ch13,14,15,16 ExtraQuestions

31. Which of the following are examples of common factors in a client that may influence assessment priorities? Select all that apply. A) Diet and exercise program B) Standing in the community C) Ability to pay for services D) Developmental stage E) Need for nursing

A) Diet and exercise program D) Developmental stage E) Need for nursing

3.A novice nurse collects data on a newly admitted client. Upon evaluation of this data, the nurse provides an erroneous interpretation. What is a corrective action for this interpretation? A) Encourage the novice nurse to independently observe the same situation with a peer, validate the data, and discuss the situation afterward. B) Encourage the novice nurse to develop his or her own tool for data collection. C) Encourage the novice nurse to collect and interpret the data for the client repeatedly, until the novice nurse arrives at the correct interpretation. D) Encourage the novice nurse to meet with the nurse manager to discuss the situation and seek mentoring for communication skills.

A) Encourage the novice nurse to independently observe the same situation with a peer, validate the data, and discuss the situation afterward.

2.A nurse has come on day shift and is assessing the client's intravenous setup. The nurse notes that there is a mini-bag of the client's antibiotic hanging as a piggyback, but that the bag is still full. The nurse examines the patient's medication administration record (MAR) and concludes that the night nurse likely hung the antibiotic but failed to start the infusion. As a result, the antibiotic is three hours late and the nurse has consequently filled out an incident report. In doing so, the nurse has exhibited which of the following? A) Ethical/legal skills B) Technical skills C) Interpersonal skills D) Cognitive skills

A) Ethical/legal skills

31.After assessing a client, the nurse formulates several nursing diagnoses. Which of the following would the nurse identify as an actual nursing diagnosis? A) Impaired urinary elimination B) Readiness for enhanced sleep C) Risk for infection D) Possible impaired adjustment

A) Impaired urinary elimination

2.In planning the care for a client who has pneumonia, the nurse collects data and develops nursing diagnoses. Which of the following is an example of a properly developed nursing diagnosis? A) Ineffective airway clearance as evidenced by inability to clear secretions B) Ineffective health maintenance as evidenced by unhealthy habits C) Ineffective breathing pattern related to pneumonia D) Ineffective therapeutic regimen management due to smoking

A) Ineffective airway clearance as evidenced by inability to clear secretions

26. The nurse observes the client as he walks into the room. What information will this provide the nurse? A) Information regarding the client's gait B) Information regarding the client's personality C) Information regarding the client's psychosocial status D) Information on the rate of recovery from surgery

A) Information regarding the client's gait

30.A nurse who is caring for an unresponsive client formulates the nursing diagnosis, "Risk for Aspiration related to reduced level of consciousness." The nurse documents this nursing diagnosis as correct based on the understanding that which of the following is a characteristic of this type of diagnosis? A) Is written as a two-part statement B) Describes human response to a health problem C) Describes potential for enhancement to a higher state D) Made when not enough evidence supports the problem

A) Is written as a two-part statement

35. The nurse has entered a client's room to find the client diaphoretic (sweat-covered) and shivering, inferring that the client has a fever. How should the nurse best follow up this cue and inference? A) Measure the client's oral temperature. B) Ask a colleague for assistance. C) Give the client a clean gown and warm blankets. D) Obtain an order for blood cultures

A) Measure the client's oral temperature.

5.The nurse has entered a client's room to find the client diaphoretic (sweat-covered) and shivering, inferring that the client has a fever. How should the nurse best follow up this cue and inference? A) Measure the client's oral temperature. B) Ask a colleague for assistance. C) Give the client a clean gown and warm blankets. D) Obtain an order for blood cultures.

A) Measure the client's oral temperature.

1. Which of the following is a correct guideline to follow when composing a nursing diagnosis statement? A) Place defining characteristics after the etiology and link them by the phrase "as evidenced by." B) Phrase the nursing diagnosis as a client need. C) Place the etiology prior to the client problem and linked by the phrase "related to." D) Incorporate subjective and judgmental terminology.

A) Place defining characteristics after the etiology and link them by the phrase "as evidenced by."

25.An unconscious patient is brought to the emergency department. Which of the following assessments should be implemented first? A) The client's airway should be assessed. B) The nurse should determine the reason for admission. C) The nurse should review the client's medications. D) The client's past medical history is assessed.

A) The client's airway should be assessed.

