Nursing process 2
Which quantity of vitamin C is recommended for wound healing? Record your answer using a whole number. ______ mg/day
1000
How many classes are included in the second level of the Nursing Interventions Classification (NIC) model? Record your answer using a whole number. ________
30
Which prevention level would describe a clinic nurse screening a patient for diabetes? 1 Primary 2 Secondary 3 Tertiary 4 Quaternary
2
Which action would the nurse take while documenting and reporting the evaluation of care for a patient? 1 If a patient's goals are only partially met, the nurse would not document it in the patient's medical record. 2 If a patient is showing good progress, the nurse need not document it in the patient's medical record. 3 If a patient is not progressing, the nurse would report it to the health care team members. 4 If a patient is not progressing, the nurse would record the goal is difficult to meet.
3
Which implementation skill describes a nurse explaining to the patient about inserting a feeding tube? 1 Cognitive 2 Technical 3 Interpersonal 4 Psychomotor
3
Which expected outcome is written in measurable terms? 1 Patient will be pain free. 2 Patient will have less pain. 3 Patient will take pain medication every 4 hours. 4 Patient will report pain acuity less than 4 on a scale of 0 to 10.
4
Which option is an example of a nurse managing indirect care activities? 1 Infection control 2 Patient counseling 3 Medication administration 4 Lifesaving measures
1
Which component is an element of the American Nurses Association (ANA) standards of practice and scope of nursing practice? Select all that apply. One, some, or all responses may be correct. 1 Describes what a nurse is licensed to perform 2 Is a definition of skills competencies for nurses 3 Sets standards for diagnosing diseases and disorders 4 Identifies the nature and intent of the ways nurses intervene for patients 5 Is an authoritative statement regarding the duties all nurses are expected to perform
1,4,5
Place the steps in the correct order the nurse would take to evaluate outcomes of care for a patient with a skin condition. 1. Inspects the condition of the skin 2. Reviews the outcome criteria to identify the desired skin condition 3. Tries to determine why the outcome criteria and actual condition of skin do not agree, if goal is not met 4. Judges the extent to which the condition of the skin matches the outcome criteria 5. Compares the degree of agreement between the desired and actual condition of the skin
2,1,5,4,3
Which action is an example of a dependent nursing intervention? Select all that apply. One, some, or all responses may be correct. 1 Monitoring blood pressure 2 Inserting a Foley catheter 3 Dressing a surgical incision wound 4 Administering an antidepressive drug 5 Teaching a patient to do deep-breathing exercises
2,3,4
Which evaluative measure would be appropriate for determining if an obese patient who is maintaining a sleep diary achieves restful sleep? Select all that apply. One, some, or all responses may be correct. 1 Reassess the patient for any skin lesions. 2 Ask the patient if he or she feels rested after sleeping. 3 Review the sleep diary of the patient. 4 Interview the patient to reassess sleep habits. 5 Reassess the skin color of the patient.
2,3,4
Which factor would be considered when choosing a nursing intervention to address a patient problem? Select all that apply. One, some, or all responses may be correct. 1 Acceptability to the health care provider 2 Outcomes that have been set for the patient 3 Research evidence supporting the intervention 4 Capabilities of the nurse 5 Characteristics of the nursing diagnosis
2,3,4,5
Which tip would be helpful when a nurse is making a phone consultation? Select all that apply. One, some, or all responses may be correct. 1 Prepare a detailed explanation of the problem during the call. 2 Assess the patient thoroughly before making the call. 3 Have the complete information about the problem before the call. 4 Understand the reason behind the call and think through some possible solutions. 5 Use the Introduction, Situation, Background, Assessment, and Recommendation (ISBAR) approach in reporting details of the case.
2,3,4,5
which intervention would the nurse perform for a patient who has developed a hypersensitivity reaction to penicillin and has developed hives? Select all that apply. One, some, or all responses may be correct. 1 Reduce the penicillin dose. 2 Record the reaction. 3 Inform the health care provider. 4 Administer diphenhydramine, as prescribed. 5 Reassure the patient.
2,3,4,5
After the nurse raises the head of the bed and suctions a patient's lungs, which finding would be classified as an evaluative measure toward the goal that the patient's lungs will be free of secretions? Select all that apply. One, some, or all responses may be correct. 1 Patient drinks contents of water glass. 2 Patient's lungs are clear to auscultation in bases. 3 Patient reports feeling comfortable. 4 Patient's rate of breathing is 18 breaths/min. 5 Nurse positions the patient up in the bed.
2,4
Which question would the nurse ask to evaluate a patient's expectations of care? 1 "Are you hurting anywhere?" 2 "How would you rate your pain level?" 3 "Have you received adequate pain relief care?" 4 "What makes your pain decrease?"
3
Which level of prevention describes a nurse administering a vaccine to an infant? 1 Primary 2 Secondary 3 Tertiary 4 Rehabilitation
1
Which level of prevention describes a nurse conducting health awareness training programs at a community center? 1 Primary 2 Secondary 3 Tertiary 4 Indirect
1
Which type of action would describe a nurse performing cardiopulmonary resuscitation (CPR) for a patient in cardiac arrest? Select all that apply. One, some, or all responses may be correct. 1 Direct care 2 Counseling 3 Indirect care 4 Lifesaving measure 5 Patient battery
1,4
How do reminiscence strategies evaluate the memory of an older adult? 1 They produce a positive mood. 2 They reduce the patient's anxiety. 3 They resolve current conflicts by recollecting the past. 4 They allow evaluation of a patient's judgment and general knowledge.
