1. The nurse is collecting data on a new patient at an adult clinic. Which piece of data does the nurse need to validate?

a. The client’s weight is 185 lb (83.9 kg) at the clinic.

b. The client’s liver function test results are elevated.

c. The client states that blood pressure (BP) of 160/94 mm Hg is typical.

d. The client reports eating processed foods on a low-sodium diet.

d. The client reports eating processed foods on a low-sodium diet.

After collecting data on a client, the nurse reviews and sorts the information. Which example includes both objective and subjective data?

a. The client’s blood pressure reading is 132/68 mm Hg, and heart rate is 88 beats/min.

b. The client’s cholesterol is elevated and admits to liking and eating fried food.

c. The client reports having trouble sleeping and admits to drinking coffee in the evening.

d. The client verbally reports having frequent headaches and taking aspirin for the pain.

b. The client’s cholesterol is elevated and admits to liking and eating fried food.

The nurse manager in an acute care facility is orienting new graduate nurses to a patient care unit. While reviewing The Joint Commission standards, a discussion begins about assessment. Which type of assessment is to be performed on all patients in compliance with The Joint Commission?

a. Nutrition status

b. Pain

c. Cultural

d. Wellness

b. Pain

Which of the following constitutes an ongoing assessment?

a. Obtaining a patient’s temperature 1 hour after giving acetaminophen

b. Examining a patient’s throat after soreness with swallowing is reported

c. Requesting a patient to rate pain intensity level using a scale of 0 to 10

d. Asking a patient the details of a plan to return to normal exercise activities

a. Obtaining a patient’s temperature 1 hour after giving acetaminophen

Each time the nurse comes into contact with a patient, a systematic observation is made. For which reason is this type of assessment performed so frequently?

a. Time constraints support small portions of assessment at a time.

b. Validating an absence of change decreases the need to document.

c. Critical changes are less likely to occur with constant observation.

d. Repetition makes it less likely the nurse will miss an assessment area.

d. Repetition makes it less likely the nurse will miss an assessment area.

The nurse is obtaining the health history. Which question is an example of the nurse using an open-ended question?

a. “Have you had surgery before?”

b. “When was your last menstrual period?”

c. “What happens when you have a headache?”

d. “Do you have a family history of heart disease?”

c. “What happens when you have a headache?”

The nurse is interviewing a patient being admitted for gastrointestinal issues. The patient informs the nurse that he has persistent vomiting and diarrhea. Which type of assessment is the nurse performing by asking, “When did you first begin to have the vomiting and diarrhea?”

a. Comprehensive assessment

b. Ongoing focused assessment

c. Special needs assessment

d. Initial focused assessment

d. Initial focused assessment

Which step in the nursing process would involve identifying goals and outcomes, choosing interventions, and creating nursing care plans?

a. Assessment

b. Planning

c. Implementation

d. Evaluation

b. Planning

The nurse is obtaining information from a newly admitted patient during the initial nursing assessment. Which difference does the nurse recognize between the nursing history and the medical history?

a. A nursing history focuses on the patient’s responses and needs to the health problem.

b. The same information is gathered in both; the difference is in who obtains the information.

c. The nursing history is gathered by using a specific, unadaptable format.

d. A medical history collects more in-depth information.

a. A nursing history focuses on the patient’s responses and needs to the health problem.

During the initial assessment of a newly admitted client, the nurse asks about use of nutritional and herbal supplements. For which reason is it important for the nurse to obtain this specific information?

a. To determine what type of therapies are acceptable to the client

b. To identify whether the client has a nutrition deficiency

c. To help the nurse understand the client’s cultural and spiritual beliefs

d. To be aware of potential interaction with prescribed medication

d. To be aware of potential interaction with prescribed medication

For which reason would assessment data need to be accurate and complete?

a. Because the rest of the nursing process rests on this foundational knowledge

b. Because the assessment takes place only once

c. So patients do not sue the hospital

d. Because it is part of the hospital guidelines

a. Because the rest of the nursing process rests on this foundational knowledge

For which reason does the nurse use nondirective interviewing as an assessment technique?

a. Allows the nurse to have control of the interview

b. Promotes an efficient way to interview a patient

c. Facilitates thought and open communication

d. Helps focus the attention of patients who are anxious

c. Facilitates thought and open communication

. A nurse is interviewing a patient, and a question the nurse asks makes the patient cry. Which response by the nurse would be appropriate?

a. Stop asking the difficult questions.

b. Tell the patient to stop crying so that the interview can proceed.

c. Call the patient’s family.

d. Understand patients often feel better after releasing emotions.

d. Understand patients often feel better after releasing emotions.

A patient comes to the urgent care clinic because of an injury from stepping on a rusty nail. Which type of assessment does the nurse perform?

a. Comprehensive

b. Ongoing

c. Initial focused

d. Special needs

c. Initial focused

The nurse is providing care to a patient who has left-sided weakness because of a recent stroke. Which type of special needs assessment is most important for the nurse to perform?

a. Family

b. Functional ability

c. Community

d. Psychosocial

b. Functional ability

The nurse is interviewing a patient with a recent onset of migraine headaches. The patient is very anxious and cannot seem to focus on what the nurse is saying. Which directive interviewing question used by the nurse is best when beginning to gather data about the headaches?

a. “When did your migraines begin?”

b. “Tell me about your family history of migraines.”

c. “What are the things that trigger your headaches?”

d. “Describe for me what your headaches feel like.”

a. “When did your migraines begin?”