21. A client is brought to the emergency department in an unconscious condition. The client's wife hands over the previous medical files and points out that the client had suddenly fallen unconscious after trying to get out of bed. Which of the following is a primary source of information? A) Client'swife B) Medical documents C) Test results D) Assessment data

A) Client'swife

1. The nursing student uses evidence-based practice findings in the development of a care plan. This is an example of which type of nursing skill? A) Cognitive skill B) Technical skill C) Interpersonal skill D) Ethical/legal skill

A) Cognitive skill

1.Which of the following guidelines should a nursing instructor provide to nursing students who are now responsible for assessing their clients? A) "Assessment data about the client should be collected continuously." B) "Assess your client after receiving the nursing report and again before giving a report to the next shift of nurses." C) "Assess your client at least hourly if the client's vital signs are unstable, and every two hours if the vital signs are stable." D) "Assessment data should be collected prior to the physician rounding on the unit."

A) "Assessment data about the client should be collected continuously."

6. A male client is scheduled to be fitted with a prosthesis following the loss of his nondominant hand in a farm accident several weeks earlier. Nurses have documented the following outcome during this stage of his care: "After attending an educational session, client will demonstrate correct technique for applying his prosthesis." Which of this client's following statements would signal a need to amend this outcome? A) "I'm not interested one bit in wearing an artificial hand." B) "I'm worried that I'm going to get some really strange looks when I wear this thing." C) "I don't have a clue how this thing goes on and comes off." D) "I don't understand the technology that's used in this artificial hand."

A) "I'm not interested one bit in wearing an artificial hand."

30. Which of the following examples of client data needs to be validated? Select all that apply. A) A client has trouble reading an informed consent, but states he does not need glasses. B) An elderly client explains that the black and blue marks on his arms and legs are due to a fall. C) A nurse examining a client with a respiratory infection documents fever and chills. D) A client in a nursing home states that she is unable to eat the food being served. E) A pregnant client is experiencing contractions that are two minutes apart.

A) A client has trouble reading an informed consent, but states he does not need glasses. B) An elderly client explains that the black and blue marks on his arms and legs are due to a fall.

23.A nurse is assigned to care for a client diagnosed with asthma who has just been admitted to the health care facility. The nurse determines the client's priorities for care using which of the following? A) Assessment skills B) Nursing books C) Client's records D) Supervisor's advice

A) Assessment skills

27. After assessment of a client in an ambulatory clinic, the nurse records the data on the computer. The nurse recognizes which of the following as objective data? A) Auscultation of the lungs B) Complaint of nausea C) Sensation of burning in her epigastric area D) Belief that demons are in her stomach

A) Auscultation of the lungs

32.The nurse is conducting a nursing history of a client with a respiratory rate of 30, audible wheezing, and nasal flaring. During the interview, the client denies problems with breathing. What action should the nurse take next? A) Clarify discrepancies of assessment data with the client. B) Validate client data with members of the health care team. C) Document all data collected in the nursing history and physical examination. D) Seek input from family members regarding the client's breathing at home.

A) Clarify discrepancies of assessment data with the client.

4. A client with a new colostomy often becomes short and sarcastic when nurses attempt to teach him about the management of his new appliance. The nurse has consequently documented "Noncompliance related hostility" on the client's chart. What mistake has the nurse made when choosing and documenting this nursing diagnosis? A) Presuming to know the factors contributing to the problem B) Identifying a problem that cannot be changed C) Identifying a problem without corroborating evidence in the statement D) Neglecting to identify potential complications related to the problem

A) Presuming to know the factors contributing to the problem

4.The nurse is planning the care of a male client who is receiving treatment for acute renal failure and who has begun dialysis three times weekly. The nurse has identified the following outcome: "Client will demonstrate the appropriate care of his arteriovenous fistula." This outcome is classified as which of the following? A) Psychomotor B) Affective C) Cognitive D) Holistic

A) Psychomotor

5.The nurse is caring for a client who has been newly diagnosed with diabetes. One of the outcomes the nurse read on the client's plan of care this morning was: "Client will demonstrate correct technique for self-injecting insulin." The client required insulin prior to his lunch and successfully drew up and administered his insulin while the nurse observed. How should the nurse follow up this observation? A) Record an evaluative statement in the client's plan of care. B) Remove the outcome from the client's care plan. C) Ask the nurse who wrote the plan of care to document this development. D) Reassess the client's psychomotor skills at dinner time.

A) Record an evaluative statement in the client's plan of care.