3
The health care provider prescribes interventions to the nurse to treat the medical diagnosis of the patient. To which category does such an intervention belong? 1 Primary 2 Interdependent 3 Dependent 4 Independent
3
Which criterion is used to evaluate efficacy of interventions? 1 Consultation 2 Critical thinking 3 Communication 4 Expected outcome
4
Arrange the steps of the nursing process in their appropriate order. 1. Assessment 2. Diagnosis 3. Planning 4. Implementation 5. Evaluation
1,2,3,4,5
Which statement accurately describes the unit-dose system? Select all that apply. One, some, or all responses may be correct. 1 It uses carts for distribution. 2 It has labeled drawers. 3 It has controlled substances kept in foil. 4 It does not contain prn and stock medication. 5 It includes prescribed doses of medication for a full course.
1,2
Which action describes an independent nursing intervention? Select all that apply. One, some, or all responses may be correct. 1 Inserting a urinary catheter 2 Offering counseling for coping 3 Initiating early mobility protocols 4 Instructing patients on side effects of medications 5 Positioning patients to prevent pressure injury formation
2,3,4,5
Which classification of drug promotes gluconeogenesis of protein? 1 Antiparkinson 2 Antipsychotic 3 Antihypertensive 4 Antiinflammatory
4
Which element is the final step of the nursing process? 1 Counseling 2 Discharge 3 Evaluation 4 Implementation
3
The nurse reviews potential interventions for a patient who is experiencing pain. When considering the administration of an analgesic, the nurse identifies that the medication may cause an adverse reaction, including increasing the patient's fall risk. The nurse is demonstrating which principle of critical judgment and decision-making? 1 Review the set of all possible nursing interventions for the patient's problem. 2 Review all possible consequences associated with each possible nursing action. 3 Judge the value of the consequences to the patient. 4 Determine the probability of all possible consequences.
2
Which patient evaluative measure would be most appropriate for determining if the obese patient achieves the goal of a 15-pound weight loss? 1 Eats 1500 calories a day 2 Is weighed during each clinic visit 3 Discusses factors for starting an exercise program 4 Reviews the food diary that tracks intake of daily meals
2
Which priority action would the nurse take before administering a new drug? 1 Confer with a colleague before giving the medication. 2 Consult with a pharmacist to obtain knowledge about the medication. 3 Ask the patient about the medication. 4 Administer the medication as prescribed and on time.
2
Which priority level would be assigned to the patient diagnosed with decreased gas exchange? 1 High 2 Low 3 Medium 4 Intermediate
1
Which problem would the nurse add to the care plan after evaluating a diabetic patient who had a problem with glucose control but is now restless and asking many questions about an upcoming procedure on the big toe? 1 Anxiety 2 Glucose control 3 Diabetes 4 Risk of toe infection
1
Which action would the nurse take when a nursing goal is not met in the care of a patient? Select all that apply. One, some, or all responses may be correct. 1 Reassess the patient. 2 Repeat the entire nursing process. 3 Revise the care plan. 4 Notify the health care provider immediately. 5 Discontinue the care plan for the patient.
1,2,3
Which action performed for the patient is a nurse-initiated intervention? Select all that apply. One, some, or all responses may be correct. 1 Elevating an edematous leg 2 Offering counseling for coping 3 Preparing the patient for diagnostic tests 4 Initiating early mobility protocols 5 Administering insulin
1,2,4
Which action would the nurse take when administering a new, unfamiliar medication to a patient who cannot have food or fluids for 24 hours? Select all that apply. One, some, or all responses may be correct. 1 Ask the pharmacist for help. 2 Consult an experienced nurse for help regarding the drug. 3 Administer a different but similar drug. 4 Look up the medication in a drug book. 5 Request that the health care provider prescribe an oral medication.
1,2,4
Which intervention would be appropriate for a postoperative patient who is on bed rest and at risk of skin injuries after surgery? Select all that apply. One, some, or all responses may be correct. 1 Reposition the patient frequently. 2 Administer analgesics before turning. 3 Teach the patient about postoperative care. 4 Use pressure relief devices, if necessary. 5 Ambulate the patient.
1,2,4
Which nursing intervention is an example of direct care for a patient? Select all that apply. One, some, or all responses may be correct. 1 Administering medications 2 Inserting an intravenous (IV) line 3 Keeping the patient's room infection free 4 Counseling the patient about required care 5 Keeping all of the patient's paperwork updated
1,2,4
Which action is classified as an indirect care measure? Select all that apply. One, some, or all responses may be correct. 1 Checks the monthly performance improvement report on fall occurrences on a unit 2 Discusses with the patient exercise restrictions to follow upon return home 3 Consults with a dietitian about a patient's therapeutic diet food choices 4 Administers a tube feeding 5 Assists a colleague in applying a complex dressing to a patient's wound
1,3
Which problem is considered a high priority for a patient? Select all that apply. One, some, or all responses may be correct. 1 Reduced oxygenation 2 Compromised physical mobility 3 Insufficient circulation 4 Lack of knowledge about postoperative recovery 5 Skin lesions
1,3
Which action would a student nurse take when asked to perform a procedure that the student nurse has been trained in but has not performed in the hospital? Select all that apply. One, some, or all responses may be correct. 1 Check the hospital's procedure manual to obtain more information. 2 Request the unit manager assign the procedure to another student nurse. 3 Ask an experienced nurse for supervision and guidance during the procedure. 4 Verbalize the steps of the procedure with an instructor before performing it. 5 Refuse to perform the procedure.
1,3,4
Which factor would the nurse consider before setting a goal that the patient will self-administer insulin injections? Select all that apply. One, some, or all responses may be correct. 1 Patient's ability to meet the goal 2 Nurse's competency in teaching about insulin 3 Patient's cognitive function 4 Availability of the patient's support network to assist 5 Patient's social network
1,3,4
Which action by the nurse reflects critical thinking while implementing interventions with patients? 1 Implement interventions as per standing orders without question. 2 Review all potential complications associated with the interventions. 3 Carry out the interventions while reviewing for any complications. 4 Perform interventions as per the prescriptions given by the health care provider.