Which action would protect the nurse and confirm interventions have been performed?

a. Implementation

b. Documentation

c. Collaboration

d. Investigation

b. Documentation

A nursing instructor asked his nursing students to discuss their experiences with charting assessment data. Which comment by the student indicates the need for further teaching?

a. “I find it difficult to avoid using phrases like ‘the patient tolerated the procedure well.’”

b. “It’s confusing to have to remember which abbreviations this hospital allows.”

c. “I need to work on charting assessments and interventions right after they are done.”

d. “My patient was really quiet and didn’t say much, so I charted that he acted

d. “My patient was really quiet and didn’t say much, so I charted that he acted

The nurse prefers to review patient data on a graphic flow sheet, when possible. Which situation is the best example of the reason a graphic flowsheet is superior to other methods of recording data?

a. Provides documentation of routine vital signs

b. Reflects the patterns of a patient’s fever visually

c. Describes symptoms accompanying vital sign changes

d. Enables a quick check for patient tolerance of care

b. Reflects the patterns of a patient’s fever visually

Which is the most obvious reason for using a framework for collecting and recording patient data during an assessment?

a. Prioritizes collection of assessment data

b. Organizes and clusters data efficiently

c. Separates subjective and objective data

d. Identifies both primary and secondary data

b. Organizes and clusters data efficiently

The nurse is preparing to conduct an admission interview with an adult client who is alert and oriented. The client’s spouse and two children are visiting and are watching television. Which action by the nurse is conducive to a successful interview?

a. Ask the patient closed-ended questions while the family is present.

b. Ask the client’s preference for how to be addressed by the nurse.

c. Ask if the client is willing to answer questions after the family leaves.

d. Ask the patient if they want to have the interview while the family watches

c. Ask if the client is willing to answer questions after the family leaves.

The nurse obtains information from a patient during admission. The patient is noted to be alert and oriented, is married, and has a history of heart disease. Obtaining this information is an example of which process?

a. Collecting data

b. Analyzing data

c. Categorizing data

d. Physical assessment

a. Collecting data

The nurse on a medical-surgical unit receives the third admission over a period of 1.5 hours. A certified nursing assistant (CNA) offers to assist the nurse with the assessment process. Which response by the nurse would be most appropriate?

a. “Thank you. I am having a busy day, and I can use your help.”

b. “I’m sorry, but nurses are responsible for all activities related to patient assessments.”

c. “Can you start an assessment on the last patient? I will continue it later.”

d. “If you could obtain and record the vital signs, it would be a big help.”

d. “If you could obtain and record the vital signs, it would be a big help.”

During the assessment process, the patient tells the nurse, “I have numbness and tingling in my right arm.” Which type of data is this?

a. Subjective data

b. Objective data

c. Secondary data

d. Comprehensive data

a. Subjective data

The nurse is performing an initial interview with an older adult patient. Which statement by the patient indicates a need for a special needs assessment by the nurse?

a. “I don’t go to church as much as I used to, but I watch services on TV.”

b. “I have fallen twice at home in the past 6 months, but I have not injured myself.”

c. “I don’t eat much red meat anymore, but I get my protein from other foods.”

d. “I had a toothache recently, so I made an appointment to see the dentist.”

b. “I have fallen twice at home in the past 6 months, but I have not injured myself.”

A patient comes to the emergency department to be evaluated after feeling ill at home. Which is the first question the nurse asks in the initial nursing interview with the patient?

a. “Do you live alone?”

b. “Are you having any pain?”

c. “What is your medical history?”

d. “Why did you come to the hospital today?”

d. “Why did you come to the hospital today?”

The patient comes to the emergency department complaining of chest pain. Which question by the nurse will encourage the patient to provide the most details about the pain?

a. “When did your chest pain begin?”

b. “On a scale of 0 to 10, what is your pain level?”

c. “Can you give a description of the pain you are having?”

d. “Have you taken any medication for your pain?”

c. “Can you give a description of the pain you are having?”

Which patient issue is a problem that nurses can treat independently?

a. Hemorrhage after surgery

b. Nausea after ambulating in the hall

c. Fracture pain after an accident

d. Infection in a wound

b. Nausea after ambulating in the hall

Which of the following is an example of what the nurse recognizes as a cluster of related cues?

a. Has nausea and stomach pain after eating

b. Has a productive cough and states stools are loose

c. Has a daily bowel movement and eats a high-fiber diet

d. Has a respiratory rate of 20 breaths/min, heart rate of 85 beats/min, and blood pressure of 136/84 mm Hg

a. Has nausea and stomach pain after eating

The nurse works in an extended care facility for primarily older adults with health factors that put them in danger of falling. Which option best describes the type of nursing diagnosis the nurse is likely to use?

a. A risk diagnosis

b. A possible diagnosis

c. A wellness diagnosis

d. A syndrome diagnosis

a. A risk diagnosis

Which of the following describes the difference between a collaborative problem and a medical diagnosis?

a. A collaborative problem is treated by the nurse; a physician is responsible for the treatment of a medical problem.

b. A collaborative problem is a nursing diagnosis that requires specific orders from a physician; a medical diagnosis directs all nursing care.

c. A collaborative problem has the potential to become an actual nursing diagnosis; a medical diagnosis rarely changes.

d. A collaborative problem requires intervention by the nurse and the physician or other professional; a medical diagnosis requires intervention by a physician.

d. A collaborative problem requires intervention by the nurse and the physician or other professional; a medical diagnosis requires intervention by a physician.

The nurse is aware that which approach is best to validate a clinical inference?

a. Have an unlicensed assistive provider evaluate it.

b. Have the physician evaluate it.

c. Have sufficient supportive data.

d. Have the client’s family confirm it.

c. Have sufficient supportive data

The nurse manager notices that a staff nurse writes a nursing diagnosis as “impaired physical mobility related to laziness and not having appropriate shoes.” Which issue related to the nursing diagnosis will the nurse manager discuss with the staff nurse?

a. The staff nurse is being judgmental.

b. As written, the diagnosis is too complex.

c. The diagnosis is legally questionable.

d. There is deficiency of supportive data.

a. The staff nurse is being judgmental.