3.Increasingly, health care institutions are implementing computerized plans of nursing care. A benefit of using computerized plans includes which of the following? A) Reduction in the time spent on care planning B) Increased autonomy related to the nursing care planning process C) Enhanced individualization of a care plan D) Increased nursing expertise in care planning

A) Reduction in the time spent on care planning

26.After completing an assessment of a client, the nurse uses critical thinking and clinical reasoning to prioritize the client's problems. Which of the following would the nurse determine is the highest priority? A) Severe bleeding from a wound B) History of asthma C) Diabetes D) Lack of family support

A) Severe bleeding from a wound

22.The nurse is performing an assessment of a client who has a small wound on the knee, collecting cues about the client's health status. Which of the following would the nurse identify as a subjective cue? A) Sharp pain in the knee B) Small bloody drainage on dressing C) Temperature of 102 degrees F D) Pulse rate of 90 beats per minute

A) Sharp pain in the knee

3.A client who has been admitted to the hospital for the treatment of a gastrointestinal bleed requires a transfusion of packed red blood cells. Which of the following aspects of the nurse's execution of this order demonstrates technical skill? A) Starting a new, large-gauge intravenous site on the client, and priming the infusion tubing B) Understanding the Rh system that underlies the client's blood type C) Ensuring that informed consent has been obtained and properly filed in the client's chart D) Explaining the process that will be involved in preparing and administering the transfusion

A) Starting a new, large-gauge intravenous site on the client, and priming the infusion tubing

30. Which intervention does the nurse recognize as a collaborative intervention? A) Teach the client how to walk with a three-point crutch gait. B) Administer spironolactone (Aldactone). C) Perform tracheostomy care every eight hours. D) Straight catheterize every six hours.

A) Teach the client how to walk with a three-point crutch gait.

28. When the nurse assesses the client's blood sugar, what is the term for the type of skill the nurse is using? A) Technical B) Therapeutic C) Interactional D) Adaptive

A) Technical

3.The nurse has identified a number of risk nursing diagnoses in the care of an adolescent who has been admitted to the hospital for treatment of an eating disorder. These risk diagnoses indicate which of the following? A) The client is more vulnerable to certain problems than other individuals would be. B) The diagnoses present significant risks for the development of medical diagnoses. C) The data necessary to make a definitive nursing diagnosis is absent. D) The diagnosis has yet to be confirmed by another practitioner.

A) The client is more vulnerable to certain problems than other individuals would be.

29. Which of the following is a correctly written client goal? Select all that apply. A) The client will identify five low-sodium foods by October 9. B) The client will know the signs and symptoms of infection. C) The client will rate pain as a 3 or less on a 10-point scale by 5 pm today. D) The client will understand the side effects of digoxin (Lanoxin). E) The client will eat at least 75% of all meals by May 5.

A) The client will identify five low-sodium foods by October 9. C) The client will rate pain as a 3 or less on a 10-point scale by 5 pm today. E) The client will eat at least 75% of all meals by May 5.

29. Which of the following data regarding a client with a diagnosis of colon cancer are subjective? Select all that apply. A) The client's chemotherapy causes him nausea and loss of appetite. B) The client became teary when his daughter from out of state came to the bedside. C) The client's ileostomy put out 125 mL of effluent in the past four hours. D) The patient is unwilling to manipulate or empty his ostomy bag. E) The patient has been experiencing fatigue in recent weeks.

A) The client's chemotherapy causes him nausea and loss of appetite. E) The patient has been experiencing fatigue in recent weeks.

24.A client age 50 years reports to a primary care unit with an open wound due to a fall in the bathroom. Which of the following nursing actions represents caring skills? A) The nurse cleans the wound and applies a dressing to it. B) The nurse inspects and examines the wound for swelling. C) The nurse tells the client to use caution while on slippery surfaces. D) The nurse informs the client that the wound is small and will heal easily.

A) The nurse cleans the wound and applies a dressing to it.

2.Nurses make common errors in the identification and development of outcomes. Which of the following is a common error made when writing client outcomes? A) The nurse expresses the client outcome as a nursing intervention. B) The nurse develops measurable outcomes using verbs that are observable. C) The nurse develops a target time when the client is expected to achieve that outcome. D) The outcome should include a subject, verb, conditions, performance criteria, and target time.

A) The nurse expresses the client outcome as a nursing intervention.

35. Which of the following reflects the diagnosis phase? A) The nurse identifies that the client does not tolerate activity. B) The nurse performs wound care using sterile technique. C) The nurse sets a tolerable pain rating with the client. D) The nurse documents the client's response to pain medication.

A) The nurse identifies that the client does not tolerate activity.

4. In which of the following situations would the nurse be most justified in implementing trial-and-error problem solving? A) The nurse is attempting to landmark an obese client's apical pulse. B) The nurse is attempting to determine the range of motion of a client's hip joint following hip surgery. C) The nurse is attempting to determine which PRN (as needed) analgesic to offer a client who is in pain. D) The nurse is attempting to determine whether a poststroke client has a swallowing deficit.