2
Which conclusion would the nurse infer when during a follow-up visit, the patient's wound infection is resolved and the patient followed proper instructions? 1 The care plan needs to be reassessed. 2 The patient has met the expected outcome. 3 The nursing diagnosis needs to be redefined. 4 The nurse would revise the care plan.
2
Which option correctly describes a nurse's actions? Select all that apply. One, some, or all responses may be correct. 1 Helping with instrumental activities of daily living (IADLs) is an indirect care measure. 2 Calling an ostomy and wound care specialist is an indirect care measure. 3 Cleansing the skin is a direct care measure. 4 Applying a skin barrier is a direct care measure. 5 Teaching a patient how to conserve energy while shopping is an indirect care measure.
2,3,4
Which action would the nurse perform when revising interventions for a patient? Select all that apply. One, some, or all responses may be correct. 1 Continue with all existing interventions. 2 Modify the frequency of interventions. 3 Maintain high-quality standards of care. 4 Avoid changes in the frequency of interventions. 5 Change the level of nursing care.
2,3,5
Which level of prevention describes the nurse working in collaboration with a physiotherapist to help aid the ambulatory functions of a patient who suffered a motor vehicle accident? 1 Primary 2 Secondary 3 Tertiary 4 Quaternary
3
Which step of the nursing process describes the nurse observing that the patient's redness on the heels has decreased over the past 2 days after using measures to relieve pressure points? 1 Planning 2 Diagnosis 3 Evaluation 4 Assessment
3
After evaluation of the patient, which action would the nurse take when the intervention is unsuitable? Select all that apply. One, some, or all responses may be correct. 1 Reprioritize the nursing diagnosis. 2 Discontinue the care plan. 3 Discontinue the unsuitable intervention. 4 Add new interventions. 5 Change the frequency of the intervention.
3,4,
Which expected outcome is correctly written and would be appropriate for a patient who must have surgery for a knee injury? Select all that apply. One, some, or all responses may be correct. 1 The patient discusses the surgical outcomes with the surgeon. 2 The patient demonstrates how to cleanse the surgical wound. 3 The patient describes the purpose of surgery after talking to the surgeon. 4 The patient discusses the surgical outcomes with the surgeon in 24 hours. 5 The patient describes activity restrictions to follow by discharge in 48 hours. 00:00:02 Question Answer Confidence ButtonsJust a guessPretty sureNailed it
3,4,5
Which action would allow the nurse to interpret and judge a patient's condition and whether predicted changes occurred during the evaluation phase of the nursing process? 1 Evaluating the patient's response to selected nursing interventions 2 Selecting an observable or measurable state or behavior that reflects goal achievement 3 Reviewing the patient's nursing diagnoses 4 Comparing expected outcomes with actual patient findings
4
Which action would be an example of a collaborative intervention? 1 Provide frequent mouth care. 2 Maintain intravenous (IV) infusion at 100 mL/hr. 3 Administer prochlorperazine via rectal suppository. 4 Consult with dietitian on initial foods to offer patient.
4
Which action would the nurse take during consultations? 1 Ask the consultant to summarize the problem. 2 Allow the consultant to solve the problem. 3 Influence the consultant as per the nurse's understanding. 4 Avoid bias by not sharing subjective and emotional conclusions.
4
Which modification would the nurse make to the care plan for a patient with diabetes who can no longer prepare or administer insulin because of tremors and has a caregiver who lives in the home? 1 Continue with the current care plan. 2 Continue with the patient preparing the insulin but have the caregiver administer it. 3 Teach the caregiver to prepare the insulin but have the patient administer it. 4 Teach the caregiver to prepare and inject the insulin.
4
Which option explains the primary purpose for the nurse performing evaluative measures? 1 To verify specific nursing interventions were completed 2 To validate the nurse's physical assessment 3 To make sure the nurse made the correct nursing diagnoses 4 To determine whether a patient met expected outcomes
4
Which statement is true about the standards of care? 1 It is implemented to standardize nursing language for outcomes. 2 It is used to analyze the findings obtained from evaluation. 3 It is judgments regarding whether changes have occurred in the patient's condition. 4 It is the minimum acceptable level of care to ensure that a patient receives high-quality care.
4
Which type of implementation skill is described when the nurse correctly administers an enema solution to a patient? 1 Interpersonal 2 Cognitive 3 Collaborative 4 Psychomotor
4
Prioritize the nursing diagnoses for an older-adult patient with pneumonia who is fatigued and lives alone. 1. Reduced oxygenation 2. Threat of immobility 3. Possible isolation from the community 4. Poor health management
1,2,4,3
The reduction of which incidence is a nursing-sensitive quality outcome? Select all that apply. One, some, or all responses may be correct. 1 Severe pressure injuries 2 Vascular catheter-associated infections 3 Catheter-associated infections 4 Falls 5 Hospital readmissions
1,2,3,4
Which information would the nurse include in a teaching session about the levels of prevention? Select all that apply. One, some, or all responses may be correct. 1 Primary prevention involves immunizations, health education programs, nutrition, and physical activities. 2 Secondary prevention involves early diagnosis and prompt treatment. 3 Tertiary prevention involves minimizing the effects of long-term illness or disability, including rehabilitation. 4 Secondary prevention focuses on people who are experiencing health problems or illnesses.
1,2,3,4
Place the steps of consultation in the correct sequence. 1. Direct the consultation to the right professional. 2. Identify the problems associated with the patient. 3. Incorporate the consultant's recommendations into the care plan. 4. Provide the consultant with relevant information about the problem area. 5. Be available to discuss the consultant's findings and recommendations.
2,1,4,5,3
Which characteristic is a component of well-written goals and expected outcomes? Select all that apply. One, some, or all responses may be correct. 1 Priority 2 Observable 3 Nonmeasurable 4 Timed 5 Patient-specific
2,4,5
Which nursing-sensitive patient outcome is written correctly? Select all that apply. One, some, or all responses may be correct. 1 The patient will administer a self-injection of insulin and control diet. 2 The patient will administer a self-injection by discharge. 3 The patient will appear less anxious. 4 The body temperature will remain at or below 37° C (98.6° F). 5 The heart rate will remain between 70 to 90 beats per minute.
