NUR 297A: Exam 2 Questions

If the nurse chooses the Nursing Outcome Classification (NOC), Appetite for a chemotherapy patient, which outcome indicators would be acceptable for evaluation of goal attainment? (Select all that apply.) a. Expressed desire to eat b. Report that food smells good c. Use of relaxation techniques before meals d. Preparation of home-cooked meals for self and family e. Uses nutritional information on labels to guide selections

a, b, d

What situations would necessitate modification of a patient's plan of care? (Select all that apply.) a. Decrease in patient's level of orientation b. Discharge of patient to rehabilitation facility c. Patient adherence to established plan of care d. Sudden onset of shortness of breath in patient receiving oxygen

a, b, d

Which actions does the nurse need to take before determining the types of nursing diagnoses that are applicable to a patient? (Select all that apply.) a. Review the patient's past and present medical history. b. Analyze the nursing assessment data to determine whether information is complete. c. Outline an individualized plan of care to address each concern. d. Consider potential complications to which the patient is susceptible. e. Evaluate how the patient has responded to treatment.

a, b, d

the clinic nurse prepares to perform a focused assessment on a client who is complaining of symptoms of a cold, a cough, and lung congestion. which should the nurse include for this type of assessment. select all that apply a. auscultating lung sounds b. obtaining the clients temperature c. assessing the strength of peripheral pulses d. obtaining information about the client's respirations e. performing a musculoskeletal and neurological examination f. asking the client about a family history of any illness or disease

a, b, d

the nurse is setting up the physical environment for an interview with a client and plans to obtain subjective data regarding the client's health. which interventions are appropriate? select all that apply a. set the room temperature at a comfortable level b. remove distracting objects from the interviewing area c. place a chair for the client client across from the nurses desk d. ensure comfortable seating at eye level for the client and nurse e. provide seating for the client so that the client faces a strong light f. ensure that the distance between the client and the nurse is at least 7 feet

a, b, d

which action does the nurse need to take before determining the type(s) nursing diagnoses that are applicable to a pt? (select all that apply) a. thoroughly review the pts medical history b. analyze the nursing assessment data to determine whether information c. outline a individualized plan of care to address each concern d. consider potential complications to which the pt is susceptible e. evaluate how the pt has responded to treatment

a, b, d

Which actions are part of the evaluation step in the nursing process? (Select all that apply.) a. Recognizing the need for modifications to the care plan b. Documenting performed nursing interventions c. Determining if nursing interventions were completed d. Reviewing whether a patient met their short-term goal e. Identifying realistic outcomes with patient input

a, d

which action is a part of the evaluation step in the nursing process? select all that apply a. recognizing the need for modifications to the care plan b. documenting performed nursing interventions c. determining if nursing interventions were completed d. reviewing whether a patient met their short term goal e. identifying realistic outcomes with patient input

a, d

Which action by the nurse is most appropriate during the orientation phase of the patient interview? a. Always position patients in a comfortable reclined position to ensure their comfort during questioning. b. Ask which name a patient prefers to be called during care to show respect and build trust. c. Quickly conduct a review of systems to determine the need for a complete or focused assessment. d. Begin with questions about intimacy and sexuality to address sensitive issues first.

b

Which activity by the nurse best demonstrates part of the working phase of a patient interview? a. Summarizing previously discussed key topics b. Including selected family members in care planning c. Transferring care responsibilities to the home health nurse d. Verifying the name by which a patient prefers to be addressed

b

Which nursing goal is written correctly for a patient with the nursing diagnosis of Risk for Infection after abdominal surgery? a. Nurse will encourage use of sterile technique during each dressing change. b. Patient's white blood count will remain within normal range throughout hospitalization. c. Patient's visitors will be instructed in proper handwashing before direct interaction with patient. d. Patient will understand the importance of cleaning around the incision with a clean cloth during bathing.

b

Which nursing intervention is most important to complete before giving medication to a patient? a. Provide water to aid in the patient's ability to swallow the medication. b. Double-check the patient's allergies before giving the drug. c. Ask the patient to verify having taken the medication before. d. Place the patient in a side-lying position to prevent aspiration.

