Unit 5 NCLEX styled questions

The nurse intends to identify nursing diagnoses for a patient. She can best do this by using a data-collection form organized according to (select all that apply): 1) A body systems model 2) A head-to-toe framework 3) Maslow's Hierarchy of Needs 4) Gordon's functional health patterns

1) A body systems model 4) Gordon's functional health patterns

Using a "patient preferences" framework, which of the following nursing diagnoses would probably have the highest priority for a patient who fractured his leg yesterday and now is wearing a cast? 1) Acute Pain 2) Disturbed Body Image 3) Ineffective Peripheral Perfusion 4) Impaired Physical Mobility

1) Acute Pain

In which of the following ways do collaborative problems differ from nursing diagnoses? Choose all correct answers. 1) All patients who have a certain disease are at risk for developing the same problem. 2) Collaborative problems are always potential problems. 3) The complications can be prevented with nursing interventions alone. 4) The problem statement does not need to be approved by a medical provider.

1) All patients who have a certain disease are at risk for developing the same problem. 2) Collaborative problems are always potential problems.

Critical thinking and the nursing process have which of the following in common? Both: 1) Are important to use in nursing practice 2) Use an ordered series of steps 3) Are patient-specific processes 4) Were developed specifically for nursing

1) Are important to use in nursing practice

As the nurse is inserting a urinary catheter she observes blood in the urine returned in the tubing. Which two nursing process phases does this demonstrate? 1. Assessment 2. Diagnosis 3. Implementation 4. Planning: Interventions

1) Assessment 2) Implementation

A young adult client is in the hospital after a motor vehicle accident. He is in a body cast and essentially immobile, but he is otherwise stable. Which activity or activities can the nurse delegate to a nursing assistant? Choose all that apply. 1) Bathing the client 2) Taking the client's vital signs 3) Choosing nursing interventions 4) Prioritizing interventions

1) Bathing the client 2) Taking the client's vital signs

How can the nurse help promote client participation and adherence to a treatment regimen? 1) Be certain the care plan considers cultural and spiritual needs. 2) Explain that the treatments were prescribed by a physician. 3) Acknowledge that treatment is difficult, but that other patients do manage it. 4) Provide detailed written instructions about the client's disease process.

1) Be certain the care plan considers cultural and spiritual needs

A facility is using ___________ nursing care when scientifically sound research data are used to make nursing care decisions. 1) Evidence-based 2) Standardized 3) Individualized 4) Theoretical

1) Evidence-based

What is the most basic reason that self-knowledge is important for nurses? Because it helps the nurse to: 1) Identify personal biases that may affect his thinking and actions. 2) Identify the most effective interventions for a patient. 3) Communicate more efficiently with colleagues, patients, and families .4) Learn and remember new procedures and techniques.

1) Identify personal biases that may affect his thinking and actions

How are critical-thinking skills and critical-thinking attitudes similar? Both are: 1) Influences on the nurse's problem-solving and decision making 2) Like feelings rather than cognitive activities 3) Cognitive activities rather than feelings 4) Applicable in all aspects of a person's life

1) Influences on the nurse's problem-solving and decision making

Which of the following functions both as a care plan and a documentation form? Choose all correct answers. 1) Integrated plan of care (IPOC) 2) Critical pathway 3) Individualized patient care plan 4) Standardized (model) care plan

1) Integrated plan of care (IPOC) 2) Critical pathway

In diagnostic reasoning, which of the following does the nurse usually do first? 1) Interpret patient data. 2) Draw conclusions about health status. 3) Verify problems with the patient. 4) Prioritize health problems.

1) Interpret patient data.

Using the mnemonic H E L P (from Volume 1 of your textbook), which of the following correctly illustrates the letter E—Equipment and Environment? 1) Is the oxygen running? 2) Who else is in the room with the patient? 3) Does the patient have any questions? 4) Take a thorough look at the patient.

1) Is the oxygen running?

When writing an individualized patient care plan, which of the following should the nurse do first? 1) Transcribe medical orders to the appropriate documents. 2) Individualize standardized plans as needed. 3) Write basic care needs on the Kardex or in special sections of the care plan. 4) Make a working problem list with problems in priority order.

1) Make a working problem list with problems in priority order.

An 80-year-old resident in a long-term-care facility comes to the emergency department with dehydration. The nurse writes a diagnosis of Deficient Fluid Volume related to excessive fluid loss. An individualized nursing goal identified for this client is "The client will maintain urine output of at least 30 mL/hour." Which nursing interventions would directly help achieve or evaluate the stated goal? Choose all that are correct. 1) Measure and record urine output every hour; report an output of less than 30 mL/hour.\ 2) Monitor skin turgor and moistness of mucous membranes every shift. 3) Administer intravenous (IV) fluids as prescribed. 4) Keep oral fluids within the patient's reach and encourage the patient to drink.

1) Measure and record urine output every hour; report an output of less than 30 mL/hour. 3) Administer intravenous (IV) fluids as prescribed. 4) Keep oral fluids within the patient's reach and encourage the patient to drink.

Which of the following is true of the Nursing Interventions Classification (NIC)? Select all that apply. 1) NIC interventions can be used in all specialty areas of nursing practice. 2) The American Nurses Association (ANA) has approved it for use. 3) It is used mainly by home health nurses. 4) It is designed primarily for use in hospitals.

1) NIC interventions can be used in all specialty areas of nursing practice. 2) The American Nurses Association (ANA) has approved it for use.

A patient with high blood pressure receives a daily oral medication to control his blood pressure. However, he has been vomiting for the past 24 hours. The nurse knows that oral medications are absorbed in the gastrointestinal tract, and that without the drug, the patient's blood pressure may become dangerously high. So the nurse notifies the primary provider to see whether the drug can be given by another route (e.g., intravenously or rectally). The nurse's thinking and actions illustrate which of the following? 1) Nursing is an applied discipline. 2) Nursing uses knowledge from other fields. 3) Nursing is fast paced. 4) Nursing requires ethical knowledge.

1) Nursing is an applied discipline 2) Nursing uses knowledge from other fields

Which standardized intervention vocabulary was designed specifically for community health nurses? 1) Omaha System 2) Clinical Care Classification 3) Nursing Interventions Classification 4) International Classification for Nursing Practice

1) Omaha System

A patient underwent surgery 3 days ago for colorectal cancer. The patient's critical pathway states that he should participate in a teaching session with the wound ostomy nurse to learn colostomy self-care. The patient appears depressed and refuses to look at the colostomy or even make eye contact. How should the nurse proceed? 1) Postpone the teaching session until the patient is more receptive. 2) Follow the critical pathway for patient teaching. 3) Administer a prescribed antidepressant and notify the healthcare provider. 4) Explain to the patient the importance of skin care around the ostomy site

1) Postpone the teaching session until the patient is more receptive.

Which of the following nursing diagnoses is written in correct format? Assume the facts are correct in all of them. 1) Readiness for Enhanced Nutrition 2) Pain related to stating, "On a scale of 1 to 5, it's a 5." 3) Impaired Mobility related to pain A.M.B. hip fracture 4) Risk for Infection related to compromised immunity A.M.B. fever

1) Readiness for Enhanced Nutrition

The nurse is recording assessment data. She writes, "The patient seems worried about his surgery. Other than that, he had a good night." Which errors did the nurse make? Select all that apply. 1) Used a vague generality 2) Did not use the patient's exact words 3) Used a "waffle" word (e.g., seems) 4) Recorded an inference rather than a cue

1) Used a vague generality3) Used a "waffle" word (e.g., seems)

Which is true of unit standards of care? Unit standards of care are (select all that apply): 1) Written for a specific medical diagnosis or treatments 2) Organized according to nursing diagnoses 3) A description of minimal level of care a patient is expected to receive 4) Not part of the care plan that is included in the patient's chart

1) Written for a specific medical diagnosis or treatment 3) A description of minimal level of care a patient is expected to receive

The nurse completes the plan of care for a patient with a medical diagnosis of Gall Bladder Disease. Which consideration will the nurse use when selecting nursing interventions to best help the patient achieve desired outcomes? Select all that apply. 1. Age of the patient 2. Patient abilities and preferences 3. Education levels of the nursing staff 4. Medical orders 5. General health status

1. Age of the patient 2. Patient abilities and preferences 3. Education levels of the nursing staff 4. Medical orders 5. General health status

The nurse works in an extended care facility. The residents are primarily older adults with health factors that put them in danger of falling. Which option best describes the type of nursing diagnosis the nurse is likely to use? 1. A risk diagnosis, because it is based on data about the patients 2. A possible diagnosis, because a suspected diagnosis is present 3. A wellness diagnosis, because of the health status and patient environment 4. A syndrome diagnosis, because of the age and physical condition of the patients

1. A risk diagnosis, because it is based on data about the patients

The nurse is providing care for various patients with the assistance of a licensed practical nurse/licensed vocational nurse (LPN/LVN). Which tasks does the nurse delegate to the LPN/LVN? Select all that apply. 1. Administer oral pain medications. 2. Insert an indwelling urinary catheter. 3. Perform an admission assessment on a patient. 4. Establish a new teaching plan for a patient with diabetes. 5. Call a patient's physician to validate a new prescription.