2,4,5
Which action would the nurse take for a patient who agrees with the nurse that expected outcomes were met? 1 Modify the care plan. 2 Revise the plan of care. 3 Discontinue the care plan. 4 Continue with the plan of care.
3
Which action would the nurse perform to redefine the diagnosis after evaluation of a patient goal? 1 Rewrite the expected outcomes. 2 Discontinue the interventions. 3 Revise the patient's problem list. 4 Reassess the patient.
3
Which response would the nurse make for a patient who expresses confusion about how to manage a leg wound after discharge? 1 Provide a written document that contains the necessary instructions. 2 Tell the patient that a relative will be taught how to take care of the wound. 3 Explain and demonstrate the necessary action to the patient. 4 Inform the patient that it will be explained later during discharge.
3
Which category is a type of nursing intervention? Select all that apply. One, some, or all responses may be correct. 1 Primary 2 Secondary 3 Interdependent 4 Nurse-initiated 5 Health care provider-initiated
3,4,5
Which action would the nurse perform first when he or she enters the room and finds the patient's drainage tube disconnected, 100 mL of fluid in the intravenous (IV) line, and the patient asking to be turned? 1 Reconnect the drainage tubing. 2 Inspect the condition of the IV dressing. 3 Improve the patient's comfort and turn to the side. 4 Obtain the next IV fluid bag from the medication room.
1
Which evaluative measure would the nurse use to determine care for a patient with a myocardial infarction (heart attack)? 1 Patient rates the pain level. 2 Patient's pain level remains below a 3 out of 10. 3 Patient understands that stress is a risk factor for chest pain. 4 Patient knows the importance of a pain scale rating tool.
1
Which expected outcome for the goal "Patient will achieve a gain of 10 pounds (4.5 kg) in body weight in a month" is written correctly? 1 Patient will eat at least three-fourths of each meal by the end of 1 week. 2 Patient will verbalize relief of nausea and have no episodes of vomiting in 1 week. 3 Administer patient liquid supplements 3 times a day. 4 Provide patient high-calorie meals 3 times a day.
1
Which standard would the nurse use to evaluate a middle-aged patient's response to chemotherapy? Select all that apply. One, some, or all responses may be correct. 1 Goals 2 Outcomes 3 Attitudes 4 Skills 5 Knowledge
1,2
Which action would the nurse take when the patient who is nothing by mouth (NPO) (no food or fluids allowed) develops an adverse reaction to a new intravenous (IV) drug? Select all that apply. One, some, or all responses may be correct. 1 Record the reaction. 2 Stop further administration of the drug. 3 Notify the health care provider. 4 Start oral medication. 5 Stop the medication and administer it again after the reaction subsides.
1,2,3
Which evaluative criterion would the nurse use to measure nursing care for a patient who is short of breath? Select all that apply. One, some, or all responses may be correct. 1 Observe the patient's level of comfort. 2 Measure the respiratory rate. 3 Ask the patient if breathing is easier. 4 Administer a bronchodilator. 5 Instruct the patient to perform deep breathing.
1,2,3
Which intervention performed by the nurse would require an order from a health care provider? Select all that apply. One, some, or all responses may be correct. Correct1 Getting an x-ray of the chest to rule out pulmonary complications Correct2 Administering an antibiotic to prevent infection Correct3 Starting an intravenous (IV) infusion of normal saline 4 Instructing the patient to splint the incision when coughing 5 Teaching the patient about the side effects of the medication
1,2,3
Which action would the home-health nurse take first when during a follow-up visit, the nurse finds the goal not met? 1 Modify the care plan. 2 Perform a reassessment. 3 Continue the earlier interventions. 4 Notify the health care provider.
2
Place the following events in order of priority, starting with the most important event. 1. The patient expresses concern about pain. 2. The patient's vital signs change, showing a drop in blood pressure. 3. The charge nurse approaches the nurse and requests a report at end of shift. 4. The family comes to visit the patient.
2,1,4,3
Which feature is true about standing orders? 1 Meet instrumental activities of daily living. 2 Ensure familiarity with evidence-based guidelines for nursing care. 3 Allow a quick response to a rapidly changing clinical situation. 4 Minimize documentation issues for nurses.
3
Which interpretation would the nurse make regarding a patient with pneumonia whose cough decreased and respiratory rate decreased from 33 to 25 breaths/min after nebulization treatments? 1 Discontinue the care plan. 2 The patient can be discharged to home immediately. 3 The patient needs continued nebulization therapy. 4 Modify the care plan to include a transfer to the intensive care unit (ICU).
3
Which action would be implemented when the nurse is unsure about implementing fall prevention guidelines for an older-adult patient? 1 Refer to the clinical practice protocol. 2 Ask a colleague who knows about it. 3 Allow the next shift to begin the skill. 4 Wait until the health care provider makes rounds.
1
Which activity is the third step in the five-step nursing process? 1 Planning 2 Assessment 3 Implementation 4 Evaluation
1
Which activity would the nurse include in a nursing plan for indirect care of a patient? 1 Manage the patient's environment. 2 Administer medication on time. 3 Change the intravenous solution when empty. 4 Counsel the patient about coping strategies.
1
Which factor helps ensure quality data collection of nursing practices and enables evaluation across health care organizations? 1 Standard nursing language 2 Transcription services 3 Computerized nursing records 4 Voice dictation of nursing notes
1
Which information is characteristic of evaluation? 1 Is ongoing and comprehensive 2 Occurs at particular intervals set by the nurse 3 Requires a quick check of a patient 4 Is performed once in the nursing process
1
Which outcome would be directly related to the goal of pain relief for a confused patient? 1 Patient will express three or fewer nonverbal signs of discomfort. 2 Patient will follow a set care routine. 3 Patient will be oriented to person, time, and place. 4 Patient will exit a low bed without falling.