b

an older client is admitted to the hospital with severe diarrhea. the RN is completing an assessment and notes the client has dry mucous membranes and poor skin turgor. which assessment data should the RN gather to determine if the client has a fluid volume deficit a. lower extremity edema b. orthostatic hypotension c. elevated BP d. cheyne-stokes respirations

b

the nurse is testing extraocular movements in a client to assess for muscle weakness in the eyes. the nurse should implement which assessment technique to assess for muscle weakness a. tests the corneal reflexes b. tests the 6 cardinal positions of gaze c. tests visual acuity, using a snellen eye chart d. tests sensory function by asking the client to close eyes and then lightly touching the forehead, cheeks, and chin

b

which nursing intervention is most important to complete before giving medication to a pt a. provide water to aid in the pts ability to swallow the medication b. double check the pts allergies before giving the drug c. ask the pt to verify having taken the medication before d. place the pt in a side lying position to prevent aspiration

b

Which interventions can the nurse initiate independently while providing patient care? (Select all that apply.) a. Ordering a blood transfusion b. Auscultating lung sounds c. Monitoring skin integrity d. Applying heel protectors e. Adjusting antibiotic dosages

b, c, d

Which nursing diagnosis statements are appropriately written according to 2018-2020 NANDA-I format? (Select all that apply.) a. Risk for Infection (ICNP) related to elevated temperature and white blood count b. Readiness for Effective Family Process (ICNP) as evidenced by an expressed desire for improved communication and mutual respect verbalized by family members c. Impaired health maintenance (ICNP) related to inability to access care as evidenced by failure to keep appointments, homebound status d. Risk for Hemorrhaging (ICNP) as evidenced by prolonged clotting time e. Chronic Pain (ICNP) related to osteoarthritis as manifested by verbalized postoperative discomfort

b, c, d

What signs and symptoms would the nurse appropriately cluster as supporting data for a patient with extreme anxiety? (Select all that apply.) a. Denies any difficulty falling asleep b. Elevated pulse rate auscultated at 140 bpm c. Continuous foot tapping throughout intake interview d. Demonstrates how to give insulin self-injection without hesitation e. Patient states, "I feel nervous all the time, especially when I am alone."

b, c, e

A nurse administers an antihypertensive medication to a patient at the scheduled time of 0900. The nursing assistant then reports to the nurse that the patient's blood pressure was low when it was taken at 0830. The nursing assistant states she 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 re-checked, and it has dropped even lower. The nurse first made an error in what phase of the nursing process? A. Evaluation B. Planning C. Assessment D. Diagnosis

c

A patient exhibits the following symptoms: tachycardia, increased thirst, headache, decreased urine output, and increased body temperature. After analyzing these data, the nurse assigns which of the following nursing diagnoses? A. Nausea B. Hypothermia C. Deficient fluid volume D. Adult failure to thrive

c

A patient of Middle Eastern descent has lost 5 lbs during hospitalization and states that the food offered is not allowed in his diet owing to religious preferences. Based on this information, an appropriate nursing diagnostic statement is Imbalanced nutrition: less than body requirements related to A. Weight loss. B. Religious preferences. C. Decreased oral intake. D. Race and ethnicity.

c

A patient with a spinal cord injury is seeking to enhance his urinary elimination abilities by learning self-catheterization versus assisted catheterization by home health nurses and family members. The nursing diagnosis Readiness for enhanced urinary elimination is which type of diagnosis? A. Wellness B. Risk C. Health promotion D. Actual

c

Identify the defining characteristics in the nursing diagnosis statement: 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 complaints of abdominal pain. A. Pain medication B. Decreased gastrointestinal motility C. Abdominal distention D. Constipation

c

On what premise is a nursing diagnosis identified for a patient? a. First impressions b. Nursing intuition c. Clustered data d. Medical diagnoses

c

What action should the nurse take regarding a patient's plan of care if the patient appears to have met the short-term goal of urinating within 1 hour after surgery? a. Consult the surgeon to see if the clinical pathway is being followed. b. Discontinue the plan of care, because the patient has met the established goal. c. Monitor patient urine output to evaluate the need for the current plan of care. d. Notify the patient that the goal has been attained and no further intervention is needed

c

What is one purpose of using standard formal nursing diagnoses in practice? A. Help nurses focus on the scope of medical practice. B. Allow for the communication of patient needs to assistive personnel. C. Distinguish the nurse's role from the physician's role. D. Form a language that can be encoded only by nurses.