1. Administer oral pain medications. 2. Insert an indwelling urinary catheter.

The quality assurance team is reviewing nursing documentation for quality and correctness. Which is the best example of a well-written nursing order? 1. Administer pain medication 30 minutes prior to physical therapy exercises. 2. Teach patient how to self-administer insulin injections prior to discharge. 3. The nurse will assess vital signs and report changes, as needed. 4. Consider patient and family cultural preferences in diet order.

1. Administer pain medication 30 minutes prior to physical therapy exercises.

The nurse is conducting an interview with a patient in a clinic setting. Which questions will be effective for obtaining information from the patient? Select all that apply. 1. "How did this happen to you?" 2. "What was your first symptom?" 3. "Why didn't you seek healthcare earlier?" 4. "When did you start having symptoms?" 5. "Why did you decide to seek help now?"

1. "How did this happen to you?" 2. "What was your first symptom?" 4. "When did you start having symptoms?"

Which statement made by the nurse is an example of stereotyping? 1. "Patients with a Japanese background are always quiet and emotionless." 2. "Patients with type 1 diabetes do not make insulin and will need to take insulin regularly." 3. "The patient needs to understand the benefits of getting out of bed and not cry each time." 4. "I am confused why the client at 2 years of age is having a tantrum; my child never has one."

1. "Patients with a Japanese background are always quiet and emotionless."

The nurse is interviewing a patient with a recent onset of migraine headaches. The patient is very anxious and cannot seem to focus on what the nurse is saying. Which comment by the nurse is best when beginning to gather data about the headaches? 1. "When did your migraines begin?" 2. "Tell me about your family history of migraines." 3. "What are the things that trigger your headaches?" 4. "Describe for me what your headaches feel like."

1. "When did your migraines begin?"

The nurse is conducting a patient interview in an acute care setting. Which statements made by the nurse during the interview are appropriate? Select all that apply. c 3. "I can see you are in pain. I will bring pain medication and complete the interview later." 4. "If it is a good time for you, we can complete your interview now." 5. "Have you noticed any changes in your ability to sleep or patterns of sleeping?"

1. "You shouldn't be smoking cigarettes; you have already had one heart attack." 2. "Why don't you take your blood pressure medications? Your blood pressure remains high." 5. "Have you noticed any changes in your ability to sleep or patterns of sleeping?"

An adult patient returns to the medical-surgical unit after undergoing abdominal surgery for colon cancer. Which is an appropriate, correctly written nursing order for this patient? 1. (Date) Encourage use of the incentive spirometer every hour while the client is awake. (Nurse's Signature) 2. (Date) Uses incentive spirometer 10 times every hour while awake to 1,000 mL. (Nurse's Signature) 3. (Date) Incentive spirometer hourly while awake. 4. Offer incentive spirometer to the client.

1. (Date) Encourage use of the incentive spirometer every hour while the client is awake. (Nurse's Signature)

The nurse and the nursing assistive personnel (NAP) are providing care for various clients on a medical-surgical unit. For which clients can the nurse delegate to the NAP the task of bathing? Select all that apply. 1. A 75-year-old client who is newly admitted with a diagnosis of dehydration 2. A 65-year-old client diagnosed with a stroke, whose BP is currently 189/90 mm Hg 3. A 92-year-old client with stable vital signs admitted with a urinary tract infection 4. A 56-year-old client with chronic renal failure, whose vital signs remain stable 5. An 80-year-old client who is 2 days postoperative after repair of a hernia

1. A 75-year-old client who is newly admitted with a diagnosis of dehydration 3. A 92-year-old client with stable vital signs admitted with a urinary tract infection 4. A 56-year-old client with chronic renal failure, whose vital signs remain stable 5. An 80-year-old client who is 2 days postoperative after repair of a hernia

The nurse is selecting nursing interventions for a patient with diabetes mellitus. Which available resources does the nurse use to assist in the selection of interventions? Select all that apply. 1. A computer-generated list of standardized interventions 2. Self-generated interventions based on knowledge and experience 3. Traditional interventions that seem to have worked in the past 4. Only those interventions that agree with patient preferences 5. Suggested interventions from the facility policy and procedures

1. A computer-generated list of standardized interventions 2. Self-generated interventions based on knowledge and experience

The nurse is obtaining information from a newly admitted patient during the initial nursing assessment. Which difference does the nurse recognize between the nursing history and the medical history? 1. A nursing history focuses on the patient's responses and needs to the health problem. 2. The same information is gathered in both; the difference is in who obtains the information. 3. A nursing history is gathered by using a specific format. 4. A medical history collects more in-depth information.

1. A nursing history focuses on the patient's responses and needs to the health problem.

Which nursing intervention is considered an independent intervention? 1) Administering 1 liter of dextrose 5% in normal saline solution at 100 mL/hour 2) Encouraging the postoperative client to perform coughing and deep-breathing exercises 3) Explaining his diet to the client; then communicating the teaching with the dietitian 4) Administering morphine sulfate 2 mg IV to the client with postoperative pain

2) Encouraging the postoperative client to perform coughing and deep-breathing exercises

A physician prescribes an indwelling urinary catheter for a client who is mildly confused and combative. In which manner does the nurse proceed? 1. Ask a colleague for help because the nurse cannot safely perform the procedure alone. 2. Gather and prepare the equipment before informing the client about the procedure. 3. Obtain a prescription to restrain the client before inserting the urinary catheter. 4. Inform the physician the nurse cannot perform the procedure because the client is confused.

1. Ask a colleague for help because the nurse cannot safely perform the procedure alone.

The nurse is gathering data on a patient who is admitted. During the admission process, the nurse notices constant throat clearing behaviors by the patient. Which intervention does the nurse implement if viewing the patient's behavior from a physiological viewpoint? 1. Ask the patient to explain the noted behavior. 2. Seek a prescription for a bedside humidifier. 3. Administer prescribed pain medication. 4. Inquire about the patient's anxiety level.

1. Ask the patient to explain the noted behavior

The nurse is providing care for a patient after abdominal surgery and has just completed a prescribed dressing change. Which activities does the nurse perform soon after this task completed? Select all that apply. 1. Assess the patient's response to the procedure. 2. Provide patient teaching about the procedure. 3. Document the procedure in the nursing progress notes. 4. Ask if the patient is interested in helping with the next dressing change. 5. Provide a handout about the dressing changes after discharge.

1. Assess the patient's response to the procedure. 3. Document the procedure in the nursing progress notes

Nurses use the professional standards of nursing assessment when formulating patient care. Which statements regarding professional standards of nursing assessment are true? Select all that apply. 1. Assessment is a professional nursing responsibility. 2. Assessment helps the nurse identify problems and priorities. 3. Assessment helps the nurse formulate the medical diagnosis. 4. Assessment of pain is focused on patients indicating the presence of pain. 5. Assessments can be delegated according to state practice acts and agency policies.

1. Assessment is a professional nursing responsibility. 2. Assessment helps the nurse identify problems and priorities. 5. Assessments can be delegated according to state practice acts and agency policies.

The nurse has relocated to a different state and has accepted a position as a staff nurse on an acute care nursing unit. The patient care team consists of both registered nurses (RNs) and licensed practical nurses/licensed vocational nurses (LPNs/LVNs). Which action by the nurse constitutes a possible theoretical error? 1. Assigning an LPN/LVN to formulate a nursing diagnosis 2. Instructing an LPN/LVN to perform a prescribed dressing change 3. Delegating an RN to perform the admitting history on a new client 4. Expecting RNs and LPNs/LVNs to administer medications to assigned clients

1. Assigning an LPN/LVN to formulate a nursing diagnosis

The nurse recognizes which examples of objective data? Select all that apply. 1. Blood pressure of 120/80 mm Hg 2. Pain rated as 6 on a pain scale of 0 to 10 3. Moderate amount of yellow drainage from right ear 4. Spouse stating the client is not sleeping well at night 5. Patient reporting the presence of stomach pain

1. Blood pressure of 120/80 mm Hg 3. Moderate amount of yellow drainage from right ear

The nurse obtains information from a patient during admission. The patient is noted to be alert and oriented, be married, have a history of heart disease. Obtaining this information is an example of which process? 1. Collecting data 2. Analyzing data 3. Categorizing data 4. Physical assessment

1. Collecting data

Which of the following is an example of what the nurse recognizes as a cluster of related cues? 1. Complains of nausea and stomach pain after eating 2. Has a productive cough and states stools are loose 3. Has a daily bowel movement and eats a high-fiber diet 4. Has a respiratory rate of 20 breaths/min, heart rate of 85 beats/min, and blood pressure of 136/84 mm Hg

1. Complains of nausea and stomach pain after eating

The nurse reviews a patient's chart and sees a physician's prescription for a new medication. The nurse is able to clearly read the medication name, but the dose is not legible. Which is the best action by the nurse? 1. Contact the physician for clarification. 2. Ask another nurse to read the order. 3. Ask the unit secretary to read the order. 4. Contact the pharmacist to read the order.

