Unit 2 - Chapter 16 - Nursing Process

1. The nurse carefully enters a new patient's medical history and current medication list into the agency's electronic health record (EHR). Which step of the nursing process is being performed by the nurse? a. Assessment b. Implementation c. Evaluation d. Diagnosis

a

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

13. Which statement by the nurse is an example of back-channeling? a. "I completely understand. Can you tell me more?" b. "When did you first seek health care for your symptoms?" c. "I am sure the doctor will answer all of your questions shortly." d. "Try not to worry. I'm sure that you will be just fine."

a

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. b. The nurse administers pain medicine due at 1700 at 1600 because the patient reports increased pain and the family wants 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

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

17. The nurse becomes frustrated when a patient insists on taking herbal remedies rather than prescribed medications and spends certain hours of each day in prayer. The patient also prefers the care of the spiritualist healer over the attending physician. Which factor may be responsible for the nurse's frustration? a. Cultural differences in health-related practices b. Delay in the patient's psychosocial development c. Impaired ability of the patient to cope with acute illness d. Incorrect organization of health assessment findings

a

18. The nurse is caring for a patient who will be having surgery shortly. The patient requests that a religious bracelet be worn in the operating room to help ensure a good surgical outcome. Which is the most appropriate action of the nurse? a. Call the operating room staff to determine if the bracelet can stay on during surgery. b. Insist that the patient remove the bracelet and give it to a family member during surgery. c. Notify the patient's surgeon of the patient's refusal to remove the bracelet before having surgery. d. Remove the bracelet from the patient's wrist after sedating medication has been administered.

a

26. The nurse is caring for a patient with the nursing diagnosis constipation related to side effects of medications. Which is an appropriate goal for this patient? a. "The patient will have a soft formed bowel movement by the end of the shift." b. "The nursing assistant will ambulate the patient to the toilet as needed." c. "The patient will not have any nausea, vomiting, or feeling of abdominal fullness." d. "The nurse will palpate for abdominal distention and encourage oral fluid intake."

a

27. The nurse is preparing to insert an indwelling urinary catheter into the patient. Where will the nurse check to ensure that the packaging is sterile, intact, and not past the expiration date? a. In the clean utility room immediately after removing the package from the shelf b. At the patient's bedside after verifying the patient's name and birth date c. At the nurses' station after verifying the physician's order for the procedure d. At the patient's bedside after performing careful perineal care for the patient

a

31. The extended care agency administers the flu vaccination to all of the patients who do not have contraindications to the injection. What is the reason that the nurses do not have to obtain orders from each patient's physician for vaccination each year? a. The agency's medical director placed a standing order for patients to receive the flu vaccination yearly unless contraindicated. b. The Centers for Disease Control and Prevention highly recommend yearly flu vaccinations for all individuals over the age of 65. c. The State Licensing Board for extended care facilities requires annual flu vaccinations for all residents and staff. d. The administrator of the agency has the authority to order annual flu vaccinations for all residents and staff.

a

7. The nurse is completing the charting after a patient suffered a fall. Which statement is appropriate for the nurse to include in the description of the incident? a. The patient was found on the floor and his urinal was on the floor next to him. b. The patient's nurse assistant always took her time to answer his call lights. c. The patient probably urinated on the floor and slipped on the wet floor. d. The patient is grouchy and inappropriate, always causing trouble for the nurses.

a

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

2. Which actions by the nurse are examples of independent nursing interventions for a postoperative patient? (Select all that apply). a. Teaching patients with heart failure how to do accurate daily weights b. Administering intravenous fluids when the patient is unable to eat or drink c. Advancing a patient's diet from clear liquids to solid foods after surgery d. Elevating the head of the patient's bed to facilitate use of the incentive spirometer e. Switching the patient's injected pain medication to oral tablets before discharge

a,d

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

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

14. The nurse is conducting an admission assessment for a patient who was brought to the hospital after having a seizure. Which question will the nurse ask to quickly focus on the patient's symptoms? a. "Have you been to this hospital before?" b. "How long did the seizure last?" c. "Are you currently seeing a neurologist?" d. "You don't abuse drugs, do you?"

b

15. The nurse is caring for a trauma patient who has just arrived to the emergency room. The nurse listens to the patient's lung sounds, palpates the patient's peripheral pulses, and obtains vital signs. What is the best description of the nurse's actions? a. Establishing priorities for outcomes b. Performing a physical examination c. Demonstrating diagnostic reasoning d. Setting time frames for interventions

b

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

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

2. The nurse is caring for a patient who has just arrived at the hospital with chest pain. Which is the most important question for the nurse to ask the patient? a. "Did your family doctor tell you to come to the hospital?" b. "When did your chest pain begin?" c. "Do you have a family history of heart disease?" d. "Did someone come to the hospital with you?"