A) The nurse is attempting to landmark an obese client's apical pulse.

4. When documenting subjective data, the nurse should do which of the following? A) Use the client's own words placed in quotation marks. B) Paraphrase the information stated by the client. C) Validate the information with the client's family prior to documentation. D) Record the information using nonspecific words.

A) Use the client's own words placed in quotation marks.

5.The nurse has drafted a nursing diagnosis of Imbalanced Nutrition: More Than Body Requirements in the care of moderately obese client. How should the nurse proceed after writing this diagnosis? A) Validate the nursing diagnosis B) Identify potential complications C) Cross-reference the nursing diagnosis with medical diagnoses D) Modify interventions based on the diagnosis

A) Validate the nursing diagnosis

34.The nurse is providing care for a pediatric client on night shift. At 0400, the nurse notes that the child has a high fever but does not have an order for an antipyretic. What nursing action represents a good example of teamwork and collaboration as defined by the Quality and Safety Education for Nurses (QSEN) competencies? The nurse: A) calls the health care practitioner, reports her findings, and requests an order for an antipyretic. B)gives the child a common over-the-counter antipyretic based on dosing recommendations and reports this to the oncoming nurse. C)reports to the oncoming nurse at 0700 that the child has a fever so that when the healthcare provider comes in, she can obtain an order for an antipyretic. D) requests that the child 's mother give the child something for the fever that she brought from home.

A) calls the health care practitioner, reports her findings, and requests an order for an antipyretic.

1.The nurse develops long-term and short-term outcomes for a client admitted with asthma. Which of the following is an example of a long-term goal? A)Client returns home verbalizing an understanding of contributing factors, medications, and signs and symptoms of an asthma attack. B) By day 3 of hospitalization, the client verbalizes knowledge of factors that exacerbate the symptoms of asthma. C) Within one hour of a nebulizer treatment, adventitious breath sounds and cough are decreased. D) Within 72 hours of admission, the client's respiratory rate returns to normal and retractions disappear.

A)Client returns home verbalizing an understanding of contributing factors, medications, and signs and symptoms of an asthma attack.

29.Nurses apply critical thinking to clinical reasoning and judgment in their nursing practice every day. Which of the following are characteristics of this practice? Select all that apply. A) It is guided by standards, policies and procedures, ethics codes, and laws. B) It is based on principles of nursing process, problem solving, and the scientific method. C) It carefully identifies the key problems, issues, and risks involved. D) It is driven by the nurse's need to document competent, efficient care. E) It calls for strategies that make the most of human potential.

A, It is guided by standards, policies and procedures, ethics codes, and laws. B) It is based on principles of nursing process, problem solving, and the scientific method. C) It carefully identifies the key problems, issues, and risks involved. E) It calls for strategies that make the most of human potential.

28.A client has an external fixation device on his leg due to a compound fracture. The client says that the device and swelling makes his leg look ugly. Which nursing diagnosis should the nurse document in his care plan based on the client's concern? A) Impaired physical mobility B) Disturbed body image C) Risk for infection D) Risk for social isolation

B) Disturbed body image

34. Which of the following is not appropriate in writing client-centered measurable outcomes? A) The client or a part of the client B) A flexible time frame C) Observable, measurable terms D) The action the client will perform

B) A flexible time frame

32.The nursing student asks the nurse about nurse-initiated and physician-initiated interventions. Which of the following is a physician-initiated intervention? A) Teach client how to transfer from bed to chair and chair to bed. B) Administer oxygen 4 L/min per nasal cannula. C) Assist the client with coughing and deep breathing every hour. D) Monitor intake and output every 2 hours.

B) Administer oxygen 4 L/min per nasal cannula

34.The nurse is providing care for a client who experienced an ischemic stroke five days ago. Which of the following diagnoses would the nurse be justified in identifying and documenting in the care of this client? Select all that apply. A) Dysphagia B) Bowel Incontinence C) Impaired Swallowing D) Impaired Physical Mobility E) Risk for Hemiparesis

B) Bowel Incontinence C) Impaired Swallowing D) Impaired Physical Mobility

24.When the nurse inspects a postoperative incision site for infection, which one of the following types of assessments is being performed? A) Complete B) Focused C) General D) Time-lapse

B) Focused

23.A nurse caring for a client admitted to the intensive care unit with a stroke assesses the client's vital signs, pupils, and orientation every few minutes. The nurse is performing which type of assessment? A) Initial assessment B) Focused assessment C) Time-lapsed reassessment D) Emergency assessment

B) Focused assessment

20.A client is being prepared for cardiac catheterization. The nurse performs an initial assessment and records the vital signs. Which of the following data collected can be classified as subjective data? A) Blood pressure B) Nausea C) Heart rate D) Respiratory rate

B) Nausea

32. What is the nurse accountable for, according to the state nurse practice act? A) Continuing education B) Nursing diagnoses C) Prescribing medications D) Mentoring other nurses

B) Nursing diagnoses

32. Self-evaluation is a method that nurses use to promote their own development, and to grow in confidence in their nursing roles. This process is referred to as what? A) Promoting the nurse's self-esteem. B) Reflective practice. C) Assessment of oneself. D) Learning from mistakes.