1. Contact the physician for clarification.

What are the benefits for nursing practice in using a standardized nursing language when writing nursing diagnoses? Select all that apply. 1. Defines and communicates nursing knowledge 2. Assists the nurse in understanding medical diagnoses 3. Facilitates better understanding of nursing research 4. Helps nurses provide consistent interventions for all patients 5. Promotes medical understanding of nursing functions

1. Defines and communicates nursing knowledge 3. Facilitates better understanding of nursing research

A client is admitted to the hospital with an acute respiratory problem resulting from lung disease. The nurse makes a diagnosis of Ineffective Breathing Pattern related to inability to maintain adequate rate and depth of respirations. Which nursing intervention should be listed first on the care plan? 1. Determine airway adequacy hourly and as needed. 2. Administer prescribed oxygen therapy, as needed. 3. Monitor and report arterial blood gas values. 4. Place the client in the high Fowler's position.

1. Determine airway adequacy hourly and as needed.

The nurse has written the following diagnosis: Diarrhea r/t frequent loose stools. Which of the following describes the error in that diagnostic statement? 1) Diagnostic statement does not include an etiology. 2) Etiology does not describe the cause of the problem. 3) Statement includes a medical diagnosis. 4) Problem is stated as a need rather than a response.

2) Etiology does not describe the cause of the problem.

The nurse finishes developing the nursing interventions for a patient. Which questions does the nurse ask mentally after the development and before the implementation of nursing interventions? Select all that apply. 1. Do I possess the skills and knowledge to carry out the interventions? 2. Will any of the interventions interfere with medical prescriptions? 3. Have I explained the intervention enough to obtain patient support? 4. Does administration support expenses associated with the intervention? 5. What consequences might occur from performance of this intervention?

1. Do I possess the skills and knowledge to carry out the interventions? 2. Will any of the interventions interfere with medical prescriptions? 5. What consequences might occur from performance of this intervention?

A patient verbalizes an overwhelming lack of energy, stating, "I still feel exhausted even after sleeping. I feel guilty when I can't keep up with my usual daily activities, or I sleep during the day. I've been a little depressed lately, too." The nurse notes the patient's difficulty concentrating but does not note any apparent physical problems. Which diagnoses best describes the patient's health status? 1. Fatigue related to depression 2. Fatigue related to difficulty concentrating 3. Guilt related to lack of energy 4. Chronic confusion related to lack of energy

1. Fatigue related to depression

Which nursing diagnosis is written in the correct format? 1. Imbalanced Nutrition: Less than Body Requirements, related to body weight less than 20% under ideal weight 2. Ineffective Airway Clearance, related to increased respiratory rate and irregular rhythm 3. Impaired Swallowing, related to absent gag reflex 4. Excess Fluid Volume, related to 3 lb weight gain in 24 hours

1. Imbalanced Nutrition: Less than Body Requirements, related to body weight less than 20% under ideal weight

The nurse receives a postsurgical patient who is prescribed to have vital signs taken every 15 minutes for 2 hours. Which type of client-centered evaluation does the nurse recognize? 1. Intermittent 2. Ongoing 3. Terminal 4. Process

1. Intermittent

A nurse, with a large caseload of patients, needs to delegate some assessment tasks to other members of the healthcare team. The nurse is unsure which tasks can be delegated to nursing assistive personnel (NAP) and which are appropriate for a licensed practical nurse (LPN) instead of a registered nurse (RN). Which sources does the nurse consult for clarification related to delegation? Select all that apply. 1. Nurse practice act of the nurse's state 2. American Medical Association (AMA) guidelines 3. Code of Ethics for Nurses 4. American Nurses Association (ANA) Scope and Standards of Practice 5. Facility policy and procedure guidelines

1. Nurse practice act of the nurse's state 4. American Nurses Association (ANA) Scope and Standards of Practice

The nurse is providing care for a variety of patients in an acute care facility. Which of the following constitutes an ongoing assessment? 1. Obtaining a patient's temperature 1 hour after giving acetaminophen 2. Examining a patient's throat after soreness with swallowing is reported 3. Requesting a patient to rate pain intensity level using a scale of 0 to 10 4. Asking a patient the details of a plan to return to normal exercise activities

1. Obtaining a patient's temperature 1 hour after giving acetaminophen

Which of the following are cues rather than inferences? Select all that apply. 1. Patient ate 50% of the meal. 2. Patient feels better today. 3. Patient states, "I slept well." 4. Patient's white blood cell (WBC) count is 15,000/mm3 . 5. Patient does not appear to be in pain.

1. Patient ate 50% of the meal. 3. Patient states, "I slept well." 4. Patient's white blood cell (WBC) count is 15,000/mm3

The nurse manager is reviewing documentation performed by newly hired nurses. Which of the examples does the nurse manager recognize as high-quality nursing documentation? Select all that apply. 1. Patient states, "I feel dizzy in the morning." 2. Patient is alert and oriented to person, place, and time. 3. Drainage from midline abdominal incision appears normal. 4. Patient appears angry and is refusing to talk to the spouse. 5. Patient expresses no complaints of pain at this time.

1. Patient states, "I feel dizzy in the morning." 2. Patient is alert and oriented to person, place, and time. 5. Patient expresses no complaints of pain at this time

The nurse is aware of which descriptions being best related to the primary goal(s) of evidence-based practice (EBP)? Select all that apply. 1. Presents the most effective treatments 2. Identifies the most cost-effective treatments 3. Includes all patient and family preferences 4. Creates standardized facility clinical pathways 5. Adds more studies to support an intervention

1. Presents the most effective treatments 2. Identifies the most cost-effective treatments

Which statements regarding nursing diagnoses are accurate? Select all that apply. 1. Provide the basis for nursing interventions 2. Are validated with patient and family, when possible 3. Have historically been well substantiated by research 4. Contain descriptions of pathological disease processes 5. Analyze assessment data by using critical-thinking skills

1. Provide the basis for nursing interventions 2. Are validated with patient and family, when possible 5. Analyze assessment data by using critical-thinking skills

An 85-year-old patient with hypertension (elevated blood pressure) was admitted to the hospital with dehydration. He has pressure sores on his back and hip. Which of the following tasks could the registered nurse delegate to nursing assistive personnel? Select all that apply. 1) Evaluating the healing of the pressure sores 2) Helping the patient to turn and reposition in bed 3) Coordinating the patient's care with the dietitian 4) Taking the patient's blood pressure and reporting changes in skin condition

2) Helping the patient to turn and reposition in bed 4) Taking the patient's blood pressure and reporting changes in skin condition

The nurse is using electronic care planning. The nurse enters the patient's nursing diagnosis into the computer, selects desired outcomes, and validates the patient data, diagnosis, and goals. When considering the list of program generated interventions, the nurse identifies none of them fits this patient's individual needs. Which action does the nurse take? 1. Reject them all, and enter self-generated appropriate interventions. 2. Select the most suitable interventions from the program. 3. Ask another nurse to assess the patient, and give a recommendation. 4. Restart the computer to eliminate the possibility of a program malfunction.

1. Reject them all, and enter self-generated appropriate interventions.

During the assessment process, the patient tells the nurse, "I am having numbness and tingling in my right arm." Which type of data does the nurse recognize on the basis of the patient's statement? 1. Subjective data 2. Objective data 3. Secondary data 4. Comprehensive data

1. Subjective data

The nurse is delegating patient care to a nursing assistive personnel (NAP) with whom the nurse has worked before. The nurse provides exact details of which patient, what tasks, what time period, and what feedback is expected; the NAP has no questions. Which responsibility does the nurse retain after completing the delegation assignment? 1. The nurse will determine and evaluate completion of the assignment. 2. The nurse will check the NAP's progress on the assignment every hour. 3. The nurse will immediately document the assigned tasks as being delegated. 4. The nurse periodically checks the accuracy of the NAP's documentation.

1. The nurse will determine and evaluate completion of the assignment

The nurse manager notices that a staff nurse writes a nursing diagnosis as "Impaired Physical Mobility, related to laziness and not having appropriate shoes." Which issue related to the nursing diagnosis will the nurse manager discuss with the staff nurse? 1. The staff nurse is being judgmental. 2. As written, the diagnosis is too complex. 3. The diagnosis is legally questionable. 4. There is deficiency of supportive data.

1. The staff nurse is being judgmental.

The nurse has gathered information about a client, has sorted the information, and is preparing to identify the diagnostic label, or patient problem. For which purpose are diagnostic labels primarily used? 1. To set client goals 2. To make cue clusters 3. To identify interventions 4. To understand disease etiology

1. To set client goals

After completing an initial patient assessment, for which reason does the nurse utilize a nursing assessment model? 1. To sort and cluster assessment data into specific categories 2. To organize assessment data according to body systems 3. To validate the use of the nursing process to collect data 4. To follow the American Nurses Association (ANA) Standards of Care

1. To sort and cluster assessment data into specific categories

The nurse works in an acute care facility, which implements team nursing with each team consisting of members from various levels of healthcare provision. Which statement accurately describes delegation in the nurse's work environment? 1. Transferring authority to perform a task to a qualified person in a selected situation 2. Collaborating with other caregivers to make decisions and plan patient care 3. Scheduling treatments and activities by coordinating with other departments 4. Implementing an appropriate planned intervention from a critical pathway

1. Transferring authority to perform a task to a qualified person in a selected situation

The nurse is providing care to a client admitted with pressure injuries. The nurse develops a plan of care focusing on healing measures and prevention of further injury. Which task does the nurse delegate to the nursing assistive personnel (NAP)? 1. Turn and reposition the patient every 2 hours. 2. Assess the patient's skin condition. 3. Change pressure injury dressings every shift. 4. Apply hydrocolloid dressing to the pressure injury.