When making a diagnosis using NANDA-I taxonomy, which part of the statement provides support for the diagnostic label you choose?

a. Etiology

b. Related factors

c. Diagnostic label

d. Defining characteristics

d. Defining characteristics

Which nursing diagnosis does the nurse recognize as having the highest priority according to Maslow’s hierarchy of needs?

a. Self-care deficit

b. Risk for aspiration

c. Impaired physical mobility

d. Functional urinary incontinence

b. Risk for aspiration

Which skill would be used in a nursing assessment?

a. Diagnosing

b. Referring

c. Observing

d. Analyzing

c. Observing

The patient care team consists of both registered nurses (RNs) and licensed practical nurses/licensed vocational nurses (LPNs/LVNs). Which action by the RN constitutes a possible theoretical error when delegating?

a. Assigning an LPN/LVN to formulate a nursing diagnosis

b. Instructing an LPN/LVN to perform a prescribed dressing change

c. Delegating an RN to perform the admitting history on a new client

d. Expecting RNs and LPNs/LVNs to administer medications to assigned clients

a. Assigning an LPN/LVN to formulate a nursing diagnosis

Which definition most accurately describes nursing diagnoses?

a. Supports the nurse’s diagnostic reasoning

b. Supports the client’s medical diagnosis

c. Identifies a client’s response to a health problem

d. Identifies a client’s health problem

c. Identifies a client’s response to a health problem

The nurse has gathered information about a client, has sorted the information, and is preparing to identify the diagnostic label, or patient problem. For which purpose are diagnostic labels primarily used?

a. To set client goals

b. To make cue clusters

c. To identify interventions

d. To understand disease etiology

a. To set client goals

Which nursing diagnosis is written in the correct PES format when using NANDA-I taxonomy? a. Bowel obstruction related to recent abdominal surgery, as manifested by (AMB) nausea, vomiting, and abdominal pain b. Inability to ingest food related to imbalanced nutrition: less than body requirements, AMB inadequate food intake, weight less than 20% under ideal body weight c. Impaired skin integrity related to physical immobility, AMB skin tear over sacral area d. Caregiver role strain related to alienation from family and friends, AMB 24-hour care responsibilities

c. Impaired skin integrity related to physical immobility, AMB skin tear over sacral area

Which nursing diagnosis is written in the correct format?

a. Imbalanced nutrition: less than body requirements related to body weight less than 20% under ideal weight

b. Ineffective airway clearance related to increased respiratory rate and irregular rhythm

c. Impaired swallowing related to absent gag reflex

d. Excess fluid volume related to 3 lb weight gain in 24 hours

a. Imbalanced nutrition: less than body requirements related to body weight less than 20% under ideal weight

The nurse has diagnosed decisional conflict related to unclear personal values and beliefs, and the patient shows the necessary defining characteristics. Which essential action does the nurse take to help ensure the accuracy of this diagnosis?

a. Ask a more experienced nurse to confirm it.

b. Request that a social worker interview the patient.

c. Ask for the patient’s confirmation of the diagnosis.

d. Read about decisional conflict in the NANDA-I handbook.

c. Ask for the patient’s confirmation of the diagnosis.

A client’s weight is appropriate for their height. Laboratory values and other assessments reflect normal nutrition status. However, the client states, “I probably eat a little too much red meat. And, what is this I hear about needing omega 3 oils in my diet? I don’t like to take supplements, and I think I could really improve my nutrition.” Which nursing diagnosis does the nurse use?

a. Balanced nutrition

b. Possible imbalanced nutrition: less than body requirements

c. Risk for imbalanced nutrition: less than body requirements

d. Readiness for enhanced nutrition

d. Readiness for enhanced nutrition

A patient verbalizes an overwhelming lack of energy, stating, “I still feel exhausted even after sleeping. I feel guilty when I can’t keep up with my usual daily activities, or I sleep during the day. I’ve been a little depressed lately, too.” The nurse notes the patient’s difficulty concentrating but does not note any physical problems. Which diagnosis best describes the patient’s health status?

a. Fatigue related to depression

b. Fatigue related to difficulty concentrating

c. Guilt related to lack of energy

d. Chronic confusion related to lack of energy

a. Fatigue related to depression

The nurse documents in a patient’s progress notes: “Admitted to emergency department accompanied by spouse. Patient is alert and oriented, blood pressure is 120/80 mm Hg, and pulse is 80 beats/min. The patient is anxious and becomes nervous when asked about a smoking history.” Which statement from the nurse’s note is the best example of an inference?

a. The blood pressure reading is 120/80 mm Hg.

b. The patient is accompanied by spouse.

c. The patient has a history of smoking.

d. The patient is anxious

d. The patient is anxious.

Which statement made by the nurse is an example of stereotyping?

a. “Patients with a Japanese background are always quiet and emotionless.” b. “Patients with type 1 diabetes do not make insulin and will need to take insulin regularly.”

c. “Patients need to understand the benefits of getting out of bed and not crying each time.”

d. “Patients at 2 years of age may have tantrums; my child never has one.”

a. “Patients with a Japanese background are always quiet and emotionless.”

