Nursing Process Test 2 Questions with Correctly Solved Answers, Exams of Nursing

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Nursing Process Test 2 Questions with Correctly Solved

Answers

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

1. "I believe that this patient is getting depressed."

2. "The patient doesn't look right to me; I think something is wrong."

3. "The patient's husband told me that she is feeling very uncomfortable."

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

reports more pain than yesterday and her blood pressure is elevated

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

1. Requesting the IV team to start an antibiotic drip on a patient with a history of being a difficult

stick.

2. Offering to call the kitchen to provide an alternate breakfast for a patient who does not like

cooked cereal.

3.Trying several difficulty wound dressings to determine which one the patient can apply the most

effectively.

4. Calling for another pain medication order when the current drug results in the patient

experiencing nausea.: Trying several difficult wound dressings to determine which one the patient can apply the most effectively.

3. As part of an assessment, the nurse asks for information from the patient. This information is

subjective indication of illness perceived by the patient and is called a/an:: symptom

4. term-5All of the following components can be found on the chart except the:

1. face sheet.
2. physician's order
3. patient's history & physical
4. patient's nurse assignment: patient's nurse assignment 5. Linda knows as part of her nursing assignment that she is to review & update the nursing care plan on her patients:

1. hourly

2. every shift

3. every 24 hours

4. weekly: every 24 hours

6. Which one of the following sets of assessment data is most likely to be present with the nursing diagnosis risk for infection

1. fever, dysuria, change in urine concentration, & urinary urgency.

2. Abdominal pain, sore mouth, hyperactive bowl sounds, & leukopenia.

3. Fatigue, electrocardiograhpic changes, dependent edema, & activity intol- erance.

4. abdominal incision, decreased hemoglobin, & indwelling catheter present.-

: abdominal incision, decreased hemoglobin, & indwelling catheter present

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

1. evaluating the occurrence of complications.

2. measuring quality of care.

3. measuring the effectiveness of nursing interventions.

4. stopping care when outcomes are met.: measuring the effectiveness of nursing interventions

8. During the implementation of the nursing process:

1. the planned nursing interventions are carried out.

2. reassessment of data is used to determine whether the expected outcomes have been achieved.

3. revision of the nursing care plan is performed.

4. goals are established for the patient.: the planned nursing interventions are carried out

9. Before LPN carries out any interventions such as the administration if a medication, she must know:

1. the reason for the intervention

2. the usual standard of care

3. the expected outcome

4. any potential danger

5. all of the above: all of the above

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

1. the nursing process has been completed

2. she doesn't need to revise the care plan if needs aren't met

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

support this.

4. there will be no further need for reassessment.: if the expected outcomes are considered met,

the nurse's notes must contain data to support this.

11. A student nurse, is learning about care plans. She knows all of the follow- ing are true regarding care plans except:

1. the family & patient are invited to the care planning

2. the care plan for the home health patient encompasses the needs & con- cerns of the family as

well as the patient

3. an LPN is responsible for constructing the care plan

4. students are required by most instructors to come to the clinical experience with a nursing care

plan in hand for assigned patients.: an LPN is responsible for constructing the care plan.

12. an LPN is helping her patient understand the side effects of medication. This is what type of action?
13. independent 2.dependent

3. interdependent

4. evaluation: independent

does not require a physician's order

13. When is the nurse supposed to use the evaluation step of the nursing process?

1. Upon admission

2. when the patient is ready for discharge

3. after each intervention

4. during the review of patient education: after each intervention

14.arrange the components of the nursing process in the proper order: as- sessment

diagnosis planning implementation evaluation ADPIE

15. The nurse applies the nursing process by gathering patient information to assess the patient

using which of the following methods? (select all that apply.)

1. body systems assessment

2. head-to-toe assessment

3. critical pathway

4. evidence-based practice

5. Gordon's function health patterns model: body systems assessment

head to toe assessment Gordon's functional health patterns model

16. A patient develops edema as an adverse effect to a prescribed medication. A gain of 5 pounds has occurred in 24 hours, and 2+ edema is present in the legs. Which nursing diagnosis statement does the nurse allocate to this patient?

1. Excess fluid volume related to calcium ion antagonist therapy (nifedipine) as evidence by

dependent edema (2+) and weight gain of 5 pounds in 24 hours.

2. Excess fluid volume related to medication therapy, manifested by 5-pound weight gain and leg

edema.