1. Turn and reposition the patient every 2 hours

The nurse completes assessment on a patient and begins to formulate a nursing diagnosis from the collected data. Which action does the nurse take prior to writing the nursing diagnosis statement? 1. Verifies the nursing diagnosis with the patient 2. Validates information with the primary care provider 3. Checks the medical diagnosis for consistency in treatments 4. Reviews the data and the diagnosis with another nurse

1. Verifies the nursing diagnosis with the patient

The nurse is providing care for an adult smoker hospitalized on a medical- surgical unit. The patient states, "I'd really like some help in quitting smoking." As part of the nurse's intervention plan, a smoking cessation class is included. Which type of intervention is the nurse performing? 1. Wellness 2. Prevention 3. Assessment 4. Treatment

1. Wellness

The nurse recognizes which statement(s) about nursing interventions as being true? Select all that apply. 1. Writing of nursing orders cannot be delegated to the licensed practical nurse/licensed vocational nurse (LPN/LVN). 2. The best nursing interventions are based on traditional care. 3. Nursing interventions are individualized and culturally sensitive. 4. Standardized nursing interventions improve care for a specific client. 5. Evidence-based practice (EBP) must always be used for nursing interventions.

1. Writing of nursing orders cannot be delegated to the licensed practical nurse/licensed vocational nurse (LPN/LVN). 3. Nursing interventions are individualized and culturally sensitive.

What is wrong with the format of this diagnostic statement: Possible Risk for Constipation related to irregular defecation habits A.M.B. verbalizing that "When I'm busy, I can't always take the time to go to the bathroom." 1) Possible nursing diagnoses do not have signs and symptoms. 2) A nursing diagnosis is either possible or it is a risk, not both. 3) Risk for Constipation is a medical diagnosis. 4) The etiology is actually a defining characteristic.

2) A nursing diagnosis is either possible or it is a risk, but not both

The client has a nursing diagnosis of Impaired Physical Mobility. Which of the following is a Nursing Outcomes Classification (NOC) outcome label to use with this diagnosis? 1) Increases his physical activity 2) Activities of daily living 3) Demonstrates appropriate use of adaptive equipment 4) Verbalizes feeling of increased strength

2) Activities of daily living

The nurse has written this diagnosis for a patient: Ineffective Airway Clearance related to weak cough secondary to incisional pain. Which of the following outcomes is essential for the nurse to include in the care plan? 1) Effective cough 2) Airways clear to auscultation 3) Pain less than 4 on a scale of 1 to 10 4) Demonstrates splinting of incision

2) Airways clear to auscultation

For which patient would it be most important to perform a comprehensive discharge plan? 1) A teen who is a first-time mother, single, and lives with her parents 2) An older adult who has had a stroke affecting the left side of his body and lives alone 3) A middle-aged man who has had outpatient surgery on his knee and requires crutches 4) A young woman who was admitted to the hospital for observation following an accident

2) An older adult who has had a stroke affecting the left side of his body and lives alone

The nurse phones the laboratory to schedule a blood test for a hospitalized patient. She also schedules an x-ray for the same day. Both of these require the patient to be NPO (to have no food or liquids by mouth) for several hours prior to the tests. The nurse makes sure the patient has something to drink at the last possible moment before the patient is NPO. After the tests, when analyzing the urine output, she takes into consideration that the patient has had nothing to drink for 7 hours. This is a good example of: 1) Collaborating 2) Coordinating 3) Delegating care 4) Individualizing care

2) Coordinating

In which step of the nursing process does the nurse analyze data and identify client problems? 1) Assessment 2) Diagnosis 3) Planning outcomes 4) Evaluation

2) Diagnosis

A patient is admitted with shortness of breath. The nurse specifically wants to know when the problem began, how often it occurs, what makes it worse, and what the patient has done to relieve it. What should the nurse do to obtain this information? 1. Complete a comprehensive admission assessment .2. Interview the patient about the history of her present illness. 3. Perform a review of body systems and functional abilities. 4. Ask the patient about her expectations for care.

2) Interview the patient about the history of her present illness

Which statement about the nursing process is correct? 1) It was developed from the ANA Standards of Care .2) It is a problem-solving method to guide nursing activities. 3) It is a linear process with separate, distinct steps. 4) It involves care that only the nurse will give.

2) It is a problem-solving method to guide nursing activities.

Which of the following is appropriate to the registered nurse's role in nursing diagnosis? 1) Decide when to delegate diagnosing to the LPN/LVN. 2) Make clinical judgments about the patient data. 3) Validate all nursing diagnoses with the primary care provider. 4) Use only NANDA-I standardized language to state problems.

2) Make clinical judgments about the patient data.

Why is implementation known as the action phase of the nursing process? Because it is the stage in which the nurse: 1) Reassesses to see whether goals have been met 2) Performs or delegates the planned interventions 3) Documents the care that has been given 4) Prioritizes interventions

2) Performs or delegates the planned interventions

The nurse writes a nursing diagnosis of Risk for Deficient Fluid volume for a 45-year-old patient admitted with acute pancreatitis. What type of nursing diagnosis has the nurse written for this patient? 1) Actual 2) Potential 3) Possible 4) Wellness

2) Potential

Which of the following is an example of theoretical knowledge? 1) A nurse uses sterile technique to catheterize a patient. 2) Room air has an oxygen concentration of approximately 21%. 3) Glucose-monitoring machines should be calibrated daily. 4) An irregular apical heart rate should be compared with the radial pulse.

2) Room air has an oxygen concentration of approximately 21%.

The nurse is preparing to admit a patient from the emergency department. The patient has chronic lung disease and has used tobacco for 30+ years. The nurse used to smoke a pack of cigarettes a day and worked very hard to quit smoking. She thinks to herself, "I know I tend to disapprove of people who use tobacco, especially when they have a serious lung condition; I figure if I can stop smoking, they should be able to. I must remember how difficult that is, and be very careful not to let be judgmental of this patient." This best illustrates: 1) Theoretical knowledge 2) Self-knowledge 3) Using reliable resources 4) Use of the nursing process

2) Self-knowledge

Which is the best example of a well-stated desired outcome? The patient will: 1) Use the incentive spirometer while awake 2) State pain < 4 on a scale of 1 to 10 within 1 hour after receiving pain medication 3) Increase the distance he walks each time he ambulates 4) Verbalize the side effects of his new medication

2) State pain < 4 on a scale of 1 to 10 within 1 hour after receiving pain medication

Which of the following is an example of data that should be validated? 1) The urinalysis report indicates there are white blood cells in the urine. 2) The client states she feels feverish; you measure the oral temperature at 98°F. 3) The client has clear breath sounds; you count a respiratory rate of 18 breaths/min. 4) The chest x-ray report indicates the client has pneumonia in the right lower lobe.

2) The client states she feels feverish; you measure the oral temperature at 98°F.

What is the error in the following nursing order: "7-21-15—Using 2 persons, assist the patient from bed to chair 3 times per day. Jerry Xeno, RN"? 1) There is no action verb. 2) There are no times or limits. 3) Nurses do not need to sign nursing orders. 4) The order is too long and complex.

2) There are no times or limits.

Which of the following are cues? Select all that apply. 1) Taking a brisk walk five times a week 2) Using laxatives to have a bowel movement 3) Needing more sleep than usual 4) Decreasing the amount of fat in the diet 5) Weighing less than indicated by developmental norms

2) Using laxatives... 3) Needing more sleep... 5) Weighing less than indicated by developmental norms

Using the mnemonic H E L P (from Volume 1 of your textbook), which of the following correctly illustrates the letter P—People? 1) Is the oxygen running? 2) Who else is in the room with the patient? 3) Take a thorough look at the patient. 4) Is the patient in pain?

2) Who else is in the room with the patient?

The nurse is formulating a nursing diagnosis for a patient. Which definition most accurately describes nursing diagnoses? 1. Supports the nurse's diagnostic reasoning 2. Supports the client's medical diagnosis 3. Identifies a client's response to a health problem 4. Identifies a client's health problem

3. Identifies a client's response to a health problem

The nurse is performing an initial interview with an older adult patient. Which statement by the patient indicates a need for a special needs assessment by the nurse? 1. "I don't go to church as much as I used to, but I watch services on TV." 2. "I have fallen twice at home in the past 6 months, but I have not injured myself." 3. "I don't eat much red meat anymore, but I get my protein from other foods." 4. "I had a toothache recently, so I made an appointment to see the dentist."

2. "I have fallen twice at home in the past 6 months, but I have not injured myself."

