Practice Questions

Which parties are essential for the nurse to include in the implementation of a client's plan of care? A. Client, family, and physician B. Client, physician, and hospital director C. Client, physical therapist, and nursing staff D. Client, surgeon, and physician

A. Client, family, and physician

The nurse is caring for a vegetarian who has iron deficiency anemia. The standardized nutritional plan for a client with anemia calls for the client to increase consumption of animal protein. How should the nurse plan to meet this client's nutritional needs? A. Collaborate with the nutritionist to modify the nutritional plan. B. Instruct the client that consumption of animal protein is necessary to cure the anemia. C. Meet with the client's family to emphasize the importance of nutritional modification. D. Arrange for animal protein to be disguised in the client's meal.

A. Collaborate with the nutritionist to modify the nutritional plan.

Which nursing diagnosis has priority? A. Ineffective Airway Clearance related to retention of secretions B. Disturbed Sleep Pattern related to abdominal incisional pain C. Self-care Deficit: Bathing related to joint inflammation D. Constipation related to decreased fluid intake and decreased mobility

A. Ineffective Airway Clearance related to retention of secretions

Which action should the nurse take to ensure that an unlicensed assistive personnel (UAP) understands the instructions to perform a delegated task? A. Instruct the UAP to repeat the instructions to be sure the nurse has communicated clearly. B. Request that the UAP place the steps of the task in the framework of the nursing process. C. Inform the UAP of the importance of following each step listed in the procedure manual. D. Ask another UAP to observe and assist the UAP in performing the task.

A. Instruct the UAP to repeat the instructions to be sure the nurse has communicated clearly.

After the health history and admission assessment are completed, the nurse establishes a care plan for the client. What is the rationale for documenting and planning the client's care? A. It helps deliver holistic, goal-oriented, individualized care. B. It creates a teaching log for family. C. It verifies staffing. D. It provides the client with information about treatments.

A. It helps deliver holistic, goal-oriented, individualized care.

Which action should the nurse take when a patient has achieved each expected outcome in the care plan? A. Terminate the care plan. B. Modify the care plan. C. Continue the care plan.

A. Terminate the care plan.

Which nursing action would most likely occur during the ongoing planning stage of the comprehensive care plan? A. The nurse collects new data and uses them to update the plan and resolve health problems. B. The nurse uses teaching and counseling skills to help the patient carry out self-care behaviors at home. C. The nurse who performs the admission nursing history develops a patient care plan. D. The nurse consults standardized care plans to identify nursing diagnoses, outcomes, and interventions.

A. The nurse collects new data and uses them to update the plan and resolve health problems.

Which one of the following nursing interventions is an indirect care intervention? A. A nurse explains available birth control measures to a young couple. B. A nurse meets with the collaborative care team to plan nursing measures for a patient. C. A nurse prays with a patient prior to surgery. D. A nurse administers pain medication to a patient with end-stage renal cancer.

B. A nurse meets with the collaborative care team to plan nursing measures for a patient.

Which is a physician-initiated intervention? A. Teach the client how to transfer from bed to chair and chair to bed. B. Administer oxygen at 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 at 4 L/min per nasal cannula.

The nurse performs discharge teaching for a client. How would the nurse best evaluate the effectiveness of the discharge teaching? A. Review it to see if all health care provider prescriptions were covered. B. Ask the client to repeat back to the nurse how care will be conducted at home. C. Determine if critical pathways were completed. D. Ask if the client understands the teaching.

B. Ask the client to repeat back to the nurse how care will be conducted at home.

Which nursing diagnosis would most likely be considered a high priority? A. Disturbed personal identity B. Impaired gas exchange C. Risk for powerlessness D. Activity intolerance

B. Impaired gas exchange

Which statement best explains why continuing data collection is important? A. It is difficult to collect complete data in the initial assessment. B. It is the most efficient use of the nurse's time. C. It enables the nurse to revise the care plan appropriately. D. It meets current standards of care.

C. It enables the nurse to revise the care plan appropriately.

Which provides the best framework for prioritizing client problems? A. Availability of hospital resources B. Family member statements C. Maslow's hierarchy of needs D. Nursing skill

C. Maslow's hierarchy of needs

Which is a correctly written client outcome? 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 ft (3 m) with a walker by October 12. D. The client correctly self-administers the morning dose of insulin.

C. The client will ambulate 10 ft (3 m) with a walker by October 12.

Which outcome is an affective outcome? A. By 10/09/22, the patient will correctly demonstrate the procedure for washing her newborn baby. B. By 10/09/22, the patient will list three benefits of eating a healthy diet. C. By 10/09/22, the patient will use a walker to ambulate the hallway. D. By 10/09/22, the patient will verbalize valuing his health enough to stop smoking.

D. By 10/09/22, the patient will verbalize valuing his health enough to stop smoking.

The nurse is caring for the client with pneumonia. An expected client outcome is, "The client will maintain adequate oxygenation by discharge." Which outcome criterion indicates the goal is met? A. Client drinks at least 2 to 3 liters of water each day. B. Client completes coughing and deep breathing exercises hourly. C. Client does not demonstrate signs of orthostatic hypotension when ambulating. D. Client no longer requires supplemental oxygen.

D. Client no longer requires supplemental oxygen.

A nurse administers a medication for pain but forgets to document it in the client's health care record. Legally, what does this mean? A. Nothing, the nurse's honesty will not be questioned. B. The nurse can add the documentation after the client goes home. C. The health care provider will verify that the nurse carried out the order. D. In the eyes of the law, if it is not documented, it was not done.

D. In the eyes of the law, if it is not documented, it was not done.