b

23. The nurse observed a postoperative patient trying to take her friend's narcotic pain pills in addition to the pain medication administered by the nurse. Which nursing diagnosis is the highest priority for this patient? a. Health-seeking behaviors b. Risk-prone health behavior c. Readiness for enhanced comfort d. Situational low self-esteem

b

24. The nurse is caring for a patient with the nursing diagnosis ineffective airway clearance related to narrowed airways and thick sputum. Which is an appropriate goal for this patient? a. "The patient will be resting comfortably by the morning." b. "The patient's airway will remain clear throughout the night." c. "The patient will not experience any feelings of shortness of breath or anxiety." d. "The patient's respiratory rate and pulse will remain within normal limits

b

25. The nurse is caring for an unconscious patient. The nurse repositions the patient at least every 2 hours and ensures that all of the patient's bony prominences are padded. What is the rationale for these actions? a. The nurse is following the standing orders listed in the patient's medical record. b. The nurse realizes the potential for bedsores and acts to prevent their development. c. The nurse identifies the patient care areas in which additional assistance is required. d. Nursing regulations do not allow these care tasks to be delegated to unlicensed personnel

b

29. The patient has a goal of maintaining urinary output of at least 30 mL/hour as part of the nursing care plan. However the patient's urinary output for the shift was only 20 mL/hour. What is the appropriate action of the nurse? a. Contact the physician to obtain an order for diuretics to increase urinary output. b. Reassess the patient to determine why the urinary output was less than 30 mL/hour. c. Change the goal to: patient will maintain urinary output of at least 20 mL/hour. d. Inform the patient that the urinary output goal for the shift was not met.

b

3. The nurse is caring for a patient who came to the hospital with acute shortness of breath. What is the priority action of the nurse as the assessment process is started? a. Pull the curtain around the bed and ensure patient privacy. b. Listen to the patient's lung sounds and check the pulse oximetry level. c. Tell the patient that the physician will be in shortly to start treatment. d. Reassure the patient that the shortness of breath will be relieved shortly.

b

30. Which nursing care order is an example of a standing order? a. Monitor blood glucose level before meals and at bedtime. b. Administer a soapsuds enema if no bowel movement for 3 days. c. Instruct the patient how to self-administer insulin correctly. d. Bathe the patient daily with application of moisturizer to all bony prominences.

b

6. The nurse has just completed an assessment for a patient. Which data will the nurse categorize as objective? a. The patient felt less short of breath after receiving a nebulizer treatment. b. The patient's lung sounds are diminished bilaterally with expiratory wheezes. c. The patient worries that the insurance company will not pay the hospital bill. d. The patient wonders if supplemental oxygen at home would be beneficial.

b

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

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

The nurse completes the assessment for a patient who has just been admitted to the hospital. The nurse carefully documents the patient's current drug list and asks about the use of any herbal supplements or over-the-counter medications. Which phase of the interview does this occur in? a. Orientation b. Working c. Reasoning d. Termination

b

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. a. Where is the pain located? b. What causes the pain? c. Does it come and go? d. What does the pain feel like? e. What is the rating on a scale of 0 to 10? 1. Provokes 2. Quality 3. Radiate 4. Severity 5.Time

b,d,a,e,c

3. The nurse enters the patient's room to begin teaching the patient about wound care management. The nurse notes that the patient is nauseated due to medication side effects. What are the priority actions of the nurse? (Select all that apply). a. Begin teaching the patient about wound care management, taking care to avoid using terms that the patient might find upsetting. b. Provide measures to relieve the patient's nausea and return to teach about wound care when the patient is feeling better. c. Document in the patient's chart that teaching about wound care management was not done because the patient refused to learn. d. Check the patient's order list to determine if antiemetic medication has been prescribed for the patient. e. Apply a cold cloth to the patient's forehead and maintain a quiet, odor-free environment for the patient.

b,d,e

12. Which question is the most appropriate for the nurse to use to start the health history assessment? a. "Does your family doctor know that you are here?" b. "Did you drive yourself to the hospital?" c. "What brings you to the hospital today?" d. "Did you give your insurance card to the receptionist?"

