In which phase of the nursing process did the nurse first make an error? a. Assessment b. Diagnosis c. Implementation d. Evaluation

a. Assessment

1. The nurse is using critical thinking skills during the first phase of the nursing process. Which action indicates the nurse is in the first phase? a. Completes a comprehensive database b. Identifies pertinent nursing diagnoses c. Intervenes based on priorities of patient care d. Determines whether outcomes have been achieved

a. Completes a comprehensive database

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. b. Ask the patient to make eye contact to determine her affect. c. Continue with the interview and document that the patient is depressed. d. Notify the health care provider to recommend a psychological evaluation.

a. Consider cultural differences during this assessment.

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 c. Establishes goals for a particular patient without assessment d. Evaluates the effectiveness of interventions

a. Determines whether an intervention is correct and appropriate for the given situation

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

a. Diagnosis

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

a. Etiology

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? a. Include dressing change instructions and frequency in the care plan. b. Assume that the wound nurse will perform all dressing changes. c. Request that the health care provider look at the wound. d. Encourage the patient to perform the dressing changes.

a. Include dressing change instructions and frequency in the care plan.

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. b. Patient will walk unassisted to bathroom by the end of shift. c. Patient will be offered laxatives or stool softeners this shift. d. Patient will not take any pain medications this shift.

a. Patient will have one soft, formed bowel movement by end of shift.

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? a. Patient will increase activity level this shift. 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.

a. Patient will increase activity level this shift.

14. A nurse is developing a care plan. Which intervention is most appropriate for the nursing diagnostic statement Risk for loneliness related to impaired verbal communication? a. Provide the patient with a writing board each shift. b. Obtain an interpreter for the patient as soon as possible. c. Assist the patient in performing swallowing exercises each shift. d. Ask the family to provide a sitter to remain with the patient at all times.

a. Provide the patient with a writing board each shift.

13. Which initial intervention is most appropriate for a patient who has a new onset of chest pain? a. Reassess the patient. b. Notify the health care provider. c. Administer a prn medication for pain. d. Call radiology for a portable chest x-ray.

a. Reassess the patient.

19. The nurse is intervening for a patient that has a risk for a urinary infection. Which direct care nursing intervention is most appropriate? a. Teaches proper handwashing technique b. Properly cleans the patient's toilet c. Transports urine specimen to the lab d. Informs the oncoming nurse during hand-off

a. Teaches proper handwashing technique

15. Which scenario best illustrates the nurse using data validation when making a nursing clinical decision for a patient? a. The nurse determines to remove a wound dressing when the patient reveals the time of the last dressing change and notices old and new drainage. The nurse administers pain medicine due at 1700 at 1600 because the patient reports increased pain and the family wants b. something done. c. The nurse immediately asks the health care provider for an order of potassium when a patient reports leg cramps. d. The nurse elevates a leg cast when the patient reports decreased mobility.

a. The nurse determines to remove a wound dressing when the patient reveals the time of the last dressing change and notices old and new drainage.

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. c. The patient will understand needed dietary changes by discharge. d. The patient will demonstrate increased mobility in 2 days.

a. The patient will verbalize a decreased pain level less than 3 on a 0 to 10 scale by the end of this shift.

18. The nurse is interviewing a patient with a hearing deficit. Which area should the nurse use to conduct this interview? a. The patient's room with the door closed b. The waiting area with the television turned off c. The patient's room before administration of pain medication d. The waiting room while the occupational therapist is working on leg exercises

a. The patient's room with the door closed

18. Which question would be most appropriate for a nurse to ask a patient to assist in establishing a nursing diagnosis of Diarrhea? a. "What types of foods do you think caused your upset stomach?" b. "How many bowel movements a day have you had?" c. "Are you able to get to the bathroom in time?" d. "What medications are you currently taking?"

b. "How many bowel movements a day have you had?"

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?" b. "What reasons do you think are contributing to your fatigue?" c. "What are your normal work hours?" d. "Are you sleeping 8 hours a night?"

b. "What reasons do you think are contributing to your fatigue?"

2. Which diagnosis will the nurse document in a patient's care plan that is NANDA-I approved? a. Sore throat b. Acute pain c. Sleep apnea d. Heart failure

b. Acute pain

9. A nurse has already set the agenda during a patient-centered interview. What will the nurse do next? a. Begin with introductions. b. Ask about the chief concerns or problems. c. Explain that the interview will be over in a few minutes. d. Tell the patient "I will be back to administer medications in 1 hour."

b. Ask about the chief concerns or problems.

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? a. Immediately place the patient in isolation. b. Ask the patient to describe the type of reaction. c. Proceed to the termination phase of the interview. d. Document the latex allergy on the medication administration record.

b. Ask the patient to describe the type of reaction.