B) Reflective practice.

24. A client is scheduled for surgery for an abdominal hysterectomy. During the preoperative assessment, the client states, "I am very nervous and scared to have surgery." What client outcome is the priority? A) Evaluate the need for antibiotics. B) Resolve the client's anxiety. C) Provide preoperative education. D) Prepare the client for surgery.

B) Resolve the client's anxiety.

35)While developing the plan of care for a new client on the unit the nurse must identify expected outcomes that are 35. appropriate for the new client. What is a resource for identifying these appropriate outcomes? A) Community Specific Outcomes Classification (CSO) B) The Nursing-Sensitive Outcomes Classification (NOC) C) State Specific Nursing Outcomes Classification (SSNOC) D) Department of Health and Human Resources Outcomes Classification (HHROC)

B) The Nursing-Sensitive Outcomes Classification (NOC)

25. Which of the following client outcomes best describes the parameters for achieving the outcome? A) The client will eat a well-balanced diet. B) The client will consume a 2,400-calorie diet, with three meals and two snacks, starting tomorrow. C) The client will cleanse his wound with soap and water and apply a dry sterile dressing. D) The client will be without pain in 24 hours.

B) The client will consume a 2,400-calorie diet, with three meals and two snacks, starting tomorrow.

33.The nurse is reviewing information about a client and notes the following documentation Client is confused. The nurse recognizes this information is an example of what? A) Subjective data B) A data cue C) An inference D) Primary data

C) An inference

29.A client who has to undergo a parathyroidectomy is worried that he may have to wear a scarf around his neck after surgery. What nursing diagnosis should the nurse document in the care plan? A) Risk for impaired physical mobility due to surgery B) Ineffective denial related to poor coping mechanisms C) Disturbed body image related to the incision scar D) Risk of injury related to surgical outcomes

C) Disturbed body image related to the incision scar

27.When the nurse is administering Lasix 20 mg to a client in congestive heart failure, what phase of the nursing process does this represent? A) Assessment B) Planning C) Implementation D) Evaluation

C) Implementation

33.The nurse formulates the following client outcome: Client will correctly draw up morning dose of insulin and identify 33. four signs and symptoms of hypoglycemia by September 7. Which error has the nurse made? A) Expressed the client outcomes as a nursing intervention B) Wrote vague outcomes that will confuse other nurses C) Included more than one client behavior in the outcome D) Used verbs that are not observable and measurable

C) Included more than one client behavior in the outcome

31. Which of the following is a correctly written client goal? A) The client will eliminate a soft formed stool. B) The client understands what foods are low in sodium. C) The client will ambulate 10 feet with a walker by October 12. D) The client correctly self-administers the morning dose of insulin.

C) The client will ambulate 10 feet with a walker by October 12.

34.While bathing the client, the nurse observes the client grimacing. The nurse asks if the client is experiencing pain. The client nods yes and refuses to continue the bath. The nurse removes the wash basin, makes the client comfortable, and documents the event in the client's chart. Which of the following actions clearly demonstrates assessing? A) The nurse bathing the client B) The nurse documenting the incident C) The nurse asking if the client is having pain D) The nurse removing the wash basin

C) The nurse asking if the client is having pain

33. A client is experiencing shortness of breath, lethargy, and cyanosis. These three cues provide organization or ... A) Categorizing B) Diagnosing C) Grouping D) Clustering

D) Clustering

27.According to Maslow's hierarchy of needs, which nursing diagnosis has the lowest priority for a client admitted to the intensive care unit with a diagnosis of congestive heart failure? A) Ineffective airway clearance B) Ineffective coping C) Impaired urinary elimination D) Risk for body image disturbance

D) Risk for body image disturbance

33.Nursing is a profession in a rapidly changing health care environment. What is the most important reason for the nurse to develop critical thinking and clinical reasoning? A) To be able to employ the nursing process in client care. B) The licensing examination requires nurses to be adept at critical thinking. C) Because clients deserve experts who know how to care for them. D) To provide quality care with nursing ability and knowledge.

D) To provide quality care with nursing ability and knowledge.