A patient comes to the emergency department to be evaluated after feeling ill at home. Which is the first question the nurse asks in the initial nursing interview with the patient? 1. "Do you live alone?" 2. "Are you having any pain?" 3. "What is your past medical history?" 4. "Why did you come to the hospital today?"

4. "Why did you come to the hospital today?"

Which client outcome criterion does the nurse use when evaluating client behaviors that affect the client's health status? 1. Central venous catheter site infection does not occur in 90% of cases. 2. Client will sit in the bedside chair for 20 minutes three times per day. 3. Postoperative phlebitis does not occur in 95% of surgical patients. 4. Falls in the facility will be reduced by 2% at the end of the year.

2. Client will sit in the bedside chair for 20 minutes three times per day.

The nurse works with the respiratory therapist to administer a patient's breathing treatments. The therapist reports the patient's breathing status and tolerance of the treatment to the primary care provider. The nurse then discusses with the patient the options for further treatment. Which type of implementation process is being used? 1. Delegation 2. Collaboration 3. Coordination of care 4. Supervision of care

2. Collaboration

The nurse is providing care for a patient in an acute care facility. The nurse plans to evaluate the effectiveness of the plan of care. Which action does the nurse need to take to achieve a valid evaluation? 1. Read the documentation by the previous nurse. 2. Collect reassessment data on the patient. 3. Look at the physician's progression notes. 4. Ask the patient's view about each nursing goal.

2. Collect reassessment data on the patient.

The nurse is providing care for a patient after joint replacement surgery. The standardized care plan states, "Patient will ambulate 50 feet in the hall with a walker before discharge." Which patient variable affecting this goal is the nurse unable to control? 1. Confusion and lethargy related to pain medication 2. Compromised respiratory function due to severe chronic obstructive pulmonary disease (COPD) 3. Reluctance to ambulate due to pain at level 7 4. Presence of a spouse who pushes the patient to rest

2. Compromised respiratory function due to severe chronic obstructive pulmonary disease (COPD)

The nurse is providing care to a patient who has left-sided weakness because of a recent stroke. Which type of special needs assessment is most important for the nurse to perform? 1. Family 2. Functional 3. Community 4. Psychosocial

2. Functional

The nurse is completing a plan of care for a patient with congestive heart failure. Which direct-care nursing intervention does the nurse perform? 1. Collaborate with the physician for further medication orders. 2. Instruct the patient about low-sodium and low-fat diets. 3. Refer the patient to cardiac rehabilitation for a home-care program. 4. Consult with physical therapist for cardiac rehabilitation exercises.

2. Instruct the patient about low-sodium and low-fat diets.

Before inserting a nasogastric tube, the nurse reassures the client. Reassuring the client requires which type of nursing skill? 1. Psychomotor 2. Interpersonal 3. Cognitive 4. Critical thinking

2. Interpersonal

A second-year nursing student is in a clinical rotation on a medical-surgical unit. Which is the most appropriate strategy for the student to use to assist with organizing and prioritizing patient care for the day? 1. Ask the nurse what tasks need to be completed for the day. 2. Make a time-sequenced "to-do" list for care activities for the day. 3. Ask the instructor what needs to be completed for the day. 4. Ask the patient what needs to be completed for the day.

2. Make a time-sequenced "to-do" list for care activities for the day.

The nurse is providing care for various patients in an acute care facility. Which patient issue is a problem that nurses can treat independently? 1. Hemorrhage following surgery 2. Nausea after ambulating in the hall 3. Fracture pain following an accident 4. Infection in a wound

2. Nausea after ambulating in the hall

Which statement related to the nurse prioritizing patient problems is most accurate? 1. Nurses must resolve one problem before addressing another problem. 2. Nurses prioritize problems in the order of problem urgency. 3. Nurses give priority to actual problems instead of risk problems. 4. Nurses give the highest priority to problems most important to the patient.

2. Nurses prioritize problems in the order of problem urgency.

Which nursing activity is most reflective of the evaluation phase of the nursing process? 1. Administering pain medication prior to changing a complex wound dressing 2. Obtaining patient's blood pressure (BP) 30 minutes after administering BP medication 3. Reporting there have been three patient falls in the past month on the nursing unit 4. Teaching the patient how to perform daily finger-sticks for blood glucose readings

2. Obtaining patient's blood pressure (BP) 30 minutes after administering BP medication

The nurse is aware that patient data are often difficult to analyze. Which is the most obvious reason for using a framework for collecting and recording patient data? 1. Prioritizes collection of assessment data 2. Organizes and clusters data efficiently 3. Separates subjective and objective data 4. Identifies both primary and secondary data

2. Organizes and clusters data efficiently

The nurse manager in an acute care facility is orienting new graduate nurses to a patient care unit. While reviewing The Joint Commission standards, a discussion begins about assessment. Which type of assessment is to be performed on all patients in compliance with The Joint Commission? 1. Nutritional status 2. Pain 3. Cultural 4. Wellness

2. Pain

A client is admitted to the hospital with an acute episode of chronic obstructive pulmonary (lung) disease. The nurse makes a diagnosis of Ineffective Breathing Pattern related to inability to maintain adequate rate and depth of respirations and has recorded the diagnosis and appropriate goals on the care plan. When selecting nursing interventions, which nursing action does the nurse do first? 1. Identify several interventions likely to achieve the desired outcomes. 2. Review the problem and etiology of the nursing diagnosis. 3. Choose the best interventions for the patient. 4. Review the goals written by the nurse.

2. Review the problem and etiology of the nursing diagnosis.

The nurse is applying the nursing process to the development of a plan of care for a patient. Based on the patient's problems, the nurse is using Maslow's Hierarchy of Needs. Which nursing diagnosis does the nurse recognize as having the highest priority? 1. Self-Care Deficit 2. Risk for Aspiration 3. Impaired Physical Mobility 4. Functional Urinary Incontinence

2. Risk for Aspiration

The nurse is currently performing the initial assessment on a newly admitted client. The nurse receives notification of another client's admission to the unit. Which professional standard influences the nurse's decision about who will be assigned to perform the assessment of the second client? 1. The state board for nursing-assistant testing 2. The American Nurses Association (ANA) 3. The facility policy and procedure committee 4. The bargaining committee for facility nurses

2. The American Nurses Association (ANA)

After collecting data on a client, the nurse reviews and sorts the information. Which example includes both objective and subjective data? 1. The client's blood pressure reading is 132/68 mm Hg, and heart rate is 88 beats/min. 2. The client's cholesterol is elevated, and he admits to liking and eating fried food. 3. The client reports having trouble sleeping and admits drinking coffee in the evening. 4. The client verbally reports having frequent headaches and taking aspirin for the pain.

2. The client's cholesterol is elevated, and he admits to liking and eating fried food.

The nurse is providing care for a patient following abdominal surgery. The nurse created a collaborative diagnosis of "Potential complication of surgery: hemorrhage" During patient assessment, the nurse recognizes the symptoms of serious blood loss. The nurse is aware that which action is now relative to the collaborative diagnosis? 1. The diagnosis is modified to watch for "continued" hemorrhage. 2. The diagnosis is removed because of the development of a medical problem. 3. The nurse collaborates with the physician to formulate a new diagnosis. 4. The nurse documents the effectiveness and value of the initial diagnosis.

2. The diagnosis is removed because of the development of a medical problem.

The nurse works in an acute healthcare facility on a unit where patients with chronic health problems frequently return for treatment and management. The nurses are expected to use evidence-based practice (EBP) for the determination of best care. Which action by a nurse reflects understanding about EBP? 1. The nurse submits compiled research to nursing administration. 2. The nurse conducts a systematic review of published research. 3. The nurse informs the patient care is based on research evidence. 4. The nurse only uses research that reflects the patient's condition.

2. The nurse conducts a systematic review of published research.

The nurse prefers to review patient data on a graphic flow sheet, when possible. Which situation is the best example of the reason a graphic flowsheet is superior to other methods of recording data? 1. Provides easy documentation of routine vital signs 2. Visually reflects the patterns of a patient's fever 3. Describes symptoms accompanying vital sign changes 4. Enables a quick check for patient tolerance of care

2. Visually reflects the patterns of a patient's fever

The nurse manager is evaluating the nursing diagnoses written by staff nurses. Which nursing diagnosis statements does the nurse manager identify as being written correctly? Select all that apply. 1. Chronic Pain, related to osteoarthritis, as manifested by (AMB) patient rating pain at 8 on a 0 to 10 pain scale and having difficulty with ambulation 2. Ineffective Airway Clearance, related to excessive mucus, AMB cough, shortness of breath, change in respiratory rate and rhythm 3. Caregiver Role Strain, related to increasing care needs, AMB wife stating, "He is just getting too heavy for me to lift" 4. Anxiety (moderate), related to cardiac catheterization, AMB crying and yelling at family members 5. Emotional distress, AMB inability to eat related to recent diagnosis of a terminal disease

2.Ineffective Airway Clearance, related to excessive mucus, AMB cough, shortness of breath, change in respiratory rate and rhythm 3. Caregiver Role Strain, related to increasing care needs, AMB wife stating, "He is just getting too heavy for me to lift"

A psychiatrist prescribes oral aripiprazole 10 mg daily for a client with schizophrenia. This medication is unfamiliar to the nurse, who cannot find it in the hospital formulary or other references. In which manner does the nurse proceed? 1. Administer the medication as ordered. 2. Hold the medication and notify the prescriber. 3. Consult with a pharmacist before administering it. 4. Ask the patient's registered nurse (RN) for information about the medication.