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? a. Request that the family leave, so the patient can rest. 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.

b. Ask the patient to return to the room, so the nurse can inspect the abdomen.

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. d. Send the plan of care to quality assurance for review.

b. Communicate the plan to all health care professionals involved in the patient's care.

18. The nurse is intervening for a family member with role strain. Which direct care nursing intervention is most appropriate? a. Assisting with activities of daily living b. Counseling about respite care options c. Teaching range-of-motion exercises d. Consulting with a social worker

b. Counseling about respite care options

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? a. Decreased oral intake and decreased oxygen saturation when ambulating 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 d. Productive cough and decreased oral intak

b. Decreased oxygen saturation when ambulating and reports of shortness of breath when getting out of bed

10. A new nurse is working in a unit that uses interdisciplinary collaboration. Which action will the nurse take? a. Act as a leader of the health care team. b. Develop good communication skills. c. Work solely with nurses. d. Avoid conflict.

b. Develop good communication skills.

2. A nurse is using the problem-oriented approach to data collection. Which action will the nurse take first? a. Complete the questions in chronological order. b. Focus on the patient's presenting situation. c. Make accurate interpretations of the data. d. Conduct an observational overview.

b. Focus on the patient's presenting situation.

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. W andering b. Hemorrhage c. Urinary retention d. Impaired swallowing

b. Hemorrhage

13. Which action indicates the nurse is using a PICOT question to improve care for a patient? a. Practices nursing based on the evidence presented in court b. Implements interventions based on scientific research c. Uses standardized care plans for all patients. d. Plans care based on tradition

b. Implements interventions based on scientific research

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

b. Interpersonal

11. A nurse is conducting a nursing health history. Which component will the nurse address? a. Nurse's concerns b. Patient expectations c. Current treatment orders d. Nurse's goals for the patient

b. Patient expectations

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. b. Protocols assist the clinician in making decisions and choosing interventions for specific health care problems or 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.

b. Protocols assist the clinician in making decisions and choosing interventions for specific health care problems or conditions.

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? a. The nurse makes eye contact with the patient. b. The nurse speaks only to the patient's daughter. c. The nurse leans forward while talking with the patient. d. The nurse nods periodically while the patient is speaking.

b. The nurse speaks only to the patient's daughter.

1. After assessing a patient, a nurse develops a standard formal nursing diagnosis. What is the rationale for the nurse's actions? a. To form a language that can be encoded only by nurses b. To distinguish the nurse's role from the physician's role c. To develop clinical judgment based on other's intuition d. To help nurses focus on the scope of medical practice

b. To distinguish the nurse's role from the physician's role

15. A nurse is completing a care plan. Which intervention is most appropriate for the nursing diagnostic statement Impaired skin integrity related to shearing forces? a. Administer pain medication every 4 hours as needed. b. Turn the patient every 2 hours, even hours. c. Monitor vital signs, especially rhythm. d. Keep the bed side rails up at all times.

b. Turn the patient every 2 hours, even hours.

14. Which statement by a nurse indicates a good understanding about the differences between data validation and data interpretation? a. "Data interpretation occurs before data validation." b. "Validation involves looking for patterns in professional standards." c. "Validation involves comparing data with other sources for accuracy." d. "Data interpretation involves discovering patterns in professional standards."

c. "Validation involves comparing data with other sources for accuracy."

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? a. Decreased gastrointestinal motility b. Pain medication c. Abdominal distention d. Constipation

c. Abdominal distention

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? a. Posttrauma syndrome b. Constipation c. Acute pain d. Anxiety

c. Acute pain

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 upon return. c. Ask the NAP to record the patient's vital signs before administering medications. d. Omit the vital signs because the patient is presently in no distress.

c. Ask the NAP to record the patient's vital signs before administering medications.

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? a. Proceed to the next patient's room to make rounds. b. Determine the patient does not want any pain medicine. c. Ask the patient about the facial grimacing with movement. d. Administer the pain medication ordered for moderate to severe pain.

c. Ask the patient about the facial grimacing with movement.

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 firstaction? a. Follow the clinical protocol for a stroke. 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 provider.

c. Assess the patient for other symptoms or problems, and then notify the health care provider.