3. Excess fluid volume related to adverse effects of medications, as evidence by unknown etiology.

4. Risk for fluid volume imbalance related to adverse effects of medications.: 2. Excess fluid volume

related to medication therapy, manifested by 5-pound weight gain and leg edema.

17. The nurse understand it is important to know the difference between a nursing diagnosis and a medical diagnosis because of which factor?

1.The nursing diagnosis does not have any bearing on the medical diagnosis.

2. The medical diagnosis must agree with the nursing diagnosis.

3. The nursing diagnosis refers to how the patient is responding to an illness identified in the medical

diagnosis.

4. The medical diagnosis refers to how the patient is recovering from the illness that the nursing

diagnosis has established.: the nursing diagnosis refers to how the patient is responding to an illness identified in the medical diagnosis

18. The use of evidence-based practice to guide the formulation of nursing interventions based on research and clinical expertise is part of which com- ponent of the nursing process?

1. assessment

2. nursing diagnosis

3. planning

4. evaluation: planning

19. What is the difference between nursing interventions and expected out- come statements?

1. Nursing interventions are action statements, and expected outcome state- ments are used to

identify problems.

2. Expected outcome statements are action statements, and nursing interven- tions are what will be

observed in the patient after specific actions.

3. Nursing interventions are action statements, and expected outcome state- ments are what should

be observed in the patient after specific actions.

4. Expected outcome statements are action statements, and nursing inter- ventions are prioritized

goals.: nursing interventions are action statements, and expected outcome statements are what should be observed in the patient after specific actions.

20. When the nurse decides that the patient needs to rest before ambulating, the decision is based on what factor?

1. the patient's wishes

2. the family's influences

3. the prioritization of physiologic needs

4. the healthcare provider's orders: the prioritization of physiologic needs

21. Which is an example of an independent nursing action? (Select all that apply.)

1. maintaining and modifying the medication orders

2. collaborating with qualified professionals about medication calculations

3. educating a patient on correct coughing and deep breathing exercises

4. obtaining the patient's medication history

5. documenting assessments of a patient's lung sounds.: 3 4 & 5

22. Which type of nursing diagnosis involved the potential for a complication of drug therapy?

1. actual

2. risk/high risk

3. health promotion and/or wellness

4. syndrome: risk/high risk

23.Which step of the nursing process is used when the nurse identifies the therapeutic intent of a

prescribed medication?: Planning

24.Which type of nursing action occurs when the nurse administers a med- ication to a patient?:

Dependent

25. Which is a measurable goal statement for a patient taking insulin injec- tions?

1. The patient will have a good understanding of a diabetic diet.

2. The nurse will demonstrate to the patient and family self-administration of insulin.

3. The patient will be able to self-administer insulin infections 2 weeks after initial training.

4. The nurse will explain to the patient and family how insulin works in the body.: the patient will be

able to self-administer insulin injections 2 weeks after initial training.

26. Which assessment finding is considered primary, objective information?

1. The patient states that his temperature has been 98.8 F.

2. The patient's daughter states her father reports nausea after taking his medication

3. the patient states he feels dizzy whenever he takes his medication.

4. the patient reports a sore throat after taking his regular medications.: the patient states that

his temperature has been 98.8F

27. Which information is considered objective data?

1. Medical history of a patient

2. chief problem

3. review of body systems

4. lab results: lab results

28.Which correctly identifies the NMDS classification system?: Nursing Mini- mum Data Set

29.Which phase of the five-step nursing process is diagnosis?: Second

30. Which correctly distinguishes a nursing diagnosis from a medical diagno- sis?

1. Nursing diagnosis refers to the patient's ability to function in activities of daily living.

2. Medical diagnosis tends to vary depending on the patient's rate of recovery.

3. Nursing diagnosis focuses on alterations in the patient's function and structures.

4. Nursing diagnosis results in diagnosis of disease that impairs normal physiologic function.:

nursing diagnosis refers to the patient's ability to function in activities of daily living

31. Which statement about a critical care pathway is true?

1. It is a standardized care plan derived from "best practice" patterns.

2. It documents the plan for admission.

3. It is designed to serve as a communication tool specifically for nurses.

4. It helps the nurse to develop a detailed treatment plan for a patient who

is in critical condition: it is a standardized care plan derived from "best practice" patterns

32. The nurse is preparing to administer morning medications Which action(s) does the nurse implement to identify the patient before administering medica- tions? (select all that apply.)

