NR302 Final Comprehensive Exam Questions and Answers - NR 302 Final Exam Latest Chamberlai, Exams of Nursing

Download NR302 Final Comprehensive Exam Questions and Answers - NR 302 Final Exam Latest Chamberlai and more Exams Nursing in PDF only on Docsity! NR302 Final Comprehensive Exam Questions and Answers - NR 302 Final Exam Latest Chamberlain College of Nursing 100% Correct Q & A 1.While making rounds, the nurse finds a patient on the floor in the hall. Which should be the nurse's initial response? a. Inspect the patient for injury b.Transfer the patient back to bed c. Move the patient to the closest chair d.Report the patient's condition to the nurse manager - ANSWER>>a 2.Which should the nurse do to avoid patient accidents? a. Provide a cane for walking if the patient is weak b.Determine the strength of a patient before walking c. Apply a vest restraint when a patient is using the wheelchair d.Keep the overbed table in front of a patient sitting in a chair - ANSWER>>b 3.Which assessment by the nurse most likely indicates that a patient is having difficulty breathing? a. 18 breaths per minute and inhaled through the mouth b.20 breaths per minute and shallow in character c. 16 breaths per minute and deep in character d.28 breaths per minute and noisy - ANSWER>>d 4.Which should a nurse always do when taking a rectal temperature? a. Allow self-insertion of the thermometer b. Position the patient on the left side c. Use an electronic thermometer d. Lubricate the thermometer - ANSWER>>d 5.A nurse is assessing a patient's ideal body weight. Which significant factor should be taken into consideration when performing this assessment? a. Daily intake b.Body height c. Clothing size d. Food preference - ANSWER>>b 6.A nurse asks a patient's wife specific questions about the patient's health status before admission. When collecting this information, the nurse is seeking information for a: a. Primary source b.Tertiary source c. Subjective source d.Secondary source - ANSWER>>d 7.A nurse is performing a physical assessment of a newly admitted patient. Which patient statement communicates subjective data? a. "I have sores between my toes" b. "I dye my hair but it is really gray" c. "My joints hurt when I get up in the morning" d. "My left leg drags the floor when I am walking" - ANSWER>>c 8.Which is an example of nonverbal communications? a. Letter b.Holding hands c. Noise in the room d.Telephone message - ANSWER>>b 9.A nurse takes a patient's blood pressure and records a diastolic pressure of 120 mm Hg. Which should the nurse do first? d.The patient is at risk for impaired skin integrity related to left-sided hemiparesis and incontinence - ANSWER>>d 17.A nurse is caring for a patient with a new temporary colostomy. Which is a realistic short-term goal for this patient? a. The patient will have regular bowel elimination b.The patient's bowel will function within two days c. The patient is a risk for impaired skin integrity d. The patient's skin will remain intact around the stoma - ANSWER>>d 18.A nurse is caring for a patient experiencing insomnia. The statement that is an expected outcome is, "the patient: a. Has a sleep pattern disturbance." b.Can identify techniques to induce sleep." c. Will have privacy when attempting to sleep." d.Will report an optimal balance of sleep and activity." - ANSWER>>b 19.A patient has just returned from surgery with an intravenous solution infusing and does not have a gag reflex. Which planned intervention takes priority? a. Observe the dressing for drainage b.Ensure adequacy of air exchange c. Check for an infiltration d.Monitor vital signs - ANSWER>>b 20.Which is the most effective way that nurses can prevent the spread of microorganisms in a hospital? a. Washing the hands b. Implementing contact precautions c. Administering antibiotics to those who are sick d.Using linen hampers with foot-operated covers - ANSWER>>a 21.A patient on bedrest needs a complete change of linen. Which should the nurse plan to do? a. Make an occupied bed b.Change the draw sheet and top sheet c. Use a mechanical lift to raise the patient d. Transfer the patient to a chair during the linen change - ANSWER>>a 22.The nurse should make an occupied bed for a patient who is: a. Obese b. In a cast c. Immobile d.On bedrest - ANSWER>>d 23.The nurse manager arrives on duty and discovers that several staff members have just called in sick. Which is the nurse manager's most appropriate response? a. Inform the supervisor and ask for additional staff b. Identify which