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? a. Gathers and organizes needed supplies b. Decides on goals and outcomes for the patient c. Assesses the patient's readiness for the procedure d. Calls for assistance from another nursing staff member

c. Assesses the patient's readiness for the procedure

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? a. Adult failure to thrive b. Hypothermia c. Deficient fluid volume d. Nausea

c. Deficient fluid volume

16. A charge nurse is evaluating a new nurse's plan of care. Which finding will cause the charge nurse to follow up? a. Assigning a documented nursing diagnosis of Risk for infection for a patient on intravenous (IV) antibiotics b. Completing an interview and physical examination before adding a nursing diagnosis c. Developing nursing diagnoses before completing the database d. Including cultural and religious preferences in the database

c. Developing nursing diagnoses before completing the database

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? a. Assigning clinical cues b. Defining characteristics c. Diagnostic reasoning d. Diagnostic labeling

c. Diagnostic reasoning

12. A nurse performs an assessment on a patient. Which assessment data will the nurse use as an etiology for Acute pain? a. Discomfort while changing position b. Reports pain as a 7 on a 0 to 10 scale c. Disruption of tissue integrity d. Dull headache

c. Disruption of tissue integrity

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

c. Health promotion

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. Risk for infection c. Impaired skin integrity d. Staphylococcal leg infection

c. Impaired skin integrity

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

c. Interdependent

3. Which information indicates a nurse has a good understanding of a goal? a. It is a statement describing the patient's accomplishments without a time restriction. b. It is a realistic statement predicting any negative responses to treatments. c. It is a broad statement describing a desired change in a patient's behavior. d. It is a measurable change in a patient's physical state.

c. It is a broad statement describing a desired change in a patient's behavior.

14. A nurse is making initial rounds on patients. Which intervention for a patient with poor wound healing should the nurse perform first? a. Reinforce the wound dressing as needed with 4 × 4 gauze. b. Perform the ordered dressing change twice daily. c. Observe wound appearance and edges. d. Document wound characteristics.

c. Observe wound appearance and edges.

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? a. Carefully review lab results. b. Conduct the physical assessment. c. Perform a thorough nursing health history. d. Prolong the termination phase of the interview.

c. Perform a thorough nursing health history.

6. Which method of data collection will the nurse use to establish a patient's database? a. Reviewing the current literature to determine evidence-based nursing actions b. Checking orders for diagnostic and laboratory tests c. Performing a physical examination d. Ordering medications

c. Performing a physical examination

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. Diagnosis c. Planning d. Implementation

c. Planning

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. b. Impaired physical mobility related to inability to bear weight on right leg. c. Provide assistance while the patient walks in the hallway twice this shift with crutches. d. The patient is unable to bear weight on right lower extremity.

c. Provide assistance while the patient walks in the hallway twice this shift with crutches.

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

c. Psychomotor

4. The nurse is gathering data on a patient. Which data will the nurse report as objective data? a. States "doesn't feel good" b. Reports a headache c. Respirations 16 d. Nauseated

c. Respirations 16

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. b. Medicate the patient to alleviate discomfort while ambulating. c. Review the patient's activity orders. d. Offer the patient a walker.

c. Review the patient's activity orders.

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. b. The patient can begin retaking all of the previous medications. c. The patient is apprehensive about discharge. d. The patient's surgery was not successful.

c. The patient is apprehensive about discharge.

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? a. The patient will ambulate in hallways. 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.

c. The patient will feed self at all mealtimes today without reports of shortness of breath.

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? a. Assist the patient to walk in the room with crutches. b. Obtain a walker for the patient. c. Consult physical therapy. d. Administer pain medication.

d. Administer pain medication.

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. b. Document the sleep patterns and information in the patient's chart. c. Explain that a more thorough assessment will be needed next shift. d. Ask the patient about usual sleep patterns and the onset of having difficulty resting.

d. Ask the patient about usual sleep patterns and the onset of having difficulty resting.

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? a. Consult physical therapy. b. Establish a new plan of care. c. Set new priorities for the patient. d. Assess the patient.

d. Assess the patient.

16. A patient has reduced muscle strength following a left-sided stroke and is at risk for falling. Which intervention is most appropriate for the nursing diagnostic statement Risk for falls? a. Keep all side rails down at all times. b. Encourage patient to remain in bed most of the shift. c. Place patient in room away from the nurses' station if possible. d. Assist patient into and out of bed every 4 hours or as tolerated.

d. Assist patient into and out of bed every 4 hours or as tolerated.

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

d. Dependent

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? a. Ineffective breathing pattern related to pneumonia b. Risk for infection related to chest x-ray procedure c. Risk for deficient fluid volume related to dehydration d. Impaired gas exchange related to alveolar-capillary membrane changes

d. Impaired gas exchange related to alveolar-capillary membrane changes

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? a. Gordon's Functional Health Patterns b. Activity-exercise pattern assessment c. General to specific assessment d. Problem-oriented assessment

d. Problem-oriented assessment

11. Which action should the nurse take first during the initial phase of implementation? a. Determine patient outcomes and goals. b. Prioritize patient's nursing diagnoses. c. Evaluate interventions. d. Reassess the patient.

d. Reassess the patient.

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? a. Risk for impaired skin integrity b. Risk for infection c. Spiritual distress d. Reflex urinary incontinence

d. Reflex urinary incontinence