c

What is the process of using assessment data gathered about a patient combined with critical thinking to explain a nursing diagnosis? A. Diagnostic labeling. B. Defining characteristics. C. Diagnostic reasoning. D. Assigning clinical criteria.

c

What is the purpose of the nursing process? a. Providing patient-centered care b. Identifying members of the health care team c. Organizing the way nurses think about patient care d. Facilitating communication among members of the health care team

c

When initiating a physical examination, which action should the nurse take first? a. Review of the patient's prior medical records b. Gather admission health history forms c. Assess the patient's vital signs d. Perform light and deep palpation for fluid

c

Which action by a patient marks the beginning of the physical assessment process? a. Redressing after a physical examination b. Breathing normally during auscultation c. Greeting the nurse in the examination room d. Sharing work environment information

c

Which action by the day-shift nurse provides objective data that enables the night-shift nurse to complete an evaluation of a patient's short-term goals? a. Encouraging the patient to share observations from the day b. Leaving a message with the charge nurse before shift change c. Documenting patient assessment findings in the patient's chart d. Checking with the pharmacist regarding possible drug interactions

c

Which action by the nurse would be most important in developing a patient-centered plan of care for an alert, oriented adult? a. Providing a written copy of care options to the patient and family b. Collaborating with the patient's social worker to determine resources c. Listening to the patient's concerns and beliefs about proposed treatment d. Engaging the patient's family, friends, or care providers in conversation

c

Which entry in a patient's electronic health record best indicates the need for a nurse to gather secondary rather than primary subjective data? a. Complaining of chest pain b. Apical pulse 110 c. Comatose d. Difficulty swallowing

c

Which intervention would be most important for the nurse to include in a patient's care plan if the patient is unable to complete activities of daily living without becoming fatigued? a. Instruct the patient to shower and shave simultaneously b. Discourage the patient from bathing while hospitalized c. Encourage the patient to rest between bathing activities d. Ask the patient's spouse to assist with all bathing

c

Which nursing action is critical before delegating interventions to another member of the health care team? a. Locate all members of the health care team. b. Notify the physician of potential complications. c. Know the scope of practice and competency of the other team member. d. Call a meeting of the health care team to determine the needs of the patient

c

Which of these selections is an etiology for Acute pain versus a defining characteristic? A. Complaint of pain as a 7 on a 0 to 10 scale B. Discomfort while changing position C. Disruption of tissue integrity D. Dull headache

c

Which phrase best represents a related factor in a problem-focused nursing diagnosis? a. Unsteady gait requiring the assistance of two people b. Redness and swelling around the incision site c. Ineffective adaptation to recent loss d. Patient complaint of restlessness

c

Which resource is most helpful when prioritizing identified nursing diagnoses? a. Nursing Interventions Classification (NIC) b. Gordon's functional health patterns c. Maslow's hierarchy of needs d. Nursing Outcomes Classification (NOC)

c

Which task may the registered nurse safely delegate to unlicensed assistive personnel without prior intervention? a. Ambulating a patient with ataxia and new right-sided paresthesia b. Feeding a patient with cerebral palsy who recently aspirated c. Transporting a patient to the hospital entrance for discharge d. Administering prescribed programmed medications

c

a client with a diagnosis of asthma is admitted to the hospital with respiratory distress. which type of adventitious lung sounds should the nurse expect to hear when performing a respiratory assessment on this client a. stridor b. crackles c. wheezes d. diminished