patients need care and assign staff accordingly c. Explain to patients that when the unit is short staffed, only essential care can be provided d.Provide the best care possible, but refuse to accept responsibility for the standard of care delivered. - ANSWER>>a 24.A patient is diaphoretic and is receiving oxygen by nasal cannula. During a bath, the patient experiences dyspnea and reports feeling tired. Which should the nurse plan to do? a. Give a complete bath quickly b.Bathe only the body parts that need bathing c. Arrange for several rest periods during the bath d.Continue with the bath because dyspnea is unavoidable - ANSWER>>c 25.A nurse is caring for a patient with a large pressure ulcer that has not responded to common nursing interventions. With whom should the nurse consult first to best deal with this problem? a. Plastic surgeon b.Physical therapist c. Clinical nurse specialist d. Primary health-care provider - ANSWER>>c 26.A primary nurse assigns a staff nurse to insert and indwelling urinary (Foley) catheter. Which is the first thing the staff nurse should do? a. Check the primary health-care provider's order b.Bring equipment to the patient's bedside c. Explain the procedure to the patient d.Wash hands thoroughly - ANSWER>>a 27.A patient has an order for a 2-gram sodium diet. Which should the nurse teach this patient to avoid? a. Salt b. Sugar c. Liquids d.Margarine - ANSWER>>a 28.A patient vomits while in the supine position. Which should the nurse do? a. Position the patient's head between the knees b.Raise the patient to a low-Fowlers position c. Transfer the patient to the bathroom d.Turn the patient to the side - ANSWER>>d 29.A patient reports feeling nauseated. Which should the nurse do to provide for this patient? a. Give mouth care every hour antibiotic c. Obtain another urine specimen for culture and sensitivity testing d.Determine if the patient took the medication if prescribed - ANSWER>>d 38.A newly admitted patient was provided with a regular diet consisting of three traditional meals a day. After several days it was identified that the patient was eating only approximately 50% of the meals and was losing weight. What should the nurse do? a. Assist the patient until meals are completed b.Schedule several between-meal supplements c. Change the plan of care to provide five small meals daily d.Secure an order to increase the number of calories provided - ANSWER>>c By the second postoperative day, a client has not achieved satisfactory pain relief. Based on this evaluation, which of the following actions should the nurse take, according to the nursing process? 1.Reassess the client to determine the reasons for inadequate pain relief. 2.Wait to see whether the pain lessens during the next 24 hr. 3.Change the plan of care to provide different pain relief interventions. 4. Teach the client about the plan of care for managing his pain. - ANSWER>>1 A newly licensed nurse is reporting to the charge nurse about the care she gave to a client. She states, "The client said his leg pain was back, so I checked his medical record, and he las received his pain medication 6 hours ago. The prescription reads every 4 hours PRN for pain, so I decided he needs it. I asked the unit nurse to observe me preparing and administering it. I checked with the client 40 minutes later, and he said his pain is going away." The charge nurse should inform the newly licensed nurse that she left out which of the following steps of the nursing process? 1. Assessment 2. Planning 3. Intervention 4.Evaluation - ANSWER>>1 A charge nurse is reviewing the steps of the nursing process with a group of nurses. Which of the following data should the charge nurse identify as objective data? (Select all that apply) 1.Respiratory rate is 22/min with even, unlabored respirations. 2. The client's partner states, "He said he hurts after walking about 10 minutes." 3. Pain rating is 3 on a scale of 0 to 10. 4.Skin is pink, warm, and dry. 5. The assistive personnel reports that the client walked with a limp. - ANSWER>>1,4,5 A charge nurse is talking with a newly licensed nurse and is reviewing nursing interventions that do not require a provider's prescription. Which of the following interventions should the charge nurse include? (Select all that apply.) 1.Writing a prescription for morphine sulfate as needed for pain. 2. Inserting a nasogastric (NG) tube to relieve gastric distention. 3.Showing a client how to use progressive muscle relaxation. 