Which of the following is the best example of a nursing diagnosis statement? a. Pain related to appendicitis

b. Fractured left leg related to impaired mobility

c. Impaired mobility related to fractured left leg

d. Acute pain related to out-of-bed activities

d. Acute pain related to out-of-bed activities

The nurse created a collaborative diagnosis of potential complication of surgery: hemorrhage. During patient assessment, the nurse recognizes symptoms of serious blood loss. The nurse is aware that which action is now relative to the collaborative diagnosis?

a. The diagnosis is modified to watch for continued hemorrhage.

b. The diagnosis is removed because of the development of a medical problem.

c. The nurse collaborates with the physician to formulate a new diagnosis.

d. The nurse documents the effectiveness and value of the initial diagnosis.

b. The diagnosis is removed because of the development of a medical problem

The nurse completes assessment on a patient and begins to formulate a nursing diagnosis from the collected data. Which action does the nurse take prior to writing the nursing diagnosis statement?

a. Verifies the nursing diagnosis with the patient

b. Validates information with the primary care provider

c. Checks the medical diagnosis for consistency in treatments

d. Reviews the data and the diagnosis with another nurse

a. Verifies the nursing diagnosis with the patient

Which statement related to the nurse prioritizing patient problems is most accurate?

a. Nurses must resolve one problem before addressing another problem.

b. Nurses prioritize problems in the order of problem urgency.

c. Nurses give priority to actual problems instead of risk problems.

d. Nurses give the highest priority to problems most important to the patient.

b. Nurses prioritize problems in the order of problem urgency.

The nurse receives reports on four patients on a medical-surgical unit. Which patient will the nurse attend to first?

a. Gait unsteady, uses walker, needs two-person assist with ambulation

b. Abdominal wound with foul-smelling drainage, incision margins are red, heart rate 100 beats/min

c. Blood pressure 90/50 mm Hg, heart rate 40 beats/min, patient rates chest pain at 8 on a 0-to-10 pain scale

d. Verbalizes history of migraine headaches, eyes closed during assessment interview

c. Blood pressure 90/50 mm Hg, heart rate 40 beats/min, patient rates chest pain at 8 on a 0-to-10 pain scale

The nurse asks the nurse manager, “What do initial planning, ongoing planning, and discharge planning have in common?” Which information from the nurse manager is correct?

a. They are based on assessment and diagnosis.

b. They focus on the patient’s perception of needs.

c. They require input from a multidisciplinary team.

d. They have specific timelines in which to be completed.

a. They are based on assessment and diagnosis

The nurse recognizes which client as having the greatest need for comprehensive formal discharge planning?

a. A postpartum patient after the birth of her second child, who lives with her spouse and 18-month-old daughter

b. A patient who is readmitted for exacerbation of chronic obstructive pulmonary disease (COPD)

c. A patient who is 12 years of age being discharged home with a parent after outpatient surgery

d. An adult patient just diagnosed with renal failure who is scheduled to start peritoneal dialysis

d. An adult patient just diagnosed with renal failure who is scheduled to start peritoneal dialysis

The nurse is working on a new nursing unit that uses preprinted standardized care plans along with comprehensive care plans developed by the nurse. Which is the most important advantage for the use of both types of care plans?

a. Helps ensure that important interventions for the diagnosis are not overlooked

b. May prescribe care for one or more nursing diagnoses or medical conditions

c. Includes nursing interventions along with multidisciplinary interventions

d. Promotes a consistency of care among patients with similar conditions

a. Helps ensure that important interventions for the diagnosis are not overlooked

The nurse is planning care for a patient by using a standardized (model) care plan for impaired walking related to left-side weakness. Which activity will the nurse perform when individualizing the plan for the patient?

a. Validating conflicting data with the patient

b. Transcribing medical orders

c. Stating the frequency of ambulation

d. Performing a comprehensive assessment

c. Stating the frequency of ambulation

The nurse is working on development of a plan of care for a patient hospitalized for a respiratory infection. Which is the best example of an outcome statement for this patient?

a. Uses the incentive spirometer when awake

b. Walks two times in the hall during day and evening shifts

c. Maintains oxygen saturation above 92% while performing activities of daily living (ADLs)

d. Tolerates 10 sets of range-of-motion exercises with physical therapy

c. Maintains oxygen saturation above 92% while performing activities of daily living (ADLs)

The nurse is formulating a plan of care for an older client admitted for dehydration. The nurse develops goals from a standardized care plan and the physician’s medical orders. Which nurse-sensitive goal is appropriate for this patient?

a. Ask the patient about oral fluid preferences.

b. Maintain a full water pitcher at the patient’s bedside.

c. Ensure patient’s oral intake is 100 mL/hour during the day.

d. Keep the patient on strict intake and output (I&O) monitoring.

c. Ensure patient’s oral intake is 100 mL/hour during the day

The nurse is creating a comprehensive patient plan of care. Which information does the nurse include?

a. Methods of performing patient activities of daily living (ADLs)

b. Both medical and nursing interventions

c. Reasons for assigning care personnel

d. Symptoms of patient’s medical diagnosis

b. Both medical and nursing interventions

Which description specifically differentiates short-term goals from long-term goals? Short-term goals:

a. Can be met within a few hours or a few days.

b. Flow from the problem side of the nursing diagnosis.

c. Must have target times with dates.

d. Specify desired patient responses to interventions.

a. Can be met within a few hours or a few days.

The nurse is individualizing a client’s plan of care for the nursing diagnosis anxiety. For which reason does the nurse write goals/outcomes on the plan of care?

a. To recognize desirable changes related to formulated interventions

b. To monitor specific patient responses to medical interventions

c. To identify specific nursing behaviors to improve a patient’s health

d. To use criteria to evaluate the appropriateness of a nursing diagnosis

a. To recognize desirable changes related to formulated interventions

Which outcome statement written by the nurse contains the best example of performance criteria?

a. Patient turns self in bed frequently while awake.

b. Patient understands how to use crutches by day 2.

c. Patient states that pain is decreased after being medicated.

d. Patient eats 75% of each meal without complaint of nausea.

d. Patient eats 75% of each meal without complaint of nausea.

