Fundamentals 2 Test 1

Which statement is the best example of a nurse using evidence-based practice?

"Research shows that this is the safest way to implement that procedure."

Which of the following is an example of a nurse's statement that reflects using the scientific method in the nursing process?

"The patient reports more pain than yesterday and her blood pressure is elevated."

Which statement is true regarding construction and utilization of nursing care plans?

Nursing students use nursing care plans for their assigned patients.

The role of the LPN/LVN in the patient admission procedure differs from that of the RN and might include: (Select all that apply.)

Obtains an ordered urine specimen. Takes the patients history Assists with physical data collection Orients the pt to the unit

Rapport is established with the patient during which part of the patient interview?

Opening

Which stages are included in an interview? (Select all that apply.)

Opening, body, closing

Input from the ___________ during the planning stage of the nursing process results in greater success

Patient

Which is the best way to demonstrate critical thinking to your clinical instructor who has just asked you about your patient?

Pausing and thinking before answering the question

To conduct a physical examination of a patient, which examination technique is used?

Percussion of an area

According to most theorists, what are the three concepts important to nursing?

Person, health, environment

The component of the nursing process that includes setting the goal is

Planning

Third step of the nursing process?

Planning

Which statement is true regarding a plan of care for a patient?

Plans of care should be a collaborative process

To reflect the patient's most immediate problems or needs, the list of nursing diagnoses should be:

Prioritized

Arranging tasks in order of importance is defined as

Prioritizing

Which is an example of clinical judgment?

Prioritizing which call light to answer first

An example of a dependent nursing action would be:

starting the continuous passive motion (CPM) machine.

During the implementation of the nursing process:

the planned nursing interventions are carried out.

Before carrying out a dependent nursing action, the nurse: (Select all that apply.)

verifies that the physician's order is on the chart. considers whether there is any contraindication for the action. schedules an appropriate time to carry out the action. gathers all equipment and supplies needed for the action.

The nurse evaluates the care provided to the patient by determining:

whether expected outcomes have been achieved.

Which of the following statements is not true?

Licensed practical nurses can initiate nursing diagnoses.

The patient's order reads: ampicillin 20 mg/kg/day, IV q 6 hr. The patient weighs 120 lb. How many milligrams (mg) per dose should you administer? _____________ (Fill in the blank.)

182 mg

Linda knows as part of her nursing assignment that she is to review and update the nursing care plan on her patients:

24 hrs

For Medicare, a reassessment of a patient in a long-term care facility must be done every:

90 days

Which statement is true regarding nursing diagnoses?

A nursing diagnosis describes a health problem amenable to intervention

Which one of the following sets of assessment data is most likely to be present with the nursing diagnosis Risk for infection?

Abdominal incision, decreased hemoglobin, and indwelling catheter present

The nursing history and initial assessment are performed at:

Admission

One of the highest priorities of nursing care is

Airway management

Critical thinking will help you in the clinical setting to:

Make good decisions most of the time

The first step in solving a problem is to

Define the problem

__________ is judgment of the effectiveness of the intervention or plan and is a collaborative process.

Evaluation

A difference in the assessment of the patient entering a long-term care facility versus that of a hospital patient is that the long-term care resident is assessed for:

Functional ability

Which is an independent nursing action?

Giving a back massage

A physician's order is needed to:

change the medical plan of care

Who was known for the implementation of evidence- based practice?

Archie Cochrane

The nursing process component that gathers subjective data from the patient is the

Assessment

Which are components of the nursing process

Assessment, nursing diagnosis, evaluation

n an acute care setting, the nursing care plan should be reviewed and updated:

At least once every 24 hours

Which of the following medical records may be ordered to determine if nursing standards are being met?

Audit

A patient who is 14 hours postoperative complains of shortness of breath. Which action should be implemented first?

Auscultate the lungs

In a nursing care plan, evaluation can:

Be incorporated into every nursing staff member's role.

When evaluating a patient admitted with a lower respiratory tract infection, which data are most important for the nurse to obtain?

Bilateral lung sounds

Etiologic factors are the

Causes of the problem

Which nursing intervention for the patient in question 4 would you rank as the highest priority?

Change the bed linens and gown.

When reviewing a patient's chart, information about religion, occupation, and significant others would most readily be found in the:

Chart face sheet

There are four cognitive levels used on the NCLEX-PN ® examination. Which of the following is not one of the four cognitive levels?

Collaboration

The following is an example of subjective assessment data

Complaint of pain

A drawing to illustrate the relationships between ideas 💡 is known as

Concept map 🗺

Which process is used by the organization to evaluate the overall effectiveness of nursing care?

Continuous quality improvement (CQI)

________ are pieces of data or information that influence decisions.

Cues

The planning phase of the nursing process correlates with which step of the scientific method?

Developing solutions

Recording pertinent data on the clinical record involves:

Documentation

Clinical reasoning is necessary to

Draw sound conclusions from assessment data

Is carried out by gathering data to determine if expected outcomes have been achieved

Evaluation

The nursing process component that is performed to determine if the plan was successful is the

Evaluation

In the nursing process, evaluation is the step in which it is determined if the _____ has been met.

Goal or expected outcome

Which data collection method uses functional patterns to represent the interaction between the patient and the environment?