4. Performing a daily bath after the evening meal. 5.Repositioning a client every 2 hr. to reduce pressure ulcer risk. - ANSWER>>3,4,5 A nurse is discussing the nursing process with a newly hired nurse. Which of the following statements by the newly hired nurse should the nurse identify as appropriate for the planning step of the nursing process? 1. "I will determine the most important client problems that we should address." 2. "I will review the past medical history on the client's record to get more information." 3. "I will go carry out the new prescriptions from the provider." 4. "I will ask the client if his nausea has resolved." - ANSWER>>1 1.Which of the following examples are steps of nursing assessment? (Select all that apply.) 1.Collection of information from patient's family members 5.A 72-year-old male patient comes to the health clinic for an annual follow- up. The nurse enters the patient's room and notices him to be diaphoretic, holding his chest and breathing with difficulty. The nurse immediately checks the patient's heart rate and blood pressure and asks him, "Tell me where your pain is." Which of the following assessment approaches does this scenario describe? 1.Review of systems approach 2.Use of a structured database format 3.Back channeling 4.A problem-oriented approach - ANSWER>>4 6.The nurse asks a patient, "Describe for me a typical night's sleep. What do you do to fall asleep? Do you have difficulty falling or staying asleep? This series of questions would likely occur during which phase of a patient- centered interview? 1. Orientation 2.Working phase 3.Data validation 4.Termination - ANSWER>>2 7.A nurse is assigned to a 42-year-old mother of 4 who weighs 136.2 kg (300 lbs), has diabetes, and works part time in the kitchen of a restaurant. The patient is facing surgery for gallbladder disease. Which of the following approaches demonstrates the nurse's cultural competence in assessing the patient's health care problems? 1. "I can tell that your eating habits have led to your diabetes. Is that right?" 2. "It's been difficult for people to find jobs. Is that why you work part time?" 3. "You have four children; do you have any concerns about going home and caring for them?" 4. "I wish patients understood how overeating affects their health." - ANSWER>>3 8.Which type of interview question does the nurse first use when assessing the reason for a patient seeking health care? 1. Probing 2. Open-ended 3. Problem-oriented 4.Confirmation - ANSWER>>2 9.A nurse gathers the following assessment data. Which of the following cues together form(s) a pattern suggesting a problem? (Select all that apply.) 1. The skin around the wound is tender to touch. 2. Fluid intake for 8 hours is 800 mL. 3. Patient has a heart rate of 78 beats/min and regular. 4. Patient has drainage from surgical wound. 5.Body temperature is 38.3° C (101° F). 6. Patient states, "I'm worried that I won't be able to return to work when I planned." - ANSWER>>1,4,5 10.A nurse is checking a patient's intravenous line and, while doing so, notices how the patient bathes himself and then sits on the side of the bed independently to put on a new gown. This observation is an example of assessing: 1. Patient's level of function. 2. Patient's willingness to perform self-care. 3. Patient's level of consciousness. 4. Patient's health management values. - ANSWER>>1 11.A nurse makes the following statement during a change-of-shift report to another nurse. "I assessed Mr. Diaz, my 61-year-old patient from Chile. He fell at home and hurt his back 3 days ago. He has some difficulty turning in bed, and he says that he has pain that radiates down his leg. He rates his pain at a 6, and he moves slowly as he transfers to a chair." What can the nurse who is beginning a shift do to validate the previous nurse's assessment findings when she conducts rounds on the patient? (Select all that apply.) 1. The nurse asks the patient to rate his pain on a scale of 0 to 10. 3.A nurse reviews data gathered regarding a patient's ability to cope with loss. The nurse compares the defining characteristics for Ineffective Coping with those for Readiness for Enhanced Coping and selects Ineffective Coping as the correct diagnosis. This is an example of the nurse avoiding an error in: (Select all that apply.) 1.Data collection. 2.Data clustering. 3.Data interpretation. 4.Making a diagnostic statement. 5.Goal setting. - ANSWER>>1,3 4.The nursing diagnosis Impaired Parenting related to mother's developmental delay is an example of a(n): 1.Risk nursing diagnosis. 