The nurse is developing a plan of care for a patient after surgery and plans to include collaborative interventions. Which definition of goal/outcome is applicable for collaborative problems?

a. Collaborative problems are monitored only by other disciplines.

b. Collaborative problems are usually affected by nursing interventions

c. Collaborative problems state that a complication will not occur.

d. Collaborative problems state only broad performance criteria.

c. Collaborative problems state that a complication will not occur

In which manner does the nurse understand that NANDA-I problem labels and Nursing Outcome Classification (NOC) outcome labels are alike?

a. Health status is expressed in terms of human responses.

b. Patient response is expressed before interventions are done.

c. Patient responses are always expressed in positive terms.

d. Both methods reveal patterns of related cues.

a. Health status is expressed in terms of human responses.

The nurse writes a nursing diagnosis for a patient: “Impaired memory related to fluid and electrolyte imbalances, as manifested by (AMB) inability to express knowledge of recent events.” Which essential goal/outcome does the nurse include on the care plan?

a. Current medications are reviewed for mind-altering side effects.

b. Demonstrates using techniques to help with memory loss.

c. Oral fluid intake will consist of a minimum of 1,500 mL of fluid per day.

d. Electrolyte supplements will be taken, as prescribed, with meals.

b. Demonstrates using techniques to help with memory loss

A client arrives in the emergency department and is pale and breathing rapidly. The client immediately becomes unconscious and collapses to the floor. The nurse rapidly assesses the client and decides the first series of actions needed. Which type of planning is the nurse demonstrating?

a. Formal planning

b. Informal planning

c. Ongoing planning

d. Comprehensive planning

b. Informal planning

The nurse works in an acute care setting as a patient educator for patients newly diagnosed with diabetes mellitus. Which nursing intervention by this nurse is an indirect-care intervention?

a. Providing emotional support to patients

b. Conducting classes for teaching diet management

c. Requesting classroom furniture for adult patients

d. Recommending medical care for diabetic ulcers

c. Requesting classroom furniture for adult patients

A nurse makes a nursing diagnosis of acute pain related to the postoperative abdominal incision. The nurse writes a nursing order to reposition the client in a comfortable position by using pillows to splint or support the painful areas. Which type of nursing intervention did the nurse write?

a. Collaborative

b. Interdependent

c. Dependent

d. Independent

d. Independent

The nurse is performing preoperative teaching for a client who is scheduled for surgery in the morning. The client does not at present have any respiratory problems. The nurse’s teaching plan includes coughing and deep-breathing exercises. Which type of nursing intervention is the nurse performing?

a. Health promotion

b. Treatment

c. Prevention

d. Assessment

c. Prevention

An adult patient returns to the medical-surgical unit after undergoing abdominal surgery for colon cancer. Which is an appropriate, correctly written nursing order for this patient?

a. (Date) Encourage use of the incentive spirometer every hour while the client is awake. (Nurse’s Signature)

b. (Date) Uses incentive spirometer 10 times every hour while awake to 1,000 mL. (Nurse’s Signature)

c. (Date) Incentive spirometer hourly while awake.

d. Offer incentive spirometer to the client.

a. (Date) Encourage use of the incentive spirometer every hour while the client is awake. (Nurse’s Signature)

A client newly diagnosed with diabetes mellitus is admitted to the hospital because of poorly controlled glucose levels. Which action by the nurse is an appropriate direct-care intervention for this client during the client’s hospitalization?

a. Consulting the diabetes nurse educator for help with a teaching plan

b. Making arrangements for the client to join a diabetes support group

c. Demonstrating blood glucose monitoring and insulin administration to the client

d. Consulting with the dietitian about the client’s dietary concerns

c. Demonstrating blood glucose monitoring and insulin administration to the client

The nurse develops a plan of care for a patient at risk for impaired skin integrity. Interventions include changing the patient’s position every 2 hours and keeping the skin clean and dry. During the evaluation phase of the nursing process, which finding would validate the effectiveness of the plan of care?

a. Documentation reflects the performance of care interventions.

b. Reassessment indicates maintenance or improvement of the condition.

c. Intervention performance is verbally validated by the assigned personnel. d. Patient states care was provided in an effective and timely manner.

a. Documentation reflects the performance of care interventions

A client is admitted to the hospital with an acute respiratory problem resulting from lung disease. The nurse makes a diagnosis of ineffective breathing pattern related to inability to maintain adequate rate and depth of respirations. Which nursing intervention should be listed first on the care plan?

a. Determine airway adequacy hourly and as needed.

b. Administer prescribed oxygen therapy, as needed.

c. Monitor and report arterial blood gas values.

d. Place the client in the high-Fowler’s position.

a. Determine airway adequacy hourly and as needed.

A nurse is studying the ANA Nursing Social Policy Statement. Which information from this document would describe health problems that can be addressed by independent nursing actions and form a body of knowledge unique to nursing?

a. Nursing competencies

b. Nursing diagnosis

c. Nursing standards of care

d. Nursing ethics

b. Nursing diagnosis

A client is admitted to the hospital with an acute episode of chronic obstructive pulmonary (lung) disease. The nurse makes a diagnosis of ineffective breathing pattern related to inability to maintain adequate rate and depth of respirations and has recorded the diagnosis and appropriate goals on the care plan. When selecting nursing interventions, which nursing action does the nurse do first?

a. Identify several interventions likely to achieve the desired outcomes.

b. Review the problem and etiology of the nursing diagnosis.

c. Choose the best interventions for the patient.

d. Review the goals written by the nurse.

b. Review the problem and etiology of the nursing diagnosis.