1
Which statement is true regarding actions after surgery? 1 Coughing is contraindicated after an eye surgery. 2 Pain and redness are normal signs of arterial occlusion. 3 The side-lying position deteriorates the lung function of patients who are obese. 4 Deep breathing improves lung function in a patient with a spinal surgery.
1
Which statement is true regarding the infant immune system? 1 The immune system matures as the child grows. 2 The immune defenses of an infant are already mature. 3 The immunity of bottle-fed infants is greater than that of breastfed infants. 4 The infant immune system is capable of producing necessary immunoglobulins.
1
Which statement or action by the nurse is characteristic of an effective hand-off report? 1 "This patient is anxious about pain after surgery; you will need to review the information about how to use a patient-controlled analgesia (PCA) pump this evening." 2 "The patient had an argument with a former boyfriend. It was like a zoo with all the yelling and name-calling." 3 The nurse talks about the problem the patient care technicians created by not assisting the patient to ambulate. 4 The nurse only talks to the oncoming nurse about the discussion of nursing care and patient goals during walking rounds.
1
Which type of nursing theory answers the question, "What is nursing?" 1 Grand theories 2 Practice theories 3 Descriptive theories 4 Prescriptive theories
1
Which statement is true about discharge planning? Select all that apply. One, some, or all responses may be correct. 1 Start discharge planning at admission. 2 Involve family members in discharge planning. 3 Begin discharge planning after 48 hours of hospitalization. 4 Initiate discharge planning only after the health care provider's prescription. 5 Plan the discharge once the patient is ready and willing.
1,2
Which principle of care coordination would the nurse use to achieve a desired outcome for patients? Select all that apply. One, some, or all responses may be correct. 1 Organizational skills 2 Good time management 3 Appropriate use of resources 4 Providing the single best intervention 5 Avoiding prioritization of patient needs
1,2,3
Which action would be classified as a health care provider-initiated intervention? Select all that apply. One, some, or all responses may be correct. 1 Giving medication 2 Starting an intravenous (IV) solution 3 Explaining the benefits of exercise 4 Providing a back rub 5 Preparing a patient for an x-ray
1,2,5
Which action would the nurse take for a patient who is not meeting the expected outcomes? Select all that apply. One, some, or all responses may be correct. 1 Try different interventions. 2 Change the frequency of interventions. 3 Repeat the existing therapies. 4 Continue the same plan of care. 5 Change the method of performing existing interventions.
1,2,5
Which category is a level of the Nursing Interventions Classification (NIC) model? Select all that apply. One, some, or all responses may be correct. 1 Domains 2 Classes 3 Primary 4 Lower 5 Interventions
1,2,5
Which nurse-initiated intervention would the nurse perform to help an anxious male patient express acceptance of his health status? Select all that apply. One, some, or all responses may be correct. 1 Listen attentively to the patient. 2 Refer the patient to a psychologist. 3 Use a calm and reassuring approach. 4 Administer medication to reduce the anxiety. 5 Provide factual information regarding recovery.
1,3,5
Which activity is classified as an instrumental activity of daily living (IADL)? Select all that apply. One, some, or all responses may be correct. 1 Shopping 2 Getting magnetic resonance imaging (MRI) 3 Ambulating 4 House cleaning 5 Preparing meals
1,4,5
Which process is involved in the planning phase of the nursing process? Select all that apply. One, some, or all responses may be correct. 1 Setting priorities 2 Collecting the history of the patient 3 Implementing the care plan 4 Prescribing nursing interventions 5 Identifying patient-centered goals
1,4,5
Which statement is true regarding the roles of a scrub nurse during surgery? Select all that apply. One, some, or all responses may be correct. 1 The scrub nurse is responsible for the patient's safety. 2 The scrub nurse manages the antimicrobial skin preparations. 3 The scrub nurse is solely responsible for ensuring the cost-efficient use of supplies. 4 The scrub nurse is involved in managing the positioning of the patients during surgery. 5 The scrub nurse should have a thorough knowledge of each step of the surgical procedure.
1,5
Which goal is appropriate for the patient who is at high risk of skin injuries? 1 Patient will be turned every 2 hours within 24 hours. 2 Patient's skin will remain intact through discharge. 3 Patient's skin condition will improve by discharge. 4 Patient will begin a weight-loss program.
2
Which option would be an appropriate goal statement for a patient at risk of an infection? 1 Patient demonstrates correct hand hygiene by the end of the shift. 2 Patient's wound will remain free of infection by discharge. 3 Patient will receive prescribed antibiotics on time over the next 3 days. 4 Patient's incision will be covered with a sterile dressing for 2 days.
2
Which patient may require a pulsatile high-pressure lavage for wound irrigation? 1 A patient who has graft sites 2 The person who has a necrotic wound 3 One who has exposed blood vessels 4 The individual who has exposed muscle, tendons, or bone
2
Which type of nursing intervention is an interdependent intervention? 1 Secondary 2 Collaborative 3 Nurse-initiated 4 Health care provider-initiated
2
Which type of problem is a high priority? 1 One related to nonurgent needs of the patients 2 One related to life-threatening needs of the patients 3 One focused on the patient's long-term health care needs
2
When does implementation begin? 1 During the assessment phase 2 Immediately in some critical situations 3 After the care plan has been developed 4 After mutual goal setting between the nurse and patient
3
Which patient care goal is a long-term goal for a newly diagnosed medically unstable patient with diabetes? 1 Patient will explain the relationship of insulin to blood glucose control. 2 Patient will describe three actions to take for low blood sugar. 3 Patient will achieve glucose control. 4 Patient will list the steps for preparing insulin in a syringe.