2. Problem-focused nursing diagnosis. 3.Health promotion nursing diagnosis. 4.Wellness nursing diagnosis. - ANSWER>>2 5.A nurse interviewed and conducted a physical examination of a patient. Among the assessment data the nurse gathered were an increased respiratory rate, the patient reporting difficulty breathing while lying flat, and pursed-lip breathing. This data set is an example of: 1.Collaborative data set. 2.Diagnostic label. 3.Related factors. 4.Data cluster. - ANSWER>>4 6. In which of the following examples are nurses making diagnostic errors? (Select all that apply.) 1. The nurse who observes a patient wincing and holding his left side and gathers no additional assessment data 2.The nurse who measures joint range of motion after the patient reports pain in the left elbow 3.The nurse who considers conflicting cues in deciding which diagnostic label to choose 4.The nurse who identifies a diagnosis on the basis of a patient reporting difficulty sleeping 5.The nurse who makes a diagnosis of Ineffective Airway Clearance related to pneumonia. - ANSWER>>1,4,5 7.A nurse is reviewing a patient's list of nursing diagnoses in the medical record. The most recent nursing diagnosis is Diarrhea related to intestinal colitis. For which of the following reasons is this an incorrectly stated diagnostic statement? 1. Identifying the clinical sign instead of an etiology 2. Identifying a diagnosis on the basis of prejudicial judgment 3. Identifying the diagnostic study rather than a problem caused by the diagnostic study 4. Identifying the medical diagnosis instead of the patient's response to the diagnosis. - ANSWER>>4 8.A nurse is assigned to a new patient admitted to the nursing unit following admission through the emergency department. The nurse collects a nursing history and interviews the patient. Place the following steps for making a nursing diagnosis in the correct order, beginning with the first step 1.Considers context of patient's health problem and selects a related factor 2.Reviews assessment data, noting objective and subjective clinical information 3.Clusters clinical cues that form a pattern 4.Chooses diagnostic label - ANSWER>>2, 3, 4, 1 9.A nursing student reports to a lead charge nurse that his assigned patient seems to be less alert and his blood pressure is lower, dropping from 140/80 to 110/60. The nursing student states, "I believe this is a nursing diagnosis of Deficient Fluid Volume." The lead charge nurse immediately goes to the patient's room with the student to 15.Which of the following nursing diagnoses is stated correctly? (Select all that apply.) 1. Fluid Volume Excess related to heart failure 2.Sleep Deprivation related to sustained noisy environment 3. Impaired Bed Mobility related to postcardiac catheterization 4. Ineffective Protection related to inadequate nutrition 5.Diarrhea related to frequent, small, watery stools. - ANSWER>>2,4 1.A nurse enters the room of a 32-year-old patient newly diagnosed with cancer at the beginning of the 0700 evening/night shift. The nurse noted in the patient's nursing history that this is her first hospitalization. She is scheduled for surgery in the morning to remove a tumor and has questions about what to expect after surgery. She is observed talking with her mother and is crying. The patient says, "This is so unfair." An order has been written for an enema to be given this evening in preparation for the surgery. The nurse establishes priorities for which of the following situations first? 1.Giving the enema on time 2.Talking with the patient about her past experiences with illness 3.Talking with the patient about her concerns and acknowledging her sense of unfairness 4.Beginning instruction on postoperative procedures - ANSWER>>3 2.A 62-year-old patient had a portion of the large colon removed and a colostomy created for drainage of stool. The nurse has had repeated problems with the patient's colostomy bag not adhering to the skin and thus leaking. The nurse wants to consult with the wound care nurse specialist. Which of the following should the nurse do? (Select all that apply.) 