The nurse is using electronic care planning. The nurse enters the patient’s nursing diagnosis into the computer; selects desired outcomes; and validates the patient data, diagnosis, and goals. When considering the list of program-generated interventions, the nurse identifies none of them fits this patient’s individual needs. Which action does the nurse take?

a. Reject them all, and enter self-generated appropriate interventions.

b. Select the most suitable interventions from the program.

c. Ask another nurse to assess the patient, and give a recommendation.

d. Restart the computer to eliminate the possibility of a program malfunction.

a. Reject them all, and enter self-generated appropriate interventions.

The nurse is completing a plan of care for a patient with congestive heart failure. Which direct-care nursing intervention does the nurse perform?

a. Collaborate with the physician for further medication orders.

b. Instruct the patient about low-sodium and low-fat diets.

c. Refer the patient to cardiac rehabilitation for a home-care program.

d. Consult with the physical therapist for cardiac rehabilitation exercises.

b. Instruct the patient about low-sodium and low-fat diets.

Nurses are expected to use evidence-based practice (EBP) for the determination of best care. Which action by a nurse reflects understanding about EBP?

a. The nurse submits compiled research to nursing administration.

b. The nurse conducts a systematic review of published research.

c. The nurse informs the patient care is based on research evidence.

d. The nurse uses only research that reflects the patient’s condition.

b. The nurse conducts a systematic review of published research.

The nurse is providing care for an adult smoker hospitalized on a medical-surgical unit. The patient states, “I’d really like some help in quitting smoking.” As part of the nurse’s intervention plan, a smoking cessation class is included. Which type of intervention is the nurse performing?

a. Wellness

b. Prevention

c. Assessment

d. Treatment

a. Wellness

Which is the best example of a well-written nursing order?

a. Provide emotional support to patient and family, as needed.

b. Assist with performance of personal hygiene, if necessary.

c. Follow prescribed fluid restriction of 1,500 mL per day.

d. Insert urinary catheter if patient has not voided within 8 hours.

d. Insert urinary catheter if patient has not voided within 8 hours.

Which is the best example of a well-written nursing order?

a. Administer pain medication 30 minutes before physical therapy exercises. b. Before discharge, teach patient how to self-administer insulin injections.

c. Assess vital signs and report changes, as needed.

d. Consider patient and family cultural preferences in diet order.

a. Administer pain medication 30 minutes before physical therapy exercises.

The nurse is providing care for a patient in the end stages of a terminal disease. Medical prescriptions are obtained from the attending physician. Which individualized nursing order represents an appropriate nursing intervention?

a. Prescribed pain medication will be administered, as needed.

b. Provide printed materials to patient’s family about patient rights.

c. Ask visitors to support the patient’s decisions for the type of care.

d. Assess pain hourly for levels above patient’s acceptable level of 5.

d. Assess pain hourly for levels above patient’s acceptable level of 5.

A psychiatrist prescribes oral aripiprazole 10 mg daily for a client with schizophrenia. This medication is unfamiliar to the nurse, who cannot find it in the hospital formulary or other references. In which manner does the nurse proceed?

a. Administer the medication as ordered.

b. Hold the medication and notify the prescriber.

c. Consult with a pharmacist before administering it.

d. Ask the patient’s registered nurse (RN) for information about the medication.

c. Consult with a pharmacist before administering it

The nurse is providing care to a client admitted with pressure injuries. The nurse develops a plan of care focusing on healing measures and prevention of further injury. Which task does the nurse delegate to the unlicensed assistive personnel (UAP)?

a. Turn and reposition the patient every 2 hours.

b. Assess the patient’s skin condition.

c. Change pressure injury dressings every shift.

d. Apply hydrocolloid dressing to the pressure injury.

a. Turn and reposition the patient every 2 hours.

A physician prescribes an indwelling urinary catheter for a client who is mildly confused and combative. In which manner does the nurse proceed?

a. Ask a colleague for help because the nurse cannot safely perform the procedure alone.

b. Gather and prepare the equipment before informing the client about the procedure.

c. Obtain a prescription to restrain the client before inserting the urinary catheter.

d. Inform the physician the nurse cannot perform the procedure because the client is confused

a. Ask a colleague for help because the nurse cannot safely perform the procedure alone.

Before inserting a nasogastric tube, the nurse reassures the client. Reassuring the client requires which type of nursing skill?

a. Psychomotor

b. Interpersonal

c. Cognitive

d. Critical thinking

b. Interpersonal

The nurse is providing care for a client newly diagnosed with type 2 diabetes mellitus. Which intervention by the nurse best promotes client cooperation with the treatment plan?

a. Teaching the client that weight must be lost to control blood glucose

b. Informing the client that it is necessary to exercise at least three times per week

c. Explaining to the client that weekly attendance is mandatory at the diabetes clinic

d. Determining the client’s main concerns about the diagnosis of diabetes

d. Determining the client’s main concerns about the diagnosis of diabetes

The nurse works in an acute care facility, which implements team nursing with each team consisting of members from various levels of healthcare provision. Which statement accurately describes delegation in the nurse’s work environment?

a. Transferring authority to perform a task to a qualified person in a selected situation

b. Collaborating with other caregivers to make decisions and plan patient care

c. Scheduling treatments and activities by coordinating with other departments

d. Implementing an appropriate planned intervention from a critical pathway

a. Transferring authority to perform a task to a qualified person in a selected situation

Which statement by the registered nurse (RN) best demonstrates clear communication to unlicensed assistive personnel (UAP) about a delegated task?

a. “Record the patient’s intake and output of fluids throughout the shift, please.”

b. “Take the patient’s temperature, pulse, respirations, and blood pressure every 2 hours today.”

c. “Assess the patient’s temperature every 4 hours; notify me if it is greater than 100.5°F (38.1°C).”

d. “Assist the patient with all meals so that the patient’s intake of calories will increase.”

c. “Assess the patient’s temperature every 4 hours; notify me if it is greater than 100.5°F (38.1°C).”