c

the RN is caring for an asian client who refuses to make eye contact during conversations. how should the RN assess this client's response a. the client cannot understand the nurse b. the client is uncomfortable with the nurse c. the client is treating the nurse with respect d. the client is purposely disrespecting the nurse

c

the RN use the mini-mental state examination (MMSE) when assessing a client for admission to an assisted living facility. which findings is the RN assessing when requesting the client to count by 7s a. recall of information b. orientation to surroundings c. attention to details d. ability to follow complex commands

c

the nurse is performing a neurological assessment on a client and elicits a positive Romberg's sign. the nurse makes this determination based on which observation a. an involuntary rhythmic, rapid, twitching of the eyeballs b. a dorsiflexion of the ankle and great toe with fanning of the other toes c. a significant sway when the client stands erect with feet together, arms at the side, and the eyes closed d. a lack of normal sense of position when the client is unable to return extended fingers to a point of reference

c

which action by the day-shift nurse provides objective data that enables the night-shift nurse to complete an evaluation of a patient's short-term goals a. encouraging the patient to share observations from the day b. leaving a message with the charge nurse before shift change c. documenting patient assessment findings in the patient's chart d. checking with the pharmacist regarding possible drug interactions

c

which intervention would be most important for the nurse to include in a pts care plan if the pt is unable to complete activities of daily living without becoming fatigued a. instruct the pt to shower and shave simultaneously b. discourage the pt from bathing while hospitalized c. encourage the pt to rest between bathing activities d. ask the pts spouse to assist with all bathing

c

which task may the RN safely delegate to UAP without prior intervention a. ambulating a pt with ataxia and new right sided paresthesia b. feeding a pt with cerebral palsy who recently aspirated c. transporting a pt to the hospital entrance for discharge d. administering prescribed programmed medications

c

A patient comes to the emergency department complaining of nausea and vomiting. What should the nurse ask the patient about first? a. Family history of diabetes b. Medications the patient is taking c. Operations the patient has had in the past d. Severity and duration of the nausea and vomiting

d

A patient discusses his job stress and family relationships with the nurse during his health history interview. In which organizational framework is this type of data likely to be recorded most extensively? a. Body systems model b. Physical assessment model c. Head-to-toe assessment model d. Functional health patterns model

d

An alert, oriented patient is admitted to the hospital with chest pain. From whom should the nurse collect primary data on this patient? a. Family member b. Physician c. Another nurse d. Patient

d

If the nurse discovers that a patient's right elbow is swollen and painful during a physical examination, which action should the nurse take next? a. Apply ice to decrease swelling and reduce pain b. Percuss the area to determine the presence of fluid c. Perform passive range of motion to promote flexibility d. Inspect the patient's left elbow to compare its appearance

d

What is the most important action for a nurse to take to have a new nursing diagnosis considered for inclusion in the ICNP or NANDA-I taxonomies? a. Share concerns with the nurse manager on the nursing unit. b. Offer alternative care for a patient and family members. c. Discuss how to address patient needs with physicians. d. Provide evidence-based research to support nursing care.

d

What is the most important reason for nurses to use a standardized taxonomy, such as the ICNP, CCC, or NANDA-I? a. Insurance documentation b. Professional autonomy c. EMR data analysis d. Patient safety

d

Which action would the nurse undertake first when beginning to formulate a patient's plan of care? a. List possible treatment options b. Identify realistic outcome indicators c. Consult with health care team members d. Rank patient concerns from assessment data

d

Which direct-care intervention would be most effective in helping a patient cope emotionally with a new diagnosis of cancer? a. Reassessing for changes in the patient's physical condition b. Teaching the patient various methods of stress reduction c. Referring the patient for music and massage therapy d. Encouraging the patient to explore options for care

d

Which line of questioning by the nurse best represents an appropriate approach to the review of systems aspect of the assessment process? a. "What do you do for a living? Can you describe your work environment?" b. "Is there a family history of heart disease, cancer, high blood pressure, or stroke?" c. "When was your last annual physical? What immunizations did you receive at that time?" d. "Do you have any chest tightness, shortness of breath, or difficulty breathing while exercising?"