3. Consult with a pharmacist before administering it.

Arrange the steps of the nursing process in the sequence in which they generally occur. A. Assessment B. Evaluation C. Planning outcomes D. Planning interventions E. Diagnosis 1) E, B, A, D, C 2) A, B, C, D, E 3) A, E, C, D, B 4) D, A, B, E, C

3) A, E, C, D, B

Which of the following explains why it is important to have the correct etiology for a nursing diagnosis? The etiology: 1) Is the cause of the problem. 2) Cannot always be observed. 3) Directs nursing interventions. 4) Is an inference.

3) Directs nursing interventions

The nurse has just finished documenting that he removed a patient's nasogastric tube. Which is the next logical step in the nursing process? 1) Assessment 2) Planning 3) Evaluation 4) Diagnosis

3) Evaluation

The nurse is beginning discharge planning for an older adult with left-side weakness. All of the following are important, but which action is most important in ensuring that the discharge plan is successful? 1) Start planning at admission. 2) Involve the family members. 3) Get patient input when making the plan. 4) Involve the multidisciplinary team.

3) Get patient input when making the plan.

In diagnostic reasoning, the nurse does all of the following when analyzing and interpreting data. Which task occurs first? 1) Cluster cues. 2) Identify data gaps and inconsistencies. 3) Identify significant data. 4) Make inferences.

3) Identify significant data.

Which of the following aids the nurse in best meeting the unique needs of a patient? 1) Kardex 2) Critical pathway 3) Individualized patient care plan 4) Standardized (model) patient care plan

3) Individualized patient care plan

Which nurse is most clearly using evidence-based practice? One who uses an intervention: 1) He read about in a study in a nursing research journal 2) From the agency's critical pathway in the electronic health record 3) Published in the clinical practice guidelines of a national organization 4) That is individualized to meet a specific patient need

3) Published in the clinical practice guidelines of a national organization

How is a critical pathway different from a standardized care plan? A critical pathway: 1) Does not include medical orders 2) Provides individualized goals and interventions 3) Specifies patient outcomes and interventions for each day, or other period of time 4) Is usually a preprinted document for a particular diagnosis or condition

3) Specifies patient outcomes and interventions for each day, or other period of time

The criterion reads: "Hallways clear and free of equipment (e.g., beds, wheelchairs)." This is an example of a criterion that would be appropriate in which type of evaluation? 1) Outcomes 2) Processes 3) Structures 4) Intermittent

3) Structures

What is missing from this goal statement? "The patient will walk to the doorway with the help of one person." 1) Action verb 2) Special conditions 3) Target time 4) Nothing is wrong with it.

3) Target time

A client newly diagnosed with diabetes mellitus is admitted to the hospital because of poorly controlled glucose levels. Which action by the nurse is an appropriate direct-care intervention for this client during the client's hospitalization? 1. Consulting the diabetic nurse educator for help with a teaching plan 2. Making arrangements for the client to join a diabetic support group 3. Demonstrating blood glucose monitoring and insulin administration to the client 4. Consulting with the dietician about the client's dietary concerns

3. Demonstrating blood glucose monitoring and insulin administration to the client

The nurse reviews a nursing order for a patient who is 4 days postoperative after hip surgery, which reads: Assist patient in bathing each morning. The nurse assesses the patient and notes the patient demonstrates the ability to bathe independently. Which action does the nurse do next? 1. Assist with the bath, as ordered. 2. Delegate the bath to the nursing assistant. 3. Discontinue the nursing order on the plan of care. 4. Collaborate with the nurse who originally wrote the order.

3. Discontinue the nursing order on the plan of care.

For which reason does the nurse use nondirective interviewing as an assessment technique? 1. Allows the nurse to have control of the interview 2. Is an efficient way to interview a patient 3. Facilitates open communication 4. Helps focus the attention of patients who are anxious

3. Facilitates open communication

The nurse is assigned to participate in a structure evaluation for an acute care facility. Which response on the nurse's structure evaluation form indicates the nurse understood the criteria related to the task? 1. "Staff refrains from sharing computer passwords." 2. "Healthcare provider washes hands with each client contact." 3. "A defibrillator is present in each client care area." 4. "Nurses verify client identification before initiating care."

3. "A defibrillator is present in each client care area."

The patient comes to the emergency department complaining of chest pain. Which question by the nurse will encourage the patient to provide the most details about the pain? 1. "When did your chest pain begin?" 2. "On a scale of 0 to 10, what is your pain level?" 3. "Can you give a description of the pain you are having?" 4. "Have you taken any medication for your pain?"

3. "Can you give a description of the pain you are having?"

Nurses are aware that documentation is essential in monitoring and validating appropriate patient care. Which statement is the best example of high-quality nursing documentation? 1. "Patient breathing is normal. No pain noted. Urine output is adequate at this time." 2. "Good strength in both lower extremities. Ambulating with walker in the hall." 3. "Started on solid foods. Ate 75% of dinner. No complaints of any nausea or vomiting." 4."Patient seems upset with visiting spouse. Physical assessment planned at a later time."

3. "Started on solid foods. Ate 75% of dinner. No complaints of any nausea or vomiting."

Which statement by the registered nurse (RN) best demonstrates clear communication to nursing assistive personnel (NAP) about a delegated task? 1. "Record the patient's intake and output of fluids throughout the shift, please." 2. "Take the patient's temperature, pulse, respirations, and blood pressure every 2 hours today." 3. "Take the patient's temperature every 4 hours; notify me if it is greater than 100.5°F (38.1°C)." 4. "Assist the patient with all meals so that the patient's intake of calories will increase."

3. "Take the patient's temperature every 4 hours; notify me if it is greater than 100.5°F (38.1°C)."

The nurse is obtaining the health history of a client. Which question is an example of the nurse using an open-ended question? 1. "Have you had surgery before?" 2. "When was your last menstrual period?" 3. "What happens when you have a headache?" 4. "Do you have a family history of heart disease?"

3. "What happens when you have a headache?"

The nurse has diagnosed Decisional Conflict related to unclear personal values and beliefs, and the patient shows the necessary defining characteristics. Which essential action does the nurse take to help ensure the accuracy of this diagnosis? 1. Ask a more experienced nurse to confirm it 2. Request a social worker interview the patient 3. Ask for the patient's confirmation of the diagnosis 4. Read about Decisional Conflict in the NANDA-I handbook

3. Ask for the patient's confirmation of the diagnosis

The nurse is preparing to conduct an admission interview with an adult client who is alert and oriented. The client's spouse and two children are visiting and are watching television. Which action by the nurse is conducive to a successful interview? 1. Provide enough chairs for the family to sit facing the client. 2. Ask the client's preference for how to be addressed by the nurse. 3. Ask if the client is willing to answer questions after the family leaves. 4. Give the client the option of having the interview while the family watches television.

3. Ask if the client is willing to answer questions after the family leaves.

The certified nursing assistant (CNA) is feeding a patient and notices that the patient is having difficulty swallowing. The CNA reports the observation to the primary registered nurse. Which action does the nurse take first? 1. Assign the task to a more experienced can. 2. Continue patient feeding by the nurse. 3. Assess the patient, and place the patient on NPO (nothing by mouth) status. 4. Call the primary care provider.

3. Assess the patient, and place the patient on NPO (nothing by mouth) status.

The nurse receives reports on four patients on a medical-surgical unit. Which patient will the nurse attend to first? 1. Gait unsteady, uses walker, needs two-person assist with ambulation 2. Abdominal wound with foul-smelling drainage, incision margins are red, heart rate 100 beats/min 3. Blood pressure 90/50 mm Hg, heart rate 40 beats/min, patient rates chest pain at 8 on a 0-to-10 pain scale 4. Verbalizes history of migraine headaches, eyes closed during assessment interview

3. Blood pressure 90/50 mm Hg, heart rate 40 beats/min, patient rates chest pain at 8 on a 0-to-10 pain scale

The nurse is developing a plan of care for a client at an adult wellness clinic. Which primary decision maker does the nurse recognize when caring for healthy adult clients? 1. Provider 2. Family 3. Client 4. Nurse

3. Client

The nurse is aware that which approach is best to validate a clinical inference? 1. Have another nurse evaluate it 2. Have the physician evaluate it 3. Have sufficient supportive data 4. Have the client's family confirm it

3. Have sufficient supportive data

Which nursing diagnosis is written in the correct format when using NANDA-I taxonomy? 1. Bowel Obstruction, related to recent abdominal surgery, as manifested by (AMB) nausea, vomiting, and abdominal pain 2. Inability to Ingest Food, related to imbalanced nutrition: less than body requirements, AMB inadequate food intake, weight less than 20% under ideal body weight 3. Impaired Skin Integrity, related to physical immobility, AMB skin tear over sacral area 4. Caregiver Role Strain, related to alienation from family and friends, AMB 24-hour care responsibilities

