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NSG3100 Exam 1 Questions with Answers Correctly Tested and Verified Updates
Typology: Exams
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Verified Updates b- patient's WBC will remain within normal range
Verified Updates throughout hospitalization c- patient's visitors will be instructed in proper hand- washing before direct interaction with patient d- patient will understand the importance of cleaning around the incision with a clean cloth during bath time
6. If the nurse chooses the Nursing Outcome Classi- fication (NOC), Appetite (1014) for a chemotherapy patient, which outcome indicators would be accept- able for evaluation of goal attainment? (Select all that apply.) a. Expressed desire to eat b. Report that food smells good c. Use of relaxation techniques before meals d. Preparation of home-cooked meals for self and fam- ily e. Uses nutritional information on labels to guide se- lections 7. which action by the nurse would be most important in developing a patient-centered plan of care for an alert, oriented adult a- providing a written copy of care options to the patient and family b- collaborrating with the patient's social worker to determine resources c- listening to patient's concerns and beliefs about proposed treatment d- engaging the patient's family, friends or care providers in conversation 8. which interventions can the nurse initiate indepen- dently while providing patient care? a- ordering blood transfusion b- auscultating lung sounds c- monitoring skin integrity d- apply heel protectors e- adjusting antibiotic dosages a, b, d c b,c,d
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Verified Updates the nurse notices that a patient is becoming short of breath and anxious. which intervention is dependent nursing action, requiring the order of a PCP? a- elevating the head of the patient's bed b- administering oxygen by nasal cannula c- assessing the patient's O2 saturation d- elevating the patient's peripheral circulation
10. which situation indicates the greatest need for collab- orative interventions provided by several health care team members? a- hospice referral b- physical assessment c- activities of daily living d- health history interview 11. what should the nurse consider before implementa- tion of all nursing interventions a- potential communication barriers b- diverse cultural practices c- scope of nursing practice d- functional status of patient e- time of most recent shift change 12. which intervention would be most important for the nurse to include in a patient's care plan if the patient is unable to complete activities of daily living without becoming fatigued? a- instruct the patient to shower and shave simultane- ously b- discourage the patient from bathing while hospital- ized c- encourage the patient to rest between bathing ac- tivities d- ask the patient's spouse to assist with all bathing 13. which nursing intervention is most important to com- plete before giving medication to a patient? a- pr ovid e wate r to aid in the patie nts abilit y to swal low med
Verified Updates a a,b,c,d c b
Verified Updates b- double-check the patient's allergies before giving the drug c- ask the patient to verify having taken the medica- tion before d- place the patient in a side-lying position to prevent aspiration
14. Which direct-care intervention would be most effec- tive in helping a patient cope emotionally with a new diagnosis of cancer? a. Reassessing for changes in the patient's physical condition b. Teaching the patient various methods of stress re- duction c. Referring the patient for music and massage thera- py d. Encouraging the patient to explore options for care 15. what should be taken into consideration by the nurse when deciding on interventions to include in a pa- tient's plan of care? a- patient's treatment preferences b- cultural and ethnic influences c- nurses professional expertise d- current evidence based research e- convenience to nursing staff 16. Which task may the registered nurse safely delegate to unlicensed assistive personnel without prior inter- vention? a. Ambulating a patient with ataxia and new right sided paresthesia b. Feeding a patient with cerebral palsy who recently aspirated c. Transporting a patient to the hospital entrance for discharge d. Administering prescribed programmed medica- tions d a,b,c,d c
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Verified Updates which actions are part of the evaluation step in the nursing process? a- recognizing the need for modifications in the care plan b. documenting performed nursing interventions c- determining if nursing interventions were complet- ed d- reviewing whether a patient met their short term goal e- identifying realistic outcomes with patient input