3
Which patient finding would be the most suitable nursing-sensitive outcome for a patient who is immobile, does not ambulate, and has a nursing diagnosis of backache? 1 Will remain free of skin breakdown in the hospital 2 Will be satisfied with the care delivered by the nurse 3 Will have reduced back pain 4 Will be able to explain the physiological effects of massage
3
Which patient outcome about a wound would allow the nurse to measure a patient's response to care more precisely? 1 Will appear normal within 3 days. 2 Will have less drainage within 72 hours. 3 Will reduce in size to less than 4 cm (1.5 inches) by day 4. 4 Will heal without redness or drainage by day 4.
3
Which patient indicator would be used to measure a reduction in pain level for a patient? Select all that apply. One, some, or all responses may be correct. 1 States that he or she is in a good mood 2 Recognizes side effects of analgesics 3 Reports pain severity 4 Identifies the frequency of pain 5 Uses a pain scale to rate pain
3,4,5
Which source is a vehicle for infection transmission? Select all that apply. One, some, or all responses may be correct. 1 Mosquitoes 2 Flies 3 Intravenous (IV) fluid 4 Food 5 Water
3,4,5
For which patient would a short-term goal be most appropriate? 1 A patient who has undergone cancer therapy 2 A patient who requires postamputation rehabilitation 3 A patient who is diagnosed with a chronic condition 4 A patient who experiences acute pain related to incisional trauma
4
Which evaluative measure for ability to tolerate ambulation would the nurse use for a patient with limited mobility in lower extremities who ambulates with a walker? 1 Score on a perceived-stress scale 2 Presence of altered balance 3 Limited mobility in lower extremities 4 Observation of dyspnea while walking
4
Which feature is typical of "missed care"? 1 Incorrect nursing diagnoses 2 Misworded outcomes 3 Wrong care goals 4 Not completed interventions
4
Which resource would the nurse use to develop a plan of care? Select all that apply. One, some, or all responses may be correct. 1 Scientific literature 2 Standard protocols 3 Procedure manuals 4 Consent form 5 Nursing Interventions Classification
1,2,3,5
Which feature is typical of an intermediate priority nursing diagnosis? 1 Life threatening 2 Long term 3 Nonemergent 4 Low priority
3
The nurse provides postoperative care for a patient and notes a slightly elevated temperature. Which intervention demonstrates the nurse's understanding of evidence-based practice? 1 Implementing a care bundle 2 Posting isolation signs 3 Limiting visitors to immediate family members only 4 Administering a broad-spectrum antibiotic
1
Which expected outcome would be appropriate for a patient who is vomiting? 1 Patient stops vomiting in 2 hours. 2 The antiemetic (drug to stop vomiting) will be administered every 6 hours. 3 The antiemetic will not produce side effects in the patient. 4 Patient will not vomit again.
1
Which initial action would the nurse take when the goals are not being met as a result of the patient's response to illness? 1 Reassess the patient. 2 Discontinue interventions that were included in the care plan. 3 Prepare a new care plan for a different diagnosis. 4 Continue with the current care plan, allowing the patient to recover at own pace.
1
Which word does the letter "T" represent in the SMART acronym as it relates to setting goals for the patient? 1 Timed 2 Treatment 3 Therapeutic 4 Thermoregulation
1
Which action would the nurse perform for unmet and partially met goals? Select all that apply. One, some, or all responses may be correct. 1 Redefine priorities. 2 Continue some or all interventions. 3 Discontinue the care plan. 4 Maintain nursing care plan as written. 5 Compare the patient's response with that of another patient.
1,2
Which characteristic of nursing goals and expected outcomes would the nurse keep in mind when developing a care plan? Select all that apply. One, some, or all responses may be correct. 1 Realistic 2 Attainable 3 Specific to patient 4 Health care provider-centered 5 No time limit
1,2,3
Which purpose describes the importance of a nurse documenting patient outcomes? Select all that apply. One, some, or all responses may be correct. 1 To inform other health care team members 2 To share information about the patient's progress 3 To make ongoing clinical decisions 4 To acknowledge revision of the care plan 5 To replicate the care in another patient
1,2,3,4
Which action would the nurse perform when revising a nursing care plan? Select all that apply. One, some, or all responses may be correct. 1 Revise the nursing diagnoses. 2 Add new data with appropriate dates. 3 Maintain irrelevant nursing diagnoses. 4 Choose the method of evaluation for monitoring patient outcomes.
1,2,4
Which information accurately describes a physical care technique? Select all that apply. One, some, or all responses may be correct. 1 Staying organized while caring for the patient 2 Protecting oneself and the patient from injury 3 Ensuring that the patient has medical reports 4 Using proper hygienic infection control practices 5 Preparing a discharge summary and rehabilitation plan
1,2,4
Which intervention would the nurse add to the nursing care plan to reduce anxiety in a patient? Select all that apply. One, some, or all responses may be correct. 1 Use a reassuring approach in discussions. 2 Teach the patient relaxation exercises using deep breathing. 3 Prevent close family members from entering the discussions. 4 Work with the health care provider to provide factual medical information. 5 Discourage the patient from sharing any feelings or expressing apprehension.
1,2,4
Which intervention would the nurse perform when communicating the patient's progress with the patient and the family members? Select all that apply. One, some, or all responses may be correct. 1 Share the patient's results with the patient. 2 Inform the patient's family about the patient's progress, with the patient's permission. 3 Avoid discussing clinical results with the patient. 4 Follow agency guidelines about sharing medical information. 5 Provide appropriate nursing care without any documentation.
1,2,4
As the nurse makes decisions about how to implement skin care for a patient, which action would the nurse implement? Select all that apply. One, some, or all responses may be correct. 1 Review the set of all possible nursing interventions for the patient's problem. 2 Examine all possible consequences associated with each possible nursing action. 3 Act before thinking. 4 Determine the probability of all possible consequences. 5 Consider supplies/resources available for skin care.