3. Impaired Skin Integrity, related to physical immobility, AMB skin tear over sacral area

A patient comes to the urgent care clinic because of injury from stepping on a rusty nail. Which type of assessment does the nurse perform? 1. Comprehensive 2. Ongoing 3. Initial focused 4. Special needs

3. Initial focused

The nurse is conducting an assessment interview with a newly admitted client. When asking open-ended questions, which action by the nurse indicates an active listening behavior? 1. Taking frequent notes 2. Asking for more details 3. Leaning toward the patient 4. Sitting comfortably with legs crossed

3. Leaning toward the patient

The nurse is performing preoperative teaching for a client who is scheduled for surgery in the morning. The client does not at present have any respiratory problems. The nurse's teaching plan includes coughing and deep-breathing exercises. Which type of nursing intervention is the nurse performing? 1. Health promotion 2. Treatment 3. Prevention 4. Assessment

3. Prevention

The nurse works in an acute care setting as a patient educator for patients newly diagnosed with diabetes mellitus. Which nursing intervention by this nurse is an indirect- care intervention? 1. Providing emotional support to patients 2. Conducting classes for teaching diet management 3. Requesting classroom furniture for adult patients 4. Recommending medical care for diabetic ulcers

3. Requesting classroom furniture for adult patients

Which of the following is a collaborative intervention? 1) Rubbing patient's back to facilitate relaxation 2) Measuring the patient's blood pressure 3) Assessing the patient's educational needs related to discharge 4) Administering prescribed medications to a patient

4) Administering prescribed medications to a patient

As the nurse is inserting a urinary catheter she observes blood in the urine returned in the tubing. Which principle of assessment does this best illustrate? 1. Assessment must be accurate because the remainder of the nursing process depends on it. 2. Nursing assessments focus on patient responses rather than disease processes. 3. Assessment is a responsibility of professional nurses and cannot be delegated. 4. Assessment is related to and overlaps with other steps of the nursing process.

4) Assessment is related to and overlaps with other steps of the nursing process.

The nurse develops a goal on the nursing care plan that states: 9/26/16, 0900—By 0800 tomorrow, will reach tube-feeding goal of 80 mL/hour. How can the nurse best collect data to evaluate this goal? (Note: Residual is the amount of undigested feeding remaining in the stomach; blood glucose levels are affected by calories ingested and digested.) 1) Weigh the client daily. 2) Monitor urine output hourly .3) Obtain blood glucose levels every 6 hours. 4) Check feeding residual every 2 hours

4) Check feeding residual every 2 hours

A clinic client has not been keeping his scheduled follow-up appointments. In talking with him about that, the nurse asks, "Do you have a car or other transportation to bring you to the clinic?" Which critical-thinking process does that question illustrate? 1) Inquiry based on credible sources 2) Reflective skepticism 3) Analyzing assumptions 4) Contextual awareness

4) Contextual awareness

Which of the following is the most obvious example of defining characteristics of the diagnosis Deficient Fluid Volume? 1) Increased metabolic rate 2) Effects of medications 3) History of falls 4) Decreased urine output

4) Decreased urine output

A patient has not achieved a desired outcome by the target date. What should the nurse do next when reviewing the care plan? 1) Reassess to see whether other outcomes have been met. 2) Implement new nursing interventions. 3) Write a new nursing diagnosis. 4) Determine whether the outcome was realistic.

4) Determine whether the outcome was realistic

A patient has a diagnosis Impaired Walking related to knee pain secondary to arthritis. The nurse has written the following set of nursing orders for that diagnosis. --Provide passive range of motion to the affected knee 3 times per day. --Assist the patient to walk to the bathroom and at least 3 times per day. Which of the following is a valid criticism of this set of orders? The orders 1) Are too long and complex .2) Do not address the etiology of the nursing diagnosis. 3) Do not address the problem side of the nursing diagnosis. 4) Should not include the words "secondary to arthritis."

4) Do not address the etiology (knee pain) of the nursing diagnosis.

Which intervention depends almost entirely on the client's adhering to the therapy? 1) Inserting an intravenous catheter 2) Turning a client every 2 hours 3) Shortening a surgical drain 4) Following a low-fat, low-calorie diet

4) Following a low-fat, low-calorie diet

Which of the following is a benefit of standardized care plans, as defined in your text? Standardized care plans: 1) Apply to every patient on a particular unit 2) Include both medical and nursing orders 3) Specify patient outcomes for each day 4) Help ensure that important interventions are not overlooked

4) Help ensure that important interventions are not overlooked

After assessing a patient, the nurse is analyzing and synthesizing the data she obtained. She thinks, "I know the patient must sit up to breathe; his respirations are shallow and fast; and he is pale. What does this mean? What are some possible explanations for these symptoms?" Which of the following critical-thinking attitudes is the nurse illustrating? 1) Fair-mindedness 2) Independent thinking 3) Intellectual courage 4) Intellectual curiosity

4) Intellectual curiosity

Using the mnemonic H E L P (from Volume 1 of your textbook), which of the following correctly illustrates the letter H—Help? 1) Is the oxygen running? 2) Who else is in the room with the patient? 3) Are there any spills? 4) Is the patient in pain?

4) Is the patient in pain?

What is wrong with this nursing order? "3/10/2015. Provide measures to relieve anxiety at every patient contact. J. King, RN" 1) Lacks a target time 2) Does not contain a verb 3) Should not be signed 4) Is vaguely worded

4) Is vaguely worded

Which nursing intervention is best individualized to meet the needs of a specific client? 1) Suction the client every 2 hours per unit policy. 2) Use incentive spirometry every hour while awake per postoperative protocols. 3) Institute swallowing precautions. 4) Move client out of bed to the chair daily; client prefers to be out of bed for dinner.

4) Move client out of bed to the chair daily; client prefers to be out of bed for dinner.

What are the similarities between a risk nursing diagnosis and a possible nursing diagnosis? 1) Both are developed primarily from nursing intuition and experience. 2) Both require intervention from physicians. 3) Neither requires the client to have increased vulnerability. 4) Neither is made on the basis of client symptoms (defining characteristics).

4) Neither is made on the basis of client symptoms (defining characteristics)

What do standardized nursing care plans and individualized care plans have in common? They both: 1) Reflect critical thinking for a specific patient 2) Apply to needs common to a group of patients 3) Address a patient's individual needs 4) Provide detailed nursing interventions

4) Provide detailed nursing interventions

What is the role of The Joint Commission in regard to patient assessment? The Joint Commission 1. States what assessments are collected by individuals with different credentials 2. Regulates the time frames for when assessments should be completed 3. Identifies how data are to be collected and documented 4. Sets standards for what and when to assess the patient

4) Sets standards for what and when to assess the patient.

Which of the following nursing activities is a direct-care intervention? 1) Consulting with the nurse practitioner about a patient's medication 2) Telephoning the physician when a pain medication is not relieving the patient's pain 3) Checking and stocking the unit's resuscitation cart daily 4) Sitting with a patient who is anxious about his upcoming surgery

4) Sitting with a patient who is anxious about his upcoming surgery

Which of the following is an example of appropriate behavior when conducting a client interview? 1) Recording all the information on the agency-approved form during the interview 2) Asking the client, "Why did you think it was necessary to seek healthcare at this time?" 3) Using precise medical terminology when asking the client questions 4) Sitting, facing the client in a chair at the client's bedside, using active listening

4) Sitting, facing the client in a chair at the client's bedside, using active listening

Using the mnemonic H E L P (from Volume 1 of your textbook), which of the following correctly illustrates the letter L—Look? 1) Is the oxygen running? 2) Who else is in the room with the patient? 3) Are there any spills? 4) Take a thorough look at the patient.

4) Take a thorough look at the patient?

Which organization's standards require that all patients be assessed specifically for pain? 1) American Nurses Association (ANA) 2) State nurse practice acts 3) National Council of State Boards of Nursing (NCSBN) 4) The Joint Commission

4) The Joint Commission

Which of the following describes the difference between a collaborative problem and a medical diagnosis? 1. A collaborative problem is treated by the nurse; a physician is responsible for the treatment of a medical problem. 2. A collaborative problem is a nursing diagnosis that requires specific orders from a physician; a medical diagnosis directs all nursing care. 3. A collaborative problem has the potential to become an actual nursing diagnosis; a medical diagnosis rarely changes. 4. A collaborative problem requires intervention by the nurse and the physician or other professional; a medical diagnosis requires intervention by a physician.

4. A collaborative problem requires intervention by the nurse and the physician or other professional; a medical diagnosis requires intervention by a physician.