d

Which notation is most appropriate for the nurse to include in a patient's chart regarding evaluation of the goal, "Patient will ambulate three times daily in the hallway before discharge without shortness of breath (SOB)"? a. Goal not met; patient states he is tired. b. Goal not met; patient ambulated three times in room. c. Goal met; patient ambulated three times in the hallway. d. Goal met; patient ambulated three times in the hallway without SOB.

d

Which nursing diagnostic statement is accurately written for a patient with a medical diagnosis of pneumonia? A. Risk for infection related to lower lobe infiltrate B. Risk for deficient fluid volume related to dehydration C. Ineffective breathing pattern related to pneumonia D. Impaired gas exchange related to alveolar-capillary membrane changes

d

Which statement best describes the relationship of medical diagnoses and nursing diagnoses? a. Medical diagnoses are imbedded in nursing diagnoses. b. Nursing diagnoses are derived from medical diagnoses. c. Medical diagnoses are not relevant to nursing diagnoses. d. Medical diagnoses may be interrelated to nursing diagnoses.

d

Which statement illustrates a characteristic of goals within the care planning process? a. Goals are vague objectives communicating expectations for improvement. b. Short-term goals need not be measurable, unlike long-term goals. c. Goal attainment can be measured by identifying nursing interventions. d. Long-term goals are helpful in judging a patient's progress.

d

when making assignments to a team consisting of a registered nurse (RN), licensed practical nurse (LPN), and two unlicensed assistive personnel (UAP), which is the best client for the LPN a. a client requiring frequent temperature checks b. a client requiring assistance with ambulation every 4 hours c. a client on a mechanical ventilator requiring frequent assessment and suctioning d. a client with a spinal cord injury requiring urinary catheterization every 6 hours as prescribed

d

which notation is most appropriate for the nurse to include in a pts chart regarding evaluation of the goal, "pt will ambulate three times daily in the hallway before discharge without shortness of breath (SOB)" a. goal not met; patient states he is tired b. goal not met; pt ambulated 3x in room c. goal met; pt ambulated 3x in the hallway d. goal met; pt ambulated 3x in the hallway without SOB

d

What should be taken into consideration by the nurse when deciding on interventions to include in a patient's plan of care? (Select all that apply.) a. Patient's treatment preferences b. Cultural and ethnic influences c. Nurse's professional expertise d. Current evidence-based research e. Convenience to the nursing staff

a, b, c, d

What should the nurse consider before implementation of all nursing interventions? (Select all that apply.) a. Potential communication barriers b. Diverse cultural practices c. Scope of nursing practice d. Functional status of the patient e. Time of most recent shift change

a, b, c, d

Which factors should be taken into consideration by the nurse before and during a patient interview? (Select all that apply.) a. Distance between the chairs in which the nurse and patient are sitting b. Traditional treatments typically used by the patient to treat disease c. Gender preference for primary care providers (PCPs) d. Physical condition of the patient e. Music preference of the patient

a, b, c, d

what should the nurse consider before implementation of all nursing interventions (select all that apply) a. potential communication barriers b. diverse cultural practices c. scope of nursing practice d. functional status of the pt e. time of most recent shift change

a, b, c, d

What is the primary purpose of the nursing diagnosis? a. Resolving patient confusion b. Communicating patient needs c. Meeting accreditation requirements d. Articulating the nursing scope of practice

b

A new graduate nurse is not sure what the heart sound is that she is listening to on a patient. To avoid diagnostic error, what should the nurse do? A. Ask a more experienced nurse to listen also. B. Check the previous shift's assessment and document what was noted on the last shift. C. Ask the patient if he has a history of cardiac problems before assigning the diagnosis of Decisional conflict. D. Assign the nursing diagnosis of Decreased cardiac output.

