Nursing Process Practice Questions

How can a nurse best evaluate the effectiveness of communication with a client? A. Client feedback B. Medical assessments C. Health care team conferences D. Client's physiologic responses

A. Client feedback

What nursing actions best promote communication when obtaining a nursing history? Select all that apply. A. Establishing eye contact B. Paraphrasing the client's message C. Asking "why" and "how" questions D. Using broad, open-ended statements E. Reassuring the client that there is no cause for alarm F. Asking questions that can be answered with a "yes" or "no"

A. Establishing eye contact B. Paraphrasing the client's message D. Using broad, open-ended statements

The nurse is communicating with an older adult who has a hearing disability. Which intervention by the nurse is beneficial to promote communication? Select all that apply. A. Giving the client a chance to speak B. Assuming the client is being uncooperative C. Chewing gum while talking to the client D. Making sure that the client knows you are speaking E. Keeping the communication concise

A. Giving the client a chance to speak D. Making sure that the client knows you are speaking E. Keeping the communication concise

Which actions should the nurse perform while collecting subjective data from a client during a focused urinary assessment? Select all that apply. A. Inquire about painful urination B. Ask the client about changes in characteristics of urination C. Assess the levels of blood urea nitrogen and creatinine D. Palpate the abdomen for bladder distention or masses E. Inspect the urinary meatus for inflammation or discharge

A. Inquire about painful urination B. Ask the client about changes in characteristics of urination

A registered nurse teaches a nursing student about considerations for administering medication in infants. Which statement of the nursing student indicates a need for additional learning? A. "I should administer nasal drops 20-30 minutes before a feeding." B. "I should pull the ear pinna up and back while administering ear drops." C. "I should wait until the infant stops crying for administering oral medication." D. "I should restrain the head and place an eye drop at the corner near the nose if the infant is uncooperative."

B. "I should pull the ear pinna up and back while administering ear drops."

Which intervention does the nurse implement to develop a caring relationship with the client's family? A. Deciding healthcare options for the client B. Identifying the client's family members and their roles C. Declining to inform the client's family after performing a procedure D. Refraining from discussing the client's health with the family

B. Identifying the client's family members and their roles

Which is an example of an actual nursing diagnosis? A. Risk for acute confusion B. Impaired social interaction C. Readiness for enhanced nutrition D. Readiness for increased family coping

B. Impaired social interaction

Which nursing action is a part of the evaluation phase of the critical thinking process? Select all that apply. A. Collecting all the data in order B. Looking at all the situations objectively C. Support the findings and drawing conclusions D. Be open-minded to information about a client E. Using several criteria to determine the effectiveness of a nursing intervention

B. Looking at all the situations objectively E. Using several criteria to determine the effectiveness of a nursing intervention

Which is an indirect nursing care intervention? A. Administering medications B. Managing the client's environment C. Counseling the family during a time of grief D. Inserting intravenous infusion

B. Managing the client's environment

While providing palliative care, the nurse finds symptoms of dyspnea. What will be the priority nursing intervention in this situation? A. Administering benzodiazepines B. Providing prescribed oxygen by nasal cannula C. Applying wet clothes on the client's face D. Encouraging imagery and deep breathing

B. Providing prescribed oxygen by nasal cannula

17. The nurse is assessing a client after surgery. Which assessment finding does the nurse obtain from the primary source? A. X-ray reports B. Severity of pain C. Results of blood work D. Family caregiver interview

B. Severity of pain

A 93-year-old client in a nursing home has been eating less food during mealtimes. What is the priority nursing intervention? A. Substitute a supplemental drink for the meal. B. Spoon-feed the client until the food is completely eaten. C. Allow the client a longer period of time to complete the meal. D. Arrange a consultation for the placement of a gastrostomy tube.

C. Allow the client a longer period of time to complete the meal.

What should the nurse do when the defining characteristics of assessment data for a client can apply to more than one diagnosis? Select all that apply. A. Reassess the client. B. Reject all diagnoses. C. Gather more information. D. Identify related factors. E. Review all defining characteristics.

C. Gather more information. D. Identify related factors. E. Review all defining characteristics.

The nurse documents the data gathered during the assessment in a client's medical record. What should the nurse do to ensure that the data is meaningful to other healthcare providers? A. Record subjective information in own words. B. Form judgments through written communication. C. Record objective information using accurate terminology. D. Compare data from the physical examination with client behavior.

C. Record objective information using accurate terminology.

The nurse teaches a client about cleaning the skin to prevent pressure ulcers. Which statement made by the client indicates the nurse needs to follow up? A. "I should gently pat the skin." B. "I should use mild, heavily fatted soap." C. "I should wash with tepid rather than hot water." D. "I should apply powders or talc on a perineum wound."