Which of the following is the best example of a nursing diagnosis statement? 1. Pain related to appendicitis 2. Fractured left leg related to impaired mobility 3. Impaired mobility related to fractured left leg 4. Acute pain related to out of bed activities

4. Acute pain related to out of bed activities

When making a diagnosis using NANDA-I taxonomy, which part of the statement provides support for the diagnostic label you choose? 1. Etiology 2. Related factors 3. Diagnostic label 4. Defining characteristics

4. Defining characteristics

The nurse on a medical-surgical unit receives the third admission over a period of 1.5 hours. A certified nursing assistant (CNA) offers to assist the nurse with the assessment process. Which response by the nurse is the most appropriate? 1. "Thank you. I am having a busy day, and I can use your help." 2. "I'm sorry, but nurses are responsible for all patient assessments." 3. "If you start an assessment on the last patient, I will continue it later." 4. "If you could obtain and record the vital signs, it would be a big help."

4. "If you could obtain and record the vital signs, it would be a big help."

A nursing instructor asked his nursing students to discuss their experiences with charting assessment data. Which comment by the student indicates the need for further teaching? 1. "I find it difficult to avoid using phrases like 'the patient tolerated the procedure well.'" 2. "It's confusing to have to remember which abbreviations this hospital allows." 3. "I need to work on charting assessments and interventions right after they are done." 4. "My patient was really quiet and didn't say much, so I charted that he acted depressed."

4. "My patient was really quiet and didn't say much, so I charted that he acted depressed."

A nursing instructor is guiding nursing students on best practices for interviewing patients. Which of the following comments by a student would indicate a need for further instruction? 1. "My patient is a young adult, so I plan to talk to her without her parents in the room." 2. "Because my patient is old enough to be my grandfather, I will address him with 'Mr.'" 3. "When reading my patient's health record, I thought of a few questions to ask." 4. "When I give my patient his pain medication, I will have time to ask questions."

4. "When I give my patient his pain medication, I will have time to ask questions."

A staff nurse states, "I get tired of all the paperwork about nursing diagnosis and plans for patient care." Which of the following describes the most important purpose for developing a nursing diagnosis? 1. Differentiates the nurse's role from that of the physician 2. Identifies a body of knowledge unique to nursing 3. Helps nursing develop a more professional image 4. Describes the client's needs for nursing care

4. Describes the client's needs for nursing care

The nurse is providing care for a client newly diagnosed with type 2 diabetes mellitus. Which intervention by the nurse best promotes client cooperation with the treatment plan? 1. Teaching the client that weight must be lost to control blood glucose 2. Informing the client it is necessary to exercise at least three times per week 3. Explaining to the client attendance is mandatory at the diabetic clinic weekly 4. Determining the client's main concerns about the diagnosis of diabetes

4. Determining the client's main concerns about the diagnosis of diabetes

The nurse creates a plan of care for a patient diagnosed with severe dehydration. One nursing goal reads, "Patient will maintain urine output of at least 30 mL/hour." Which time frame will the nurse use to collect evaluation data for this expected outcome? 1. At the end of the shift 2. Every 24 hours 3. Every 4 hours 4. Every hour

4. Every hour

A nurse makes a nursing diagnosis of Acute Pain related to the postoperative abdominal incision. The nurse writes a nursing order to reposition the client in a comfortable position by using pillows to splint or support the painful areas. Which type of nursing intervention did the nurse write? 1. Collaborative 2. Interdependent 3. Dependent 4. Independent

4. Independent

The nurse is interviewing a patient being admitted for gastrointestinal issues. The patient informs the nurse that he has persistent vomiting and diarrhea. Which type of assessment is the nurse performing by asking, "When did you first begin to have the vomiting and diarrhea?"? 1. Comprehensive assessment 2. Ongoing focused assessment 3. Special needs assessment 4. Initial focused assessment

4. Initial focused assessment

Which is the best example of a well-written nursing order? 1. Provide emotional support to patient and family, as needed. 2. Assist with performance of personal hygiene, if necessary. 3. Follow prescribed fluid restriction of 1,500 mL per day. 4. Insert urinary catheter if patient has not voided within 8 hours.

4. Insert urinary catheter if patient has not voided within 8 hours.

After gathering and analyzing data and identifying patient needs, the nurse begins the implementation phase of developing a plan of care. Which is the best example of the implementation phase of the nursing process? 1. Patient verbalizes pain is reduced from 8 to 3 after receiving pain medication. 2. Nurse observes that patient has a small, quarter-sized skin tear over coccyx area. 3. Nurse writes in the care plan: Patient requires two-person assist with ambulation to bathroom. 4. Nurse inserts urinary catheter after reporting to physician the patient's inability to void.

4. Nurse inserts urinary catheter after reporting to physician the patient's inability to void.

The nurse is providing care for a patient in the end stages of a terminal disease. Against the patient's family's wishes, the patient makes the decision for comfort care only. Medical prescriptions are obtained from the attending physician. Which individualized nursing order represents an appropriate nursing intervention? 1. Prescribed pain medication will be administered, as needed. 2. Printed materials are given to patient's family about patient rights. 3. Visitors are asked to support the patient's decisions for the type of care. 4. Pain assessed hourly for levels above patient's acceptable level of 5.

4. Pain assessed hourly for levels above patient's acceptable level of 5.

A client's weight is appropriate for the client's height, and laboratory values and other assessments reflect normal nutritional status. However, the client states, "I probably eat a little too much red meat. And, what is this I hear about needing omega 3 oils in my diet? I don't like to take supplements, and I think I could really improve my nutrition." Which nursing diagnoses does the nurse use? 1. Balanced Nutrition 2. Possible Imbalanced Nutrition: Less Than Body Requirements 3. Risk for Imbalanced Nutrition: Less Than Body Requirements 4. Readiness for Enhanced Nutrition

4. Readiness for Enhanced Nutrition

Each time the nurse comes into contact with a patient, a systematic observation is made. For which reason is this type of assessment performed so frequently? 1. Time constraints support small portions of assessment at a time. 2. Validating an absence of change decreases the need to document. 3. Critical changes are less likely to occur with constant observation. 4. Repetition makes it less likely the nurse will miss an assessment area.

4. Repetition makes it less likely the nurse will miss an assessment area.

The nurse is collecting data on a new patient at an adult clinic. Which data does the nurse need to validate? 1. The client's weight is 185 lb (83.9 kg) at the clinic. 2. The client's liver function test results are elevated. 3. The client states that blood pressure (BP) of 160/94 mm Hg is typical. 4. The client reports eating processed foods on a low-sodium diet.

4. The client reports eating processed foods on a low-sodium diet.

The nurse documents in a patient's progress notes: "Admitted to emergency department accompanied by spouse. Patient is alert and oriented, blood pressure is 120/80 mm Hg, and pulse is 80 beats/min. The patient is anxious and becomes nervous when asked about a smoking history." Which statement from the nurse's note is the best example of an inference? 1. The blood pressure reading is 120/80 mm Hg. 2. The patient is accompanied by spouse. 3. The patient has a history of smoking. 4. The patient is anxious.

4. The patient is anxious.

During the initial assessment of a newly admitted client, the nurse asks about use of nutritional and herbal supplements. For which reason is it important for the nurse to obtain this specific information? 1. To determine what type of therapies are acceptable to the client 2. To identify whether the client has a nutrition deficiency 3. To help the nurse understand the client's cultural and spiritual beliefs 4. To be aware of potential interaction with prescribed medication

4. To be aware of potential interaction with prescribed medication

Intellectual empathy

Asking a patient's feelings about his cancer diagnosis

Intellectual humility

Asking for help with a procedure because you have not done it before

Nurses use a five-step process in selecting the best nursing interventions for their patients. Using the five-step process, arrange the option numbers in the correct order of completion. (Enter the number of each step in the proper sequence; do not use commas.) A. Review the desired outcomes/goals. B. Identify several actions or interventions. C. Individualize standardized interventions. D. Review the nursing diagnosis. E. Choose the best interventions for the patient.

D A B E C

Using Maslow's Hierarchy of Needs, rank the following nursing diagnoses in order of importance, beginning with the highest-priority diagnosis. (Enter using the following format: 1, 2, 3, 4) A. Anxiety B. Risk for infection C. Disturbed body image D. Sleep deprivation

D .Sleep deprivation B. Risk for infection A. Anxiety C C. Disturbed body image

In which phase of the nursing process does the nurse decide whether her actions have successfully treated the client's health problem? ________________

Evaluation

The nurse has developed and implemented a care plan for a patient. Evaluation of the patient's responses ends the nursing process for this patient

False

Intellectual perseverance

Obtaining the latest research about a new diagnostic procedure even though the articles are difficult to find

Independent thinking

Questioning the reason for a new staffing policy

Intellectual courage

Questioning your feelings when a patient's family requests withholding nutrition for a terminally ill client

Intellectual curiosity

Reading the instruction manual of a new glucose-monitoring machine

A nurse is in the process of generating and selecting nursing interventions for a patient. Number the following steps in the order in which they should occur. 1) Choose the best interventions for the patient. 2) Identify several interventions or actions .3) Review the desired patient outcomes. 4) Review the nursing diagnosis. 5) Individualize standardized interventions to meet the patient's unique needs.

The steps should be done in the following order: 4, 3, 2, 1, 5

Nursing interventions are performed for the purpose of assessing health status, preventing and treating illness or disease, and promoting health

True