1. Asks the patient his or her name & birth date

2. Asks another nurse to identify the patient

3. checks the patient's identification band

4. Asks the roommate to verify the patient's name if the patient is confused

5. Check the name on the foot of the bed.: 1 and 3

33. A nurse is reviewing the documentation of a newly licensed nurse. Which of the following entries should the nurse identify as American Nurses Asso- ciation ANA standards for documentation?

1. The client is now asleep, and they ate most of their breakfast a few hours ago.

2. the client vomited 240 mL of clear emesis but denies pain or nausea.

3. The client reports not feeling good, but they look fine.

4. The client has 8 to 10 sores on their body.: the client vomited 240 mL of clear emesis but

denies pain or nausea.

34. A nurse is preparing to administer morphine 15 mg PO every 4 hr PRN pain for a client who has a new prescription. By which of the following routes should the nurse plan to administer the medication?

1. by mouth

2. intramuscularly

3. per rectum intravenously:

by mouth

35. A charge nurse is reviewing characteristics of electronic documentation with staff at a provider's office. Which of the following characteristics should the charge nurse plan to include? (select all that apply)

1. reduces medical errors

2. improves listening skills among interdisciplinary team members

3. less convenient than paper-based charting

4. makes client medical history more easily available

5. increases accuracy of coding procedures.: 1 4 5

36. A nurse is documenting information in a client's chart and makes the entry "client reports abdominal pain on exertion." Which of the following documentation formats describes this entry?

1. the "I" in PIE

2. the "S" in SOAP

3. the "R" in DAR

4. the "E" in PIE: the "S" in SOP

37. a nurse is reviewing documentation principles with a group of newly hired assistive personnel (AP). Which of the following information should the nurse include?

1. Providers designate to other staff which abbreviations cannot be used.

2. A nurse who delegates a task to an AP will review the charting for that task.

3. Providers read and cosign nursing documentation for accuracy

4. licensed personnel should document out of range vital signs for AP.: a nurse who delegates a

task to an AP will review the charting for that task.

38. a staff nurse is evaluating a newly licensed nurse's understanding of tele- phone prescriptions. Which of the following statements by the newly license nurse indicates an understanding of the information?

1. i can take a telephone prescription if a provider is making routine rounds in another area of the

facility

2. i can take a telephone prescription if a provider is directing a code for an unresponsive client

3. if a client requires an over the counter medication for relief of nausea, it is okay to accept a

telephone prescription.

4. if a client requires pain control for a terminal condition, it is okay to accept a telephone

prescription.: i can take a telephone Rx if provider is directing a code for an unresponsive patient

39. a newly licensed nurse is orienting to a facility's documentation system. The facility requires staff to only document variations from an expected set of findings when performing a physical assessment. The nurse should identify this system as which of the following documentation methods?

1. charting by exception

2. subjective, objective, assessment, plan

3. problem, intervention, evaluation

4. data, action, response: charting by exception

40. A nurse is discussing problem-oriented medical records with a group of newly licensed nurses. Which of the following information should the nurse include?

1. a problem-oriented medical record is created using the PIE model for documentation

entries

2. a problem oriented medical record contains separate sections for labs & diagnostic info

3. a problem-oriented medical record promotes information sharing among members of the

interdisciplinary team.

4. a problem-oriented medical record is rarely used in acute care settings.: a problem oriented

medical record promotes information sharing among members of the interdisciplinary team.

41. a nurse manager is reviewing the documentation of four newly licensed nurses. Which of the following medication entries should the nurse identify as being written correctly?

1. synthroid 100 mg PO every morning ac

2. Enoxaparin 75 mg SQ bid

3. Digoxin 0.25 mg PO qd

4. Metformin 500.0 mg PO with evening meal: synthroid 100 mg PO every morning ac

42. a nurse is reviewing documentation guidelines with a newly licensed nurse. Which of the following abbreviations should the nurse not as being on The Joint Commision's Do Not Use List? (Select all that apply.)

1. MSO

2. IU

3. PO

4. qhs

5. NKA: 1 2 4

43. A nurse is discussing legal regulations regarding medical records with a newly hired assistive personnel. Which of the following information should the nurse include?

1. American Nurse Association ANA standards prevent client records from being used for legal

proceedings

2. HIPAA regulations vary form one state to another

3. Privacy regulations apply to electronic data transfer rather than verbal communication

4. facilities can establish their own rules for documentation methods: facilities can establish their

own rules for documentation methods.