Gordon's Heath patterns

A basic patient needs assessment is based on Maslow's:

Hierarchy of needs

The steps of the problem solving process include

Identification of problem

A registered nurse (RN) delegates to a licensed practical nurse the task of monitoring intake and output for all patients who have been treated for heart failure on a cardiac medical unit. The unit manager is reviewing the effectiveness of heart failure management on the unit. Delegation is included in which component of the nursing process?

Implementation

In which step of the nursing process are nursing interventions carried out?

Implementation

The step of the nursing process in which nursing interventions are performed is known as:

Implementation

Which is the etiologic factor in the nursing diagnosis Impaired physical mobility r/t left-sided muscular weakness, as evidenced by the inability to use the left arm for activities of daily living?

Left sided muscular weakness

The goal of an outcome-based quality improvement (OBQI) program is to:

Improve nursing practice

Outcome-based quality improvement programs require nursing audits. The goal of such programs is the ________________________________. (Fill in the blank.)

Improvement of nursing care

A quick head-to-toe patient assessment:

Includes skin color, turtle, and temperature

Flora, an LPN, is helping her patient understand the side effects of a medication. This is what type of action?

Independent

A nursing diagnosis differs from a medical diagnosis. A nursing diagnosis:

Indicates the persons health status

Critical thinking

Is incorporated throughout the nursing process

Prioritizing pt problems is usually based on

Maslows hierarchy of needs

Priorities of care change constantly because (select all that apply)

Nurses workload may change as patients are admitted Physicians orders may change throughout shift A pts condition may deteriorate

After the assessment data are analyzed, an RN chooses a

Nursing diagnosis

What do concept maps do?

Promote critical thinking

Which is stated as a goal rather than an expected outcome?

Pt will regain use of left arm and leg

Which is a correctly stated expected outcome?

Pt will walk to the end of the hall this week

Which is the highest priority on a general medical unit?

Pt with chest pain

Which is considered a low priority pt in the ER

Pt with sore throat

Critical thinking involves

Purposeful mental activity

In the home care setting, the initial assessment is usually performed by the:

RN

In the nursing plan of care, expected outcomes should be:

Realistic and measurable

Before Ms. Bricker, LPN, carries out any interventions such as the administration of a medication, she must know:

Reason for intervention Usual standard of care Expected outcome Potential danger

Critical thinking is best described as

Reasoning

You assist a patient with her bath, change her dressing, rub her back, give her medication, review her dietary needs, and assist with physical therapy exercises. Which are examples of interdependent nursing actions? (Select all that apply.)

Reinforcing dietary teaching Assisting with her exercises

An example of an approved, correctly written NANDA-I nursing diagnosis for the patient is:

Risk for injury r/t neurologic impairment as evidenced by paralysis of right leg.

Attributes of critical thinkers include

Setting priorities Verifying accuracy and reliability of data Reasoning logically Being flexible Recognizing inconsistencies in data gathered

A goal that is achievable within 7 to 10 days is considered:

Short term

The patient's temperature is 100.4° F (38° C). The skin on her forehead is warm and dry. She has been incontinent, and her bed is wet. She complains of being very tired. Which of the data are subjective? (Select all that apply.)

States, "I'm very uncomfortable." Complains of being very tired States, "I have a headache."

Which is a long term goal for a patient

Stroke rehabilitation

When Madison is admitting a patient, the patient states, "I am having some mild pain." This is known as:

Subjective information

As part of an assessment, the nurse asks for information from the patient. This information is a subjective indication of illness perceived by the patient and is called a/an:

Symptom

Example of objective data

Temperature

Which statement is true regarding implementation of care in long-term care facilities?

The nurse performs all sterile procedures.

According to Maslow's Needs Theory, what happens when a need is met?

The person is no longer aware of the need.

How do concept maps assist critical thinking?

They help point out relationships among the data.

Which of the following nursing actions is the best example of problem solving?

Trying several difficult wound dressings to determine which one the patient can apply the most effectively

At a minimum, long-term care facilities require written documentation of a client's problem or nursing diagnosis every:

Week

A long-term goal/outcome would be:

Will walk without assistance within 3 weeks

Entering patient assessment data on the nursing care plan is a form of

Written communication

A standard nursing procedure should be written to include:

a list of all equipment needed to perform the procedure.

Debbie, a student nurse, is learning about care plans. She knows all of the following are true regarding care plans except:

an LPN is responsible for constructing the care plan.

Nursing and medical audits:

are essential for hospital accreditation.

In a clinical path or care map, evaluation:

can also be done by the pharmacist or nutritionist.

The main purpose of continuous quality improvement is to:

identify specific areas that need change.

Before carrying out a specific intervention in the patient plan of care, a nurse should: (Select all that apply.)

identify the reason for the intervention. identify the rationale for the intervention. identify the usual standard of care. identify any potential dangers.

After Ms. Bricker, LPN, has given her patient medication, she returns later to the patient's room to evaluate the effectiveness of the medication. She knows that in the evaluation phase of the nursing process:

if the expected outcomes are considered met, the nurse's notes must contain data to support this.

Revision of the nursing care plan involves:

inactivating resolved problems.

A nurse has established expected outcomes for an assigned patient. The nurse carries out this important activity for the purpose of:

measuring the effectiveness of nursing interventions.

A nursing audit must:

occur in every hospital to maintain accreditation.

All of the following components can be found on the chart except the:

patient's nurse assignment.