The nurse is delegating patient care to an unlicensed assistive personnel (UAP) with whom the nurse has worked before. The nurse provides exact details of which patient, what tasks, what time period, and what feedback are expected; the UAP has no questions. Which responsibility does the nurse retain after completing the delegation assignment?

a. The nurse will determine and evaluate completion of the assignment.

b. The nurse will check the UAP’s progress on the assignment every hour.

c. The nurse will immediately document the assigned tasks as being delegated.

d. The nurse periodically checks the accuracy of the UAP’s documentation.

a. The nurse will determine and evaluate completion of the assignment.

The nurse is assigned to participate in a structure evaluation for an acute care facility. Which response on the nurse’s structure evaluation form indicates the nurse understood the criteria related to the task?

a. “Staff refrains from sharing computer passwords.”

b. “Healthcare provider washes hands before each client contact.”

c. “A defibrillator is present in each client care area.”

d. “Nurses verify client identification before initiating care.”

c. “A defibrillator is present in each client care area.”

. Which client outcome criterion does the nurse use when evaluating client behaviors that affect the client’s health status?

a. Central venous catheter site infection does not occur in 90% of cases.

b. Client will sit in the bedside chair for 20 minutes three times per day.

c. Postoperative phlebitis does not occur in 95% of surgical patients.

d. Falls in the facility will be reduced by 2% at the end of the year.

b. Client will sit in the bedside chair for 20 minutes three times per day.

The nurse creates a plan of care for a patient diagnosed with severe dehydration. One nursing goal reads, “Patient will maintain urine output of at least 30 mL/hour.” Which time frame will the nurse use to collect evaluation data for this expected outcome?

a. Every 8 hours

b. Every 24 hours

c. Every 4 hours

d. Every hour

d. Every hour

The nurse receives a postsurgical patient who is prescribed to have vital signs taken every 15 minutes for 2 hours. Which type of client-centered evaluation does the nurse recognize?

a. Intermittent

b. Ongoing

c. Terminal

d. Process

a. Intermittent

The nurse is providing care for a patient after joint replacement surgery. The standardized care plan states, “Patient will ambulate 50 feet in the hall with a walker before discharge.” Which patient variable affecting this goal is the nurse unable to control?

a. Confusion and lethargy related to pain medication

b. Compromised respiratory function due to severe chronic obstructive pulmonary disease (COPD)

c. Reluctance to ambulate due to pain at level 7

d. Presence of a spouse who pushes the patient to rest

b. Compromised respiratory function due to severe chronic obstructive pulmonary disease (COPD)

The nurse works with the respiratory therapist to administer a patient’s breathing treatments. The therapist reports the patient’s breathing status and tolerance of the treatment to the primary care provider. The nurse then discusses with the patient the options for further treatment. Which type of implementation process is being used?

a. Delegation

b. Collaboration

c. Coordination of care

d. Supervision of care

b. Collaboration

The nurse reviews a patient’s chart and sees a physician’s prescription for a new medication. The nurse is able to clearly read the medication name, but the dose is not legible. Which is the best action by the nurse?

a. Contact the physician for clarification.

b. Ask another nurse to read the order.

c. Ask the unit secretary to read the order.

d. Contact the pharmacist to read the order.

a. Contact the physician for clarification

Which is the most appropriate strategy for the student to use to assist with organizing and prioritizing patient care for the day?

a. Ask the nurse what tasks need to be completed for the day.

b. Make a time-sequenced “to-do” list for care activities for the day.

c. Work with the charge nurse to complete tasks.

d. Collaborate with the patient on what needs to be completed for the day

b. Make a time-sequenced “to-do” list for care activities for the day.

Which action does the nurse need to take to evaluate the effectiveness of the plan of care?

a. Read the documentation by the previous nurse.

b. Collect reassessment data on the patient.

c. Look at the physician’s progression notes.

d. Ask the patient’s view about each nursing goal.

b. Collect reassessment data on the patient.

The nurse reviews a nursing order for a patient who is 4 days postoperative after hip surgery, which reads: Assist patient in bathing each morning. The nurse assesses the patient and notes the patient demonstrates the ability to bathe independently. Which action does the nurse do next?

a. Assist with the bath, as ordered.

b. Delegate the bath to the nursing assistant.

c. Discontinue the nursing order on the plan of care.

d. Collaborate with the nurse who originally wrote the order.

c. Discontinue the nursing order on the plan of care.

After gathering and analyzing data and identifying patient needs, the nurse begins the implementation phase of developing a plan of care. Which is the best example of the implementation phase of the nursing process?

a. Nurse asks the patient to verbalize if pain is reduced from 8 to 3 after receiving pain medication.

b. Nurse observes that patient has a quarter-sized skin tear over coccyx area. c. Nurse writes in the care plan: Patient requires two-person assist with ambulation to bathroom.

d. Nurse inserts urinary catheter after reporting to physician the patient’s inability to void.

d. Nurse inserts urinary catheter after reporting to physician the patient’s inability to void.

The certified nursing assistant (CNA) is feeding a patient and notices that the patient is having difficulty swallowing. The CNA reports the observation to the primary registered nurse. Which action does the nurse take first?

a. Assign the task to a more experienced CNA.

b. Continue patient feeding by the nurse.

c. Assess the patient and place the patient on NPO (nothing by mouth) status.

d. Call the primary care provider.

c. Assess the patient and place the patient on NPO (nothing by mouth) status.