44. A charge nurse is reviewing soap documentation with a group of newly license nurses. which of the following chart entries should the nurse include as an ex of objective date?

1. the client states"ice had abdominal pain for the past three days"

2. the client reports consuming about 1,500 mL of water per day.

3. rebound tenderness noted in RLQ of the abdomen

4. recommend client referral to a registered dietitian.: rebound tenderness noted in RLQ of the

abdomen

45. A nurse is talking with a client about their electronic health record at the facility. which of the following client statements indicates an understanding of EHRs?

1. i will be able to track my health information

2. my personal information will be entered into a national database

3. i will have one EHR that will encompass the health care I've received over my lifetime

4. the goal of EHRs is to improve insurance coding.: i will be able to track my health information

46.a nurse is discussing the history of electronic health records during a staff in service. the nurse

should identify that which of the following agencies advocated for nationwide use of EHRs?: the institute of medicine..

47. A nurse is preparing an in service about hipaa. which of the following information should

the nurse plan to include?

1. accessing the medical record of clients on units other than where you are assigned is allowed

2. there are large financial penalties for charting vital signs you obtain for another nurse's client

3. personnel can be terminated for breaching a client's confidentiality

4. once you have cared for a client, it is acceptable to look at their med-

ical record on subsequent health care visits.: personnel can be terminated for breaching a clients

confidentiality

48. a nurse is taking an admission. history from a client who is concerned about the facility using an electronic documentation system. which of the following information should the nurse include as a benefit of electronic documentation?

1. the system alerts providers of possible actions that could cause client harm

2. an electronic system prevents breaches of confidentiality of client data

3. providers can document client information in the electronic record during system downtime.

4. system encryption eliminates the need for security firewalls.: the system alerts providers of

possible actions that could cause client harm.

49. A nurse is performing a respiratory assessment on a client. the nurse auscultates a wet, popping sound upon inspiration of the client's breathing. the nurse should identify this observation as which of the following findings?

1. crackles

2. stridor

3. wheezes

4. friction rub: crackles

50. A nurse is performing a cardiovascular assessment on a client. which of the following findings should the nurse expect?

1. a continuous sensation of vibration felt over the second and third left intercostal spaces.

2. a high pitched, scraping sound heard in the thrid intercostal space to the left of the sternum

3. a brief felt near the fourth or fifth intercostal space near the left midclavicular line

4. a whooshing or swishing sound over the second intercostal space along

the left sternal border.: a brief thump felt near the fourth or fifth intercostal space near the left midclavicular line

51. a nurse is assessing a clients peripheral vascular status of the lower extremities. the nurse should place their fingertips on the top of the clients foot, between the tendons of the great toe and those of the toe next to it, in order to palpate which of the following pulses?

1. posterior tibial

2. popliteal

3. dorsalis pedis

4. femoral: dorsalis pedis

52. a nurse is performing a complete, head to toe physical examination for a client. which of the following phsyical assessment techniques should the nurse perform first?

1. ausculation

2. inspection

3. percussion

4. palpation: inspection

53. a nurse is palpating a tender area of a clients abdomen. the nurse slowly applies pressure over the area with their fingertips, then quickly releases it. the client reports increased pain on the release of pressure. which of the following findings should the nurse document?

1. borborygmi

2. rebound tenderness

3. tympany

4. abdominal guarding: rebound tenderness

54. a nurse is teaching a newly license nurse about using a stethoscope. which of the following instruction should the nurse include?

1. insert the earpieces at a downward angle toward your nose

2. use the diaphragm to listen to low pitched sounds

3. drape the stethoscope over your neck when not in use

4. clean the stethoscope by immersing it in soapy water.: insert the earpieces at a downward

angle toward your nose

55. a nurse is assessing a client's cranial nerves. which of the following client actions is an indication that cranial nerve I is intact?

1. the client can stick their tongue out.

2. the client can smile symmetrically

3. the client can hear whispered words

4. the client can identify a minty scent: the client can identify a minty scent.

56. a nurse is performing a physical examination of the spine for an older adult client. the nurse should identify that which of the following findings is common with aging?

1. lordosis

2. kyphosis

3. ankylosis

4. scoliosis: kyphosis

57. a nurse is preparing to perform a comprehensive physical assessment on a client. which of the following actions should the nurse plan to take first?