18. which action by the day-shift nurse provides objective data that enables the night-shift nurse to complete an evaluation of the patient's short term goals? a- encouraging the patient to share observations from the day b- leaving a message with the charge nurse before shift change c- documenting patient assessment findings in the patients chart d- checking with the pharmacist regarding possible drug interactions 19. Which notation is most appropriate for the nurse to include in a patient's chart regarding evaluation of the goal, "Patient will ambulate three times daily in the hallway before discharge without shortness of breath (SOB)"? a. Goal not met; patient states he is tired. b. Goal not met; patient ambulated three times in room. c. Goal met; patient ambulated three times in the hall- way. d. Goal met; patient ambulated three times in the hall- way without SOB. 20. what situations would necessitate modification of a patient's plan of care? a- de cr ea se in a pa tie nt' s le ve l of or ie nt ati on
Verified Updates c d a, b, d
Verified Updates b- discharge of a patient to rehab facility c- patient adherence to established plan of care d- sudden onset of shortness of breath in patient receiving oxygen
Verified Updates d. Medical diagnoses
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Verified Updates surgery? a- consult the surgeon to see if the clinical pathway is being followed b- discontinue the plan of care, because the patient has met the established goal c- monitor patient urine output to evaluate the need for current plan of care d- notify the patient that the goal has been attained and no further intervention is needed
31. what is the most important reason for nurses to use standardized taxonomy such as the ICNP, CCC, NAN- DA? a- insurance documentation b- professional autonomy c- EMR data analysis d- patient safety 32. which nursing diagnosis statements are appropriately written according to the 2018- NANDA format? (select all that apply) a- risk for infection related to elevated temperature and WBC b- readiness for effective family process as evidenced by an expressed desire for improved communication and mutual respect verbalized by family members c- impaired health maintenance related to inability to access care as evidenced by failure to keep appoint- ments, homebound status d- risk for hemorrhaging as evidenced by prolonged clotting time e- chronic pain related to osteoarthritis as manifested by verbalized postop discomfort 33. which phrase best represents a related factor in a problem-focused nursing diagnosis? a- unsteady gait requiring the assistance of two peo- ple b- re d ne ss an d s w ell in g ar o u n d in ci si o n sit e
Verified Updates d b,c,d c
Verified Updates c- ineffective adaptation to recent loss d- patient complaint of restlessness
34. Which actions does the nurse need to take before determining the types of nursing diagnoses that are applicable to a patient? (Select all that apply.) a. Review the patient's past and present medical his- tory. b. Analyze the nursing assessment data to determine whether information is complete. c. Outline an individualized plan of care to address each concern. d. Consider potential complications to which the pa- tient is susceptible. e. Evaluate how the patient has responded to treat- ment. 35. what is the primary difference between the NANDA risk nursing diagnosis and a problem-focused nurs- ing diagnosis a- related factors are not part of a risk diagnosis b- there is no cause and effect relationship estab- lished c- defining characteristics are subjective in a risk di- agnosis d- there are no nursing interventions prescribed with a risk diagnosis 36. what is the most important action for a nurse to take to have a new nursing diagnosis considered for inclu- sion in the ICNP and NANDA taxonomies? a- share concerns with the nurse manager on the nursing unit b- offer alternative care for a patient and family mem- bers c- discuss how to address patient needs with physi- cian d- provide evidence based research to support nurs- ing care a,b,d a d
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37. what is the most significant problem that may result from improperly writing NANDA nursing diagnosis statements? a- lack of direction for formulating patient plans of care b- omission of PCP c- combining two unrelated patient concerns d- increased team collaboration needs 38. which statement best describes the relationship of medical diagnosis to nursing diagnosis? a- medical diagnosis are imbedded in nursing diagno- sis b- nursing diagnosis are derived from medical diag- nosis c- medical diagnosis are not relevant to nursing diag- nosis d- medical diagnosis may be interrelated to nursing diagnosis 39. a patient has just experienced a cardiac arrest on the unit. the nurse has implemented acute care plan for management of code situations. what is the next step the nurse should take? a- resume all interventions of the nursing process related to the patient's current condition b- perform the steps of the nursing process related to the patient's current condition c- seek physician input related to updating the nurs- ing diagnosis statements d- evaluate the success of the acute care plan for management of the cardiac arrest 40. what s/s would the nurse appropriately cluster as supporting data for a patient with extreme anxiety? (Select all that apply) a- denies any difficulty falling asleep b- elevated pulse rate auscultated at 140bpm c- continuous foot tapping throughout intake inter- a d b b,c,e