c

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

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

22. The nurse is caring for a patient who has been unable to have a bowel movement for the last 4 days after taking prescribed narcotic pain medication. Which nursing diagnosis is appropriate for this patient? a. Risk for constipation related to irregular defecation habits b. Perceived constipation related to expectation of daily bowel movements c. Constipation related to side effects of pain medication d. Impaired bowel elimination related to abdominal muscle weakness

c

28. A nurse is delegating care of patients to the certified nursing assistant (CNA) and a licensed practical nurse (LPN). Which task assignment indicates that the nurse needs additional education about delegation? a. The LPN is assigned to change a sterile dressing. b. The CNA is assigned to provide skin care. c. The CNA is assigned to insert an indwelling urinary catheter. d. The LPN is assigned to administer a soapsuds enema.

c

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 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

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

5. A nurse is collecting data during the assessment of a patient. During the assessment, the nurse collects both subjective and objective data. Which information should the nurse consider as subjective data? a. The patient's catheter drained 400 mL of urine during the last 8 hours. b. The patient's incision is clean, dry, and intact with staples. c. The patient reports having sharp, burning pain with urination. d. The patient refused breakfast after vomiting 200 mL green emesis

c

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

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

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

9. The nurse is caring for a toddler who will be having surgery. Which will provide the best primary source of information about how to comfort the child after surgery is completed? a. Patient's chart b. Patient c. Parents d. Surgeon

c

1. A nurse is completing an assessment. Which findings will the nurse report as subjective data? (Select all that apply.) a. Patient's temperature b. Patient's wound appearance c. Patient describing excitement about discharge d. Patient pacing the floor while awaiting test results e. Patient's expression of fear regarding upcoming surgery

c,e

1. Which actions by the nurse are examples of dependent nursing interventions for a postoperative patient? (Select all that apply). a. Calculating the patient's fluid intake and output at the end of every shift b. Encouraging fluid and fiber intake to prevent constipation from pain medications c. Administering a mild stool softener daily to prevent constipation d. Assessing the patient's abdomen for distention, bowel sounds, and passage of flatus e. Reinserting of the patient's urinary catheter for retention of greater than 500 mL of urine

c,e

11. The nurse is assessing a patient with chest pain who has just come to the hospital. Which open-ended question will provide the nurse with helpful information about the patient's health status? a. "How long have you been experiencing chest pain?" b. "Do you have a family history of heart disease?" c. "Are you having any difficulty breathing right now?" d. "What does your chest pain feel like?"

d

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

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

16. The nurse is caring for a patient who denies having any pain. The nurse notes that the patient is restless and the patient's hands are tightly clenched. The nurse also heard the patient moaning before walking into the room. What will the nurse take into consideration as the patient assessment is completed? a. Unclear communication techniques b. Unrealistic patient expectations c. Inappropriate empathetic response d. Conflicting assessment findings

d

19. The nurse is caring for a patient with sepsis. The nurse includes potential complications: septic shock in the plan of care. Why is this nursing diagnosis considered a collaborative problem? a. The patient must be closely monitored in an intensive care unit. b. The patient has a history of noncompliance with prescribed therapeutic regimens. c. Prevention of septic shock is not a measurable patient outcome. d. Both nursing and physician-prescribed interventions are required.

d

20. Which nursing diagnosis is the highest priority for a patient with pneumonia? a. Activity intolerance related to fatigue and shortness of breath b. Knowledge deficit related to pneumonia risk factors c. Pruritus related to side effects of prescribed medications d. Impaired gas exchange related to alveolar inflammation and infection

d

21. Which nursing diagnosis is the highest priority for a patient with multiple sclerosis? a. Chronic sorrow related to loss of independence b. Disturbed sensory perception related to nerve cell damage c. Risk for powerlessness related to impaired fine- and gross-motor skills d. Risk for falls related to impaired mobility and sensation

d

4. The nurse is caring for a nonverbal patient who just had surgery. The nurse notes that the patient moans with position changes, the hands are clenched, and the skin is very sweaty. The nurse decides that the patient is in pain and decides to administer an analgesic. What is the correct term for this nursing action? a. Setting priorities b. Recognizing inconsistencies c. Using empathy d. Making inferences

d

8. Every time the nurse asks the patient a question for the admission assessment, the patient's husband interrupts and answers the question for her. What is the best action of the nurse? a. Enter the husband's responses into the patient's chart. b. Request that the husband leave the room. c. Complete the admission assessment after the husband has gone home. d. Allow time for the patient to answer each question.

d