1.Assess condition of skin before making the call 2.Rely on the nurse specialist to know the type of surgery the patient likely had 3.Explain the patient's response emotionally to the repeated leaking of stool 4.Describe the type of bag being used and how long it lasts before leaking 5.Order extra colostomy bags currently being used - ANSWER>>1,3,4 3. It is time for a nurse hand-off between the night nurse and nurse starting the day shift. The night nurse checks the most recent laboratory results for the patient and then begins to discuss the patient's plan of care to the day nurse using the standard checklist for reporting essential information. The patient has been seriously ill, and his wife is at the bedside. The nurse asks the wife to leave the room for just a few minutes. The night nurse completes the summary of care before the day nurse is able to ask a question. Which of the following activities are strategies for an effective hand-off? (Select all that apply.) 1.Using a standardized checklist for essential information 2.Asking the wife to briefly leave the room 3.Completing the hand-off without inviting questions 4.Doing prework such as checking laboratory results before giving a report 5. Including the wife in the hand-off discussion - ANSWER>>1,4,5 4.A nurse assesses a 78-year-old patient who weighs 108.9 kg (240 lbs) and is partially immobilized because of a stroke. The nurse turns the patient and finds that the skin over the sacrum is very red and the patient does not feel sensation in the area. The patient has had fecal incontinence on and off for the last 2 days. The nurse identifies the nursing diagnosis of Risk for Impaired Skin Integrity. Which of the following outcomes is appropriate for the patient? 1. Patient will be turned every 2 hours within 24 hours. 2. Patient will have normal bowel function within 72 hours. 3. Patient's skin integrity will remain intact through discharge. 4.Erythema of skin will be mild to none within 48 hours. - ANSWER>>4 5.Which of the following factors does a nurse consider in setting priorities for a patient's nursing diagnoses? (Select all that apply.) 1.Numbered order of diagnosis on the basis of severity 2.Notion of urgency for nursing action 3.Symptom pattern recognition suggesting a problem 4.Mutually agreed on priorities set with patient nursing unit to assist. The nurse is required to do hourly rounds on all patients, so she begins rounds on the patient who has recently asked for a pain medication. As the nurse begins to approach the patient's room, a nurse stops her in the hallway to ask about another patient. Which factors in this nurse's unit environment will affect her ability to set priorities? (Select all that apply.) 1. Policy for conducting hourly rounds 2.Staffing level 3. Interruption by staff nurse colleague 4.RN's years of experience 5.Competency of patient care technician - ANSWER>>1,2,3 12.A nursing student is reporting during hand-off to the registered nurse (RN) assuming her patient's care. The student states, "Mr. Roarke had a good day, his intravenous (IV) fluid is infusing at 124 mL/hr with D5 infusing in right forearm. The IV site is intact, and no complaints of tenderness. I ambulated him twice during the shift; he tolerated well walking to end of hall and back with no shortness of breath. He still uses his cane with¬out difficulty. Mr. Roarke said he slept better last night after I closed his door and gave him a chance to be uninterrupted. If the nurse's goal for Mr. Roarke was to improve activity tolerance, which expected outcomes were shared in the hand-off? (Select all that apply.) 1. IV site not tender 2.Uses cane to walk 3.Walked to end of hall 4.No shortness of breath 5.Slept better during night - ANSWER>>3,4 13.A nursing student is reporting during hand-off to the RN assuming her patient's care. She explains, "I ambulated him twice during the shift; he tolerated well walking to end of hall and back with no shortness of breath. Mr. Roarke said he slept better last night after I closed his door and gave him a chance to be uninterrupted. I changed the dressing over his intravenous (IV) site and started a new bag of D5. Which intervention is a dependent intervention? 4.The nurse reviews with the NAP, newly hired to the floor, her experience in measuring a blood pressure. 5. The nurse confers with another registered nurse about organizing priorities. - ANSWER>>1,3,4 2.The nurse administers a tube feeding via a patient's nasogastric tube. This is an example of which of the following? 1.Physical care technique 2.Activity of daily living 3. Indirect care measure 4. Lifesaving measure - ANSWER>>1 3.A nurse is caring for a complicated patient 3 days in a row. The nurse attends an interdisciplinary conference to discuss the patient's plan of care. In which ways can the nurse develop trust with members of the conference team? (Select all that apply.) 