a

A patient presents to the emergency department following a motor vehicle crash and suffers from 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 complains only of moderate discomfort. What is the most pertinent nursing diagnosis to be included in the plan of care based on the assessment data provided? A. Acute pain B. Post trauma syndrome C. Urinary retention D. Constipation

a

A patient reports feeling tired and complains of not sleeping at night. What action should the nurse perform first? a. Identify reasons the patient is unable to sleep. b. Request medication to help the patient sleep. c. Tell the patient that sleep will come with relaxation. d. Notify the physician that the patient is restless and anxious

a

What is the most significant problem that may result from improperly written NANDA-I nursing diagnostic statements? a. Lack of direction for formulating patient plans of care b. Omission of physician or primary care provider orders c. Combining of two unrelated patient concerns d. Increased team collaboration needs

a

What is the primary difference between a NANDA-I risk nursing diagnosis and a problem-focused nursing diagnosis? a. Related factors are not part of a risk diagnosis. b. There is no cause and effect relationship established. c. Defining characteristics are subjective in a risk diagnosis. d. There are no nursing interventions prescribed with a risk diagnosis.

a

What should be the primary focus for nursing interventions? a. Patient needs b. Nurse concerns c. Physician priorities d. Patient's family requests

a

Which cue by a patient can be validated by laboratory and diagnostic test results? a. Deeply sighing with fatigue b. Bilateral crackles in the lungs c. Oxygen saturation of 98% on room air d. 2+ pitting edema of the ankles and feet

a

Which diagnosis below is NANDA-I approved? A. Acute pain B. High blood pressure C. Sleep disorder D. Sore throat

a

Which situation indicates the greatest need for collaborative interventions provided by several health care team members? a. Hospice referral b. Physical assessment c. Activities of daily living d. Health history interview

a

Which statement is an appropriately written short-term goal? a. Patient will walk to the bathroom independently without falling within 2 days after surgery. b. Nurse will watch patient demonstrate proper insulin injection technique each morning. c. Patient's spouse will express satisfaction with patient's progress before discharge. d. Patient's incision will be well approximated each time it is assessed by the nurse.

a

what is the most significant problem that may result from improperly written nursing diagnostic statements a. lack of direction for formulating pt plans of care b. omission of physician or primary care provider orders c. combining of two unrelated patient concerns d. increased team collaboration needs

a

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. "When was the last time you took your medicine?" B. "Do you feel like you need to use the bathroom?" C. "Do you have a safety rail in your bathroom at home?" D. "Are you able to walk to the bathroom by yourself?"

b

A patient has just experienced a cardiac arrest on the unit. The nurse has implemented the acute care plan for management of code situations. What is the next step the nurse should take? a. Resume all interventions for previously identified nursing diagnoses. b. Perform the steps of the nursing process related to the patient's current condition. c. Seek physician input related to updating the nursing diagnosis statements. d. Evaluate the success of the acute care plan for management of the cardiac arrest.

b

If a patient is exhibiting signs and symptoms of each of these nursing diagnoses, which should the nurse address first while planning care? a. Fatigue b. Acute Pain c. Lack of Knowledge d. Disturbed Body Image

b

The charge 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 to bathroom. The nurse needs to revise which part of the diagnostic statement? A. Defining characteristic B. Etiology C. Nursing diagnosis D. Patient chief complaint

b

The nurse is reviewing a patient's electronic health record (EHR) for significant changes and discovers that the patient has not voided in over 8 hours. The patient's kidney function labs 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. Planning B. Diagnosis C. Evaluation D. Implementation

b

The nurse notices that a patient is becoming short of breath and anxious. Which intervention is a dependent nursing action, requiring the order of a primary care provider? a. Elevating the head of the patient's bed b. Administering oxygen by nasal cannula c. Assessing the patient's oxygen saturation d. Evaluating the patient's peripheral circulation

b

The patient electronic health record (EHR) reveals that a patient has decreased oral intake, decreased oxygen saturation when ambulating, complaints of shortness of breath when getting out of bed, and a productive cough. What are the 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 complaints of shortness of breath when getting out of bed C. Complaints of shortness of breath when getting out of bed and a productive cough D. Productive cough and decreased oral intake

b