Verified Updates view d- demonstrates how to give insulin self injection without hesitation e- patient states " I feel nervous all the time, especially when i'm alone"
41. An uncooperative 70-year-old male with right-sided paralysis from a recent cerebrovascular accident (CVA) has to be transferred from the bed to a wheel- chair. Which action indicates the best method to trans- fer this patient? a. A two-person lift is performed, with one person on each side of the patient. b. The patient is steadied under the arms and pivoted on his left leg. c. A full-body sling lift is used with the help of unli- censed assistive personnel (UAP). d. A stand assist lift is used with the help of another nurse. 42. after instruction, which action by a patient who can bear weight on both feet indicates an understanding of the proper use of crutches? a- adjusting the crutches so they rest directly under the axilla b- moving the opposing crutch and leg together for a two point crutch walk c- using a four-point crutch walk when not weight bearing on the left leg d- placing the crutches 28 inches forward 43. What bony prominences are at greatest risk for skin breakdown on a patient who is restricted to bed rest and placed in the side-lying position? (Select all that apply.) a. Sternum b. Ears c. Elbows c b b,c,d
d. Hips e. Coccyx
44. Which area of the central nervous system has most likely sustained damage if a patient exhibits a lack of coordination and an unsteady gait after a traumatic head injury? a. Medulla oblongata b. Articular disk c. Brainstem d. Cerebellum 45. a nurse is providing teaching on the prevention of osteoporosis. which important fact should the nurse include in the teaching care plan? a- calcium should be taken with vitamin d to increase calcium absorption b-african american women are more prone to develop- ing osteoporosis than are asian american women c- increased phosphorus metabolism may lead to bone fragility d- aerobic exercise is more advantageous than weight-bearing exercise in preventing osteoporosis 46. what nursing intervention would be most effective in preventing flaccidity in a hospitalized patient? a- early ambulation after surgery b- administering calcium with vitamin D c- coughing and deep breathing exercising d- referring the patient to occupational therapy 47. Identify all nursing interventions that are necessary when caring for a quadriplegic patient injured 2 years earlier in a motor vehicle accident. (Select all that apply.) a. Monitoring respiratory status and breathing difficul- ties b. Assisting with feeding and ADLs c. D evel opi ng a car e pla n wit h the pati ent' s po wer of atto rne y
d a a a,b,d
d. Using mechanical lifts to assist with transferring the patient e. Placing a gait belt around the patient's waist before ambulation
48. which discovery found during an admission assess- ment of a patient transferred from a long-term care facility does the nurse recognize as a result of immo- bility? a- bilateral elbow contractures b- increased muscle tone c- decreased cardiac workload d- orthostatic hypertension 49. which nursing diagnosis is a top priority for a patient who is one day status post hip replacement? a- impaired health maintenance b- activity intolerance c- impaired mobility d- self care deficit 50. After application of sequential compression devices (SCDs) on a patient, what assessment finding is es- sential for the nurse to include in documentation? a.Warmth of bilateral upper extremities b. Lower extremity circulatory status c. Circumoral cyanosis d. Bowel sounds 51. which action by a patient marks the beginning of the physical assessment process? a- redressing after a physical examination b- breathing normally during auscultation c- greeting the nurse in the examination room d- sharing work environment information 52. which factors should be taken into consideration by the nurse before and during a patient interview? a- distance between the chairs in which the nurse and the patie nt are sittin g
a c b c a,b,c,d
b- traditional treatments typically used by the patient to prevent disease c- gender preference for PCP d- physical condition of the patient e- music preference of the patient
a. "What do you do for a living? Can you describe your work environment?" b. "Is there a family history of heart disease, cancer,