D. "I should apply powders or talc on a perineum wound."

The registered nurse is teaching the student nurse about writing nursing interventions. Which intervention written by the student nurse indicates effective learning? A. "Turn the client every 2 hours." B. "Perform blood glucose measurements regularly." C. "Change the client's dressing once a shift: 6 AM—2 PM—10 PM." D. "Irrigate the wound with 100 mL normal saline until clear: 6 AM—2 PM—8 PM."

D. "Irrigate the wound with 100 mL normal saline until clear: 6 AM—2 PM—8 PM."

Which physical assessment technique involves listening to the sounds of the body? A. Palpation B. Inspection C. Percussion D. Auscultation

D. Auscultation

The unlicensed assistive personnel (UAP) recorded the vital signs of four clients. Which client needs immediate nursing interventions? A. 70 y/o w/ Pulmonary Infection, RR 28, SpO2 70% B. 55 y/o w/ Fractured Hand, RR 14, BP 140/86 mmHg C. 60 y/o w/ COPD, RR 20, SpO2 90% D. 45 y/o w/ Breast Cancer, RR 16, BP 128/62 mmHg

A. 70 y/o w/ Pulmonary Infection, RR 28, SpO2 70%

A nurse is evaluating the effectiveness of treatment for a client with excessive fluid volume. What clinical finding indicates that treatment has been successful? A. Clear breath sounds B. Positive pedal pulses C. Normal potassium level D. Decreased urine specific gravity

A. Clear breath sounds

Which step of the nursing process is directly affected if the nurse does not make a nursing diagnosis? A. Planning B. Evaluation C. Assessment D. Implementation

A. Planning

1Which feature is characteristic of a risk nursing diagnosis? A. The diagnosis does not have defining characteristics. B. The diagnosis can be used in any health state. C. The defining characteristics support the diagnostic judgment. D. The defining characteristics are supported by a client's readiness.

A. The diagnosis does not have defining characteristics.

The registered nurse teaches the student nurse about the priority of care provided to clients with chest pain. Which activity performed by the student nurse indicates effective learning? A. Placing the client in upright position B. Auscultating heart and breath sounds C. Administering oxygen via nasal cannula D. Assessing airway, breathing, and circulation (ABC)

D. Assessing airway, breathing, and circulation (ABC)

A nurse identifies the establishment of trust as a major nursing goal for a depressed client. How can this goal best be accomplished? A. By spending a day with the client B. By asking the client at least one question daily C. By waiting for the client to initiate the conversation D. By visiting frequently for short periods with the client each day

D. By visiting frequently for short periods with the client each day

After abdominal surgery a client reports pain. What action should the nurse take first? A. Reposition the client. B. Obtain the client's vital signs. C. Administer the prescribed analgesic. D. Determine the characteristics of the pain.

D. Determine the characteristics of the pain.

Which step in the research process is similar to the assessment step of the nursing process? A. Analyzing the results B. Conducting the study C. Developing hypothesis D. Identifying the problem

D. Identifying the problem

The nurse is aware that the nursing diagnosis should follow the North American Nursing Diagnosis Association International (NANDA-I) label. How should the nurse document the nursing diagnosis in a three-part format? A. NANDA-I label, related factor, and etiologies B. NANDA-I label, risk factor, and nursing interventions C. NANDA-I label, related factor, and nursing interventions D. NANDA-I label, related factor, and defining characteristics

D. NANDA-I label, related factor, and defining characteristics

The nurse plans care for a client who has anxiety related to uncertainty over the course of recovery. Which action of the client would indicate that the desired goal is achieved? A. The client discusses the surgical outcomes with the surgeon. B. The client shares concerns with the spouse before discharge. C. The client describes the effects surgery will have on recovery. D. The client expresses acceptance of health status by the day of discharge.

D. The client expresses acceptance of health status by the day of discharge.

The nurse creates a plan of care for a client with a risk of infection. Which is the most desirable expected outcome for the client? A. All nursing functions will be completed by discharge. B. All invasive intravenous lines will remain patent. C. The client will remain awake, alert, and oriented at all times. D. The client will be free of signs and symptoms of infection by discharge.

D. The client will be free of signs and symptoms of infection by discharge.

The registered nurse teaches a nursing student about the implementation process of nursing. Which example does the registered nurse use while describing indirect care interventions using his or her knowledge? A. The nurse counseling a client at the time of grief B. The nurse administering an intravenous infusion to a client C. The nurse teaching the client about an appropriate nutrition plan D. The management of the client's environment to prevent infections

D. The management of the client's environment to prevent infections

Which diagnosis made by the nurse is helpful in providing the right nursing interventions for the client? A. The nurse understands that the client has pain due to a tracheostomy. B. The nurse identifies that the client is anxious about the cardiac catheterization. C. The nurse realizes that the client has diarrhea and needs the bedpan frequently. D. The nurse identifies that the client is not aware of perineal care and has impaired skin integrity.

D. The nurse identifies that the client is not aware of perineal care and has impaired skin integrity.