1. document accurate date

2. develop a plan of care

3. validate previous data

4. evaluate outcomes of care: develop a plan of care

58. a nurse is performing a general client survey and finds that the client has. body mass index BMI of 23. which of the following should the nurse document?

1. the client has no nutritional issues or deficits.

2. the client is at high risk for obesity-related health problems

3. the client will need a referral to a dietitian

4. the client has a BMI within the expected reference range.: the client has a BMI within the

expected reference range

59. a nurse is performing preparing to conduct a romberg test on a client. the nurse should explain to the client that the romberg test is used to assess which of the following characteristics?

1. gait

2. hearing

3. vision

4. balance: balance

60. a nurse is performing an abdominal assessment on a client. over which of the following areas of the client's abdomen should the nurse attempt to auscultate active bowel sounds first?

1. right upper quadrant

2. left upper quadrant

3. right lower quadrant

4. left lower quadrant: right lower quadrant

61. A postoperative patient is having incisional pain. As part of the nurse's assessment, the nurse notes that the patient is grimacing when changing positions. The patient's grimace be useful in the assessment and can be described in what manner?

1. nursing diagnosis

2. cue

3. diagnosis

4. inference: cue

62. Which is the etiologic factor in the nursing diagnosis of decreased mobility r/t left-sided muscular weakness, as evidenced by the inability to use the left arm for ADLs?

1. decreased mobility

2. left-sided muscular weakness

3. as evidenced by

4. inability to use the left arm:

63. What is the purpose of the initial health history & assessment?

1. to collect data about a specific health problem

2. to identify life-threatening problems

3. to compare current health status to baseline data

4. to establish a database to identify the patient's current health status:

64. The patient's temperature is 100.4F. 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 data are subjective? (Select all that apply.)

1. Temperature is 100.4F

2. State, "I'm very uncomfortable.:

3. Bed is wet.

4. Compains of being very tired.

5. States, "I have a headache.:: 2 4 & 5

65. The patients temperature is 100.4 F. 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 nursing intervention should be the highest priority?

1. Allow the patient to rest

2. Change the bed linens and gown

3. Medicate for headache pain

4. apply lotion to the skin: change the bed linens & gown

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

1. writes nursing diagnoses for the patient's care plan

2. obtains an ordered urine specimen

3. takes the patients history

4. assists with physical data collection

5. orients the patient to the unit: 2. Obtains an ordered urine specimen

3.Takes the patient's history

4.Assists with physical data collection

5.Orients the patient to the unit

67. Which statement correctly describes a nursing diagnosis when compared with a medical diagnosis?

1. Nursing diagnoses and medical diagnoses

2. A nursing diagnosis supports a medical diagnosis

3. Medical and nursing diagnoses are not related to one another

4. The nursing diagnosis describes a patient response to the medical diagno- sis.: 4. The nursing

diagnosis describes a patient response to the medical diagnosis.

68. Which is a correctly stated expected outcome?

1. sit in the chair three times a day

2. patient will walk to the end of the hall this week

3. use the incentive spirometer every 2 hours for 3 days

4. patient will respond to pain medication: 2. patient will walk to the end of the hall this week

69.Input from the during the planning stage of the nursing process results in

greater success: patient

70. priorities of care-giving change constantly because: (select all that apply.)

1. The nurses workload may change as patients are admitted.

2. primary care providers' orders may change throughout the shift.

3. a patients condition may deteriorate

4. tests or therapies involve scheduled time off the unit.

5. many visitors are in the room to assist the patient.: 1 2 3

71. Clinical reasoning is most important when:

1. planning wound care for a pressure injury.

2. organizing nursing care for several patients

3. collaborating with other health team members

4. drawing sound conclusions from assessment data.: draw sound conclusions from assessment

data

72. Attributes of critical thinkers include: (select all that apply.)

1. admitting what you donk't know.

2. consulting with primary care providers

3. anticipating problems

4. reflecting on experience

5. accepting others' decisions

6. being confident about your decisions.

7. recognizing inconsistencies in gathered data.: 1 3 4 6 7

73. Critical thinking will help you in the clinical setting to:

1. delegate work more efficiently.

2. make good decisions most of the time.

3. identify the best nursing diagnoses

4. write care plans more effectively: make good decisions most of the time

74. How do concept maps assist critical thinking? (select all that apply.)

1. They help point out relationships among the data.

2. they link interventions, health problems, and nursing diagnosis.