1. Is willing to challenge other members' ideas because the nurse disagrees with their rationale 2.Shows competence in how to monitor patients' clinical status and inform the physician of critical changes 3.Asks a more experienced nurse to attend the conference 4. Listens to opinions of members of interdisciplinary team and expresses recommendations for care clearly 5.During the meeting focus on similar problems the nurse has had in delivering care to other patients. - ANSWER>>2,4 4.Which principle is most important for a nurse to follow when using a clinical practice guideline for an assigned patient? 1.Knowing the source of the guideline 2.Reviewing the evidence used to develop the guideline 3. Individualizing how to apply the clinical guideline for a patient 4.Explaining to a patient the purpose of the guideline - ANSWER>>3 5.A nurse is visiting a patient in the home and is assessing the patient's adherence to medications. While talking with the family caregiver, the nurse learns that the patient has been missing doses. The nurse wants to perform interventions to improve the patient's adherence. Which of the following will affect how this nurse will make clinical decisions about how to implement care for this patient? (Select all that apply.) 1.Reviewing the family caregiver's availability during medication administration times 2.Making a judgment of the value of improved adherence for the patient 3.Reviewing the number of medications and time each is to be taken 4.Determining all consequences associated with the patient missing specific medicines 5.Reviewing the therapeutic actions of the medications - ANSWER>>2,4 6.The nurse enters a patient's room and finds that the patient was incontinent of liquid stool. Because the patient has recurrent redness in the perineal area, the nurse worries about the risk of the patient developing a pressure ulcer. The nurse cleanses the patient, inspects the skin, and applies a skin barrier ointment to the perineal area. The nurse consults the ostomy and wound care nurse specialist for recommended skin care measures. Which of the following correctly describe the nurse's actions? (Select all that apply.) 1. The application of the skin barrier is a dependent care measure. 2. The call to the ostomy and wound care specialist is an indirect care measure. 3. The cleansing of the skin is a direct care measure. 4. The application of the skin barrier is an instrumental activity of daily living. 5. Inspecting the skin is a direct care activity. - ANSWER>>2,3 7.During the implementation step of the nursing process, a nurse reviews and revises a patient's plan of care. Place the following steps of review and revision in the correct order. 1.Modify care plan as needed. 2.Decide if the nursing interventions remain appropriate. 3.Reassess the patient. 4.Time management - ANSWER>>1 15.A nurse collects equipment needed to administer an enema to a patient. Previously the nurse reviewed the procedure in the policy manual. The nurse raises the patient's bed and adjusts the room lighting to illuminate the work area. A patient care technician comes into the room to assist. Which aspect of organizing resources and care delivery did the nurse omit? 1. Environment 2. Personnel 3. Equipment 4. Patient - ANSWER>>4 1.For the nursing diagnosis of Deficient Knowledge a nurse selects an outcome from the Nursing Outcome Classification (NOC) of patient knowledge of arthritis treatment. Which of the following are examples of an outcome indicator for this outcome? (Select all that apply.) 1.Nurse provides four teaching sessions before discharge. 2. Patient denies joint pain following heat application. 3. Patient describes correct schedule for taking antiarthritic medications. 4. Patient explains situations for using heat application on inflamed joints. 5. Patient explains role family caregiver plays in applying heat to inflamed joint. - ANSWER>>3,4 2.A nurse in a community health clinic has been caring for a young teenager with asthma for several months. The nurse's goal of care for this patient is to achieve self- management of asthma medications. Identify appropriate evaluative indicators for self- management for this patient. (Select all that apply.) 1.Quality of life 2. Patient satisfaction 3.Use of clinic services 4.Adherence to use of inhaler 5.Description of side effects of medications - ANSWER>>1,3,4 3.A nurse caring for a patient with heart failure instructs the patient on foods to eat for a low-sodium diet. The nurse will perform which of the following evaluation measures to determine success of her instruction? 