1,2,4,5
Which guideline would the nurse use to counsel a patient and family members about coping? Select all that apply. One, some, or all responses may be correct. 1 Assist them to accept a change in health status. 2 Provide emotional and psychological support. 3 Understand that a patient and family who need nursing counseling are psychologically disabled. 4 Assist the patient and family in managing stress. 5 Understand that a patient requiring nursing counseling has normal adjustment difficulties and may be upset or frustrated.
1,2,4,5
Which component would be included in a comprehensive nursing care plan? Select all that apply. One, some, or all responses may be correct. 1 Nursing diagnoses 2 Expected outcomes 3 Generalized nursing interventions 4 Orders for diagnostic tests 5 Evaluation findings
1,2,5
Which expected outcome is correctly written? Select all that apply. One, some, or all responses may be correct. 1 The patient describes two signs of urinary obstruction within 24 hours. 2 The patient understands the importance of a low-fat diet before breakfast. 3 The patient identifies three signs and symptoms of wound infection before surgery. 4 The patient is aware of feelings about a lifestyle change. 5 The patient understands and explains the importance of exercise.
1,3
Arrange the steps in proper sequence for measures the nurse would take when a patient does not meet the goal stated in the care plan. 1. Reassess the patient. 2. Establish new goals and expected outcomes. 3. Determine the accuracy of the nursing diagnosis. 4. Select a new intervention.
1,3,2,4
Which information correctly describes the evaluation process? Select all that apply. One, some, or all responses may be correct. 1 Is a complex process 2 Usually reveals obvious changes in patients 3 Involves making clinical decisions 4 Requires the use of assessment skills 5 Is performed once for each intervention
1,3,4
Which information would the nurse share with the patient when starting an intravenous (IV) medication? Select all that apply. One, some, or all responses may be correct. 1 Name of the medication that is given through the IV line 2 Name of the nurse who will come to discontinue the IV fluid 3 Duration of time that the IV bag will last 4 Physical sensations that the medication may cause 5 Expected sensation if the IV site becomes inflamed
1,3,4,5
Which activity would the nurse perform when preparing for the implementation phase of the nursing process? Select all that apply. One, some, or all responses may be correct. 1 Reassessing the patient 2 Focusing on preventive measures 3 Organizing resources and care delivery 4 Counseling and motivating the patient 5 Reviewing and revising the existing nursing care plan
1,3,5
Which capability of the nurse would help in choosing suitable nursing interventions? Select all that apply. One, some, or all responses may be correct. 1 Functioning within a particular setting of the health care unit 2 Directing the consultation to the right professional 3 Knowing the scientific rationale for the intervention 4 Aligning a consultation to identify the problems of the patient 5 Possessing the necessary psychomotor and interpersonal skills
1,3,5
Which action is an example of an independent nursing intervention? Select all that apply. One, some, or all responses may be correct. 1 Provide health education 2 Start intravenous (IV) fluids 3 Administer a hypertension agent 4 Assist with daily activities 5 Reposition a patient
1,4,5
Which action would the nurse take before implementing health care provider-initiated interventions? Select all that apply. One, some, or all responses may be correct. 1 Clarify questionable prescriptions. 2 Implement procedures automatically. 3 Administer medications without question. 4 Decide if the intervention is appropriate for the patient. 5 Determine if collaboration with other care disciplines is required.
1,4,5
Which major component would be included in a nursing care plan? Select all that apply. One, some, or all responses may be correct. 1 Nursing diagnoses 2 Illness management 3 Diagnosis and treatment 4 Specific nursing interventions 5 Goals and expected outcomes
1,4,5
A home-health nurse provides palliative care for a patient in a community setting. The patient states, "The pain pills that I have been taking are not as effective as they used to be." After reviewing the patient's standing orders, which action does the nurse take? 1 Arranges for a hospital transfer 2 Increases the medication dosage 3 Schedules an office appointment 4 Contacts the health care provider for a new order
2
When assessing a patient with a terminal illness, the nurse notes the patient's monosyllabic replies and limited eye contact. Which direct care intervention does the nurse perform? 1 Ensuring privacy 2 Providing counseling 3 Requesting an analgesic 4 Consulting a palliative care team
2
Which action would the nurse take for a patient who has an outcome of walking the entire hallway by 10/17 and the patient walks halfway down the hallway on 10/16? 1 Discontinue the care plan. 2 Continue with the care plan. 3 Notify the health care team immediately. 4 Modify the care plan with the health care team's input.
2
Which action would the nurse take for a patient who reports frequent periods of nausea that interfere with eating after chemotherapy treatments? 1 Reassess the patient. 2 Prepare a suitable diet plan for the patient. 3 Discontinue interventions for nausea. 4 Advise the patient to stop taking pain-relieving medications.
2
Which action would the nurse take next when the expected outcome was stating three side effects of chemotherapy, but after a teaching session the patient related over five side effects of the medication? 1 Ask the patient to motivate other patients about learning chemotherapy side effects. 2 Discontinue the health education related to side effects of chemotherapy. 3 Modify the expected outcome to include five side effects of chemotherapy. 4 Continue to teach the patient about chemotherapy side effects.
2
Which activity would the nurse perform when implementing indirect care measures? 1 Positioning the patient correctly 2 Collecting and transporting labeled specimens 3 Administering vaccines 4 Teaching the patient about home care
2
Which direct care measure would the nurse be using when consulting with the dietitian and health care provider to determine the initial rate that will be prescribed for the tube feeding to lessen the chance of diarrhea? 1 Preventive 2 Controlling for an adverse reaction 3 Consulting 4 Counseling for nutritional needs
2
Which initial action would the nurse take when a patient's symptoms have changed from those that were recorded earlier? 1 Consider them as minor symptom changes, irrelevant to nursing interventions. 2 Revise patient data by noting the change. 3 Continue the current treatments until there is a significant change in symptoms. 4 Add new interventions for the new symptoms.
2
Which intervention indicates the nurse is delivering ethical care? 1 Administering morphine for pain relief 2 Understanding the patient's expectations 3 Assessing the patient for any signs of organ failure 4 Referring the patient for appropriate diagnostic interventions
2
Which statement describes the unique difference between a hospital's nursing care plan and the home care plan? 1 The goals of care will always be more long term. 2 The patient and family need to be able to provide most of the health care. 3 The patient's goals need to be mutually set with family members who will care for the patient. 4 The expected outcomes need to address what can be influenced by interventions.
2
Which outcome would be appropriate for the depressed patient who lost weight but has a goal to return to baseline weight in 3 months? Select all that apply. One, some, or all responses may be correct. 1 Patient discusses the source of depression by next clinic visit. 2 Patient achieves an intake of 2400 calories daily in 2 weeks. 3 Patient reports improvement in appetite in 1 week. 4 Patient identifies food protein sources. 5 Patient does not display signs of depression in 2 weeks.
2,3
Which information about standing orders is accurate? Select all that apply. One, some, or all responses may be correct. 1 They provide instructions from the unit manager about care in emergencies. 2 They are preprinted documents that contain orders for various clinical problems. 3 They provide legal protection to the nurse when caring for the patient. 4 They are signed by the licensed prescribing health care provider in charge at the time of implementation. 5 They are signed by the patient or the patient's relative before the treatment is started.
2,3,4
Arrange the steps to be taken by the nurse in the appropriate order to evaluate the effectiveness of the care plan in meeting the expected outcome for the patient. 1. If there is no or partial agreement between the desired outcome and the patient's response, determine the reason. 2. Review the outcome criteria in the care plan to identify the exact desired patient behavior or response. 3. Evaluate the patient's actual behavior or response. 4. Compare the established outcome criteria with the actual behavior or response. 5. Judge the degree of agreement between the outcome criteria and the actual behavior or response.
2,3,4,5,1
Place the steps in proper order for modifying the plan of care when a patient develops nausea after chemotherapy. 1. Select approaches for controlling environmental factors that worsen nausea. 2. Enter data in the assessment column showing new information about the patient's nausea. 3. Decide to use the patient's self-report of appetite and fluid intake as evaluation measures. 4. Add the current patient condition of nausea as a nursing diagnosis.
2,4,1,3
The nurse would evaluate which goal based upon the following reassessment: upon removal of the intravenous (IV) line from the right arm, the site was clean and dry with no signs of redness or tenderness? 1 Patient expresses acceptance of health status by day of discharge. 2 Patient's surgical wound will be free of drainage. 3 Patient's IV site will remain free of infection. 4 Patient understands when to call the health care provider to report complications.
3
Which action does the nurse take right before implementing interventions? 1 Review the care plan. 2 Decide if the outcomes remain appropriate. 3 Reassess the patient. 4 Compare assessment findings to validate existing nursing diagnoses.
3
Which action indicates that the nurse is using physical care techniques? 1 Meeting the patient's expressed needs 2 Performing indirect care measure 3 Using safe patient-handling procedures 4 Providing a hand-off report
3
Which intervention performed by the nurse is an interdependent intervention? Select all that apply. One, some, or all responses may be correct. 1 Preparing the patient for diagnostic tests 2 Administering medications to the patient 3 Consulting with a physiotherapist for postoperative exercises 4 Collaborating with the home health department to ensure the patient will have home health visits 5 Conferring with the unit discharge coordinator to help the patient return home
3,4,5
Setting a time frame for outcomes of care determines which purpose? 1 The priority level 2 Time it takes to complete an intervention 3 How long the nurse is scheduled to care for a patient 4 When the patient is expected to respond in the desired manner
4
The family of a patient states, "We found out that our loved one has end-stage hepatitis. We don't know what that means." How does the nurse respond? 1 Offering to contact their pastor for spiritual support 2 Giving the family written information about the disease 3 Contacting the health care provider to provide more information 4 Asking about the family's understanding of the patient's illness
4
The nurse provides education for a group of nursing students about cultural preferences related to activities of daily living (ADLs). The nurse reminds the students of the need to respect patients' wishes and determine patient preferences. Which example does the nurse include? 1 Reinforcing the policy of no family presence during bathing 2 Transferring a patient's care to a staff member who is the same gender as the patient 3 Creating patient resources in several different languages 4 Explaining that all staff members are qualified to provide care to patients of all cultural backgrounds
4
Which action would the nurse take for a patient who continues to have congested lungs after coughing and deep-breathing exercises? 1 Double the dose of antibiotics. 2 Hand over the patient to another nurse. 3 Repeat the patient's chest x-ray. 4 Increase frequency of coughing and deep-breathing exercises.
4
Which outcome is correctly written and would the nurse add to the plan of care about the patient's apical pulse? 1 The patient will have a normal apical pulse. 2 The patient's apical pulse values will be stable. 3 The patient will have acceptable apical pulse values. 4 The patient's apical pulse will be at least 70 beats per minute.
4
Which step of the nursing process is the nurse performing when he or she asks the patient to rate pain 45 minutes after administering an analgesic? 1 Assessment 2 Diagnosis 3 Implementation 4 Evaluation
4
In which order would the nurse modify the patient's plan of care? 1. Add a new nursing diagnosis. 2. Determine evaluation criteria. 3. Select interventions according to the new diagnosis. 4. Revise the assessment data. 5. Select new goals and outcomes.
4,1,5,3,2
Which sequence would the nurse follow for making decisions about implementing interventions? 1. Judge the value of the consequences to the patient. 2. Determine the probability of possible consequences. 3. Review all possible consequences associated with each intervention. 4. Review all possible interventions for the patient.
4,3,2,1
Which activity would be a component of the evaluation phase of the nursing process? Select all that apply. One, some, or all responses may be correct. 1 Determining goals 2 Writing expected outcomes 3 Assessing the patient for nursing needs 4 Measuring a patient's clinical progress 5 Judging if the desired change has occurred
4,5