1.Patient weight 2.Asking patient to identify three low-sodium foods to eat for lunch 3.A calorie count of food 4.Patient description of how food selections are made - ANSWER>>2 4.From the following list of indicators, determine which indicators are goals (G) and which indicators are outcomes (O). - ANSWER>>1. G Will achieve pain relief 2. O Ambulates 10 feet down hallway 3. _G Will remain free of infection 4. _G Will be afebrile 5. O Reports pain severity reduced from 6 to a 4 on scale of 0 to 10 6. G Will gain improved mobility 5.A nurse has been caring for a patient over 2 consecutive days. During that time the patient has had an intravenous (IV) catheter in the right forearm. At the end of shift on the second day the nurse inspects the catheter site, observes for redness, and asks if the patient feels tenderness when the site is palpated. This is an example of which indicator reflecting the nurse's ability to perform evaluation: 1.Examining results of clinical data 2.Comparing achieved effects with outcomes 3.Recognizing error 4.Self-reflection - ANSWER>>1 6.A patient has been febrile and coughing thick secretions; adven¬titious lung sounds indicate rales in the left lower lobe of the lungs. The nurse decides to perform nasotracheal suction because the patient is not coughing. The nurse inspects the mucus that is suctioned, which is minimal. The nurse again auscultates for lung sounds. Auscultation and mucus inspection are examples of: 1. Evaluative measures. 2.Expected outcomes. 3. Reassessments. 4.Reflection. - ANSWER>>1 7.After caring for a young man newly diagnosed with diabetes, a nurse is reviewing what was completed in his plan of care following discharge. She considers how she related to the patient and whether she selected interventions best suited to his educational level. It was the nurse's first time caring for a new patient with 278diabetes. The nurse's behavior is an example of which of the following? 1. Reflection-in-action 2. Reassessment 3. Reprioritizing 4.Reflection-on-action - ANSWER>>4 8.A nurse has been caring for a patient over the last 10 hours. The patient's plan of care includes the nursing diagnosis of Nausea related to effects of postoperative anesthesia. The nurse has been asking the patient to rate his nausea over the last several hours after administering antiemetics and using comfort measures such as oral hygiene. The nurse reviews the patient's responses over the past 10 hours and notes how the patient's self- report of nausea has changed. This review an example of: 1.Comparing outcome criteria with actual response. 2.Gathering outcome criteria. 3. Evaluating the patient's actual response. 4.Reprioritizing interventions. - ANSWER>>1 9.A faculty member is reviewing a nursing student's plan of care, including the interventions the student provided for a patient with dementia. The student reviewed clinical guidelines on a professional 12.A patient is being discharged after treatment for colitis (inflammation of the colon). The patient has had no episodes of diarrhea or abdominal pain for 24 hours. Following instruction, the patient identified correctly the need to follow a low-residue diet and the types of food to include if a bout of diarrhea develops at home. These behaviors are examples of: 1. Evaluative measures. 2.Expected outcomes. 3. Reassessments. 4.Standards of care. - ANSWER>>2 13.Which of the following does a nurse perform when discontinuing a plan of care for a patient? 1.Confirms with the patient that expected outcomes and goals have been met 2.Talks with the patient about reprioritizing interventions in the plan of care 3.Changes the frequency of interventions provided 4.Reassesses how goals were met - ANSWER>>1 14.Purposes of the Nursing Outcomes Classification (NOC) include which of the following? (Select all that apply.) 1. To identify and label nurse-sensitive patient outcomes 2.To test the classification in clinical settings 3.To establish health care reimbursement guidelines 4.To identify nursing interventions for linked nursing diagnoses 5.To define measurement procedures for outcomes - ANSWER>>1,2,5 15.Which of the following statements correctly describes the evaluation process? (Select all that apply.) 1. Evaluation is an ongoing process. 2. Evaluation usually reveals obvious changes in patients. 3. Evaluation involves making clinical decisions. 4.Evaluation requires the use of assessment skills. 5.Evaluation is only done when a patient's condition changes. - ANSWER>>1,3,4