Which nursing activity is most reflective of the evaluation phase of the nursing process?

a. Administering pain medication before changing a complex wound dressing b. Obtaining patient’s blood pressure (BP) 30 minutes after administering BP medication

c. Reporting there have been three patient falls in the past month on the nursing unit

d. Teaching the patient how to perform daily finger sticks for blood glucose readings

b. Obtaining patient’s blood pressure (BP) 30 minutes after administering BP medication

Nurses are aware that documentation is essential in monitoring and validating appropriate patient care. Which statement is the best example of high-quality nursing documentation?

a. “Patient breathing is normal. No pain noted. Urine output is adequate at this time.”

b. “Good strength in both lower extremities. Ambulating with walker in the hall.”

c. “Started on solid foods. Ate 75% of dinner. No complaints of any nausea or vomiting.”

d. “Patient seems upset with visiting spouse. Physical assessment planned at a later time.”

c. “Started on solid foods. Ate 75% of dinner. No complaints of any nausea or vomiting.”

Which question(s) will be effective for obtaining information from the patient during an interview? Select all that apply.

a. “How did this happen to you?”

b. “What was your first symptom?”

c. “Why didn’t you seek healthcare earlier?”

d. “When did you start having symptoms?”

e. “Why did you decide to seek help now?”

a. “How did this happen to you?”

b. “What was your first symptom?”

d. “When did you start having symptoms?”

A nurse with a large caseload of patients needs to delegate some assessment tasks to other members of the healthcare team. The nurse is unsure which tasks can be delegated to unlicensed assistive personnel (UAP) and which are appropriate for a licensed practical nurse (LPN) instead of a registered nurse (RN). Which source(s) does the nurse consult for clarification related to delegation? Select all that apply.

a. Nurse practice act of the nurse’s state

b. American Medical Association (AMA) guidelines

c. Code of Ethics for Nurses

d. Agency policy

e. Facility policy and procedure guidelines

a. Nurse practice act of the nurse’s state

d. Agency policy

Which of the following are cues rather than inferences? Select all that apply. a. Patient ate 50% of the meal.

b. Patient feels better today.

c. Patient states, “I slept well.”

d. Patient’s white blood cell (WBC) count is 15,000/mm3 .

e. Patient does not appear to be in pain.

a. Patient ate 50% of the meal.

c. Patient states, “I slept well.”

d. Patient’s white blood cell (WBC) count is 15,000/mm3

Which statement would be considered true of assessment in the nursing process? Select all that apply.

a. Assessment provides contextual information that becomes a part of the patient database.

b. Assessment helps guide the choice of effective interventions and how to best implement them.

c. Assessment involves performing or delegating planned interventions.

d. Assessment encompasses identifying goals and outcomes, choosing interventions, and creating nursing care plans.

e. Assessments reveal information about motivation and resources that help formulate outcomes.

a. Assessment provides contextual information that becomes a part of the patient database.

b. Assessment helps guide the choice of effective interventions and how to best implement them.

e. Assessments reveal information about motivation and resources that help formulate outcomes.

The nurse recognizes which example(s) of objective data? Select all that apply.

a. Blood pressure of 120/80 mm Hg

b. Pain rated as 6 on a pain scale of 0 to 10

c. Moderate amount of yellow drainage from right ear

d. Spouse stating the client is not sleeping well at night

e. Patient reporting the presence of stomach pain

a. Blood pressure of 120/80 mm Hg

c. Moderate amount of yellow drainage from right ear

The nurse manager is reviewing documentation performed by newly hired nurses. Which of the example(s) does the nurse manager recognize as high-quality nursing documentation? Select all that apply.

a. Patient states, “I feel dizzy in the morning.”

b. Patient is alert and oriented to person, place, and time.

c. Drainage from midline abdominal incision appears normal.

d. Patient appears angry and is refusing to talk to the spouse.

e. Patient expresses no complaints of pain at this time.

a. Patient states, “I feel dizzy in the morning.”

b. Patient is alert and oriented to person, place, and time.

e. Patient expresses no complaints of pain at this time.

What are the benefit(s) for nursing practice in using a standardized nursing language when writing nursing diagnoses? Select all that apply.

a. Defines and communicates nursing knowledge

b. Assists the nurse in understanding medical diagnoses

c. Facilitates better understanding of nursing research

d. Helps nurses provide consistent interventions for all patients e. Promotes medical understanding of nursing functions

a. Defines and communicates nursing knowledge

c. Facilitates better understanding of nursing research

Which statement(s) regarding nursing diagnoses are accurate? Select all that apply. a. Provide the basis for nursing interventions b. Are validated with patient and family, when possible c. Have historically been well substantiated by research d. Contain descriptions of pathological disease processes e. Analyze assessment data by using critical-thinking skills

a. Provide the basis for nursing interventions

b. Are validated with patient and family, when possible

e. Analyze assessment data by using critical-thinking skills

Which nursing diagnosis statement(s) is written correctly? Select all that apply.

a. Chronic pain related to osteoarthritis, as manifested by (AMB) patient rating pain at 8 on a 0-to-10 pain scale and having difficulty with ambulation b. Ineffective airway clearance related to excessive mucus, AMB cough, shortness of breath, change in respiratory rate and rhythm

c. Caregiver role strain related to increasing care needs, AMB wife stating, “He is just getting too heavy for me to lift”

d. Anxiety (moderate) related to cardiac catheterization, AMB crying and yelling at family members

e. Emotional distress, AMB inability to eat related to recent diagnosis of a terminal disease

b. Ineffective airway clearance related to excessive mucus, AMB cough, shortness of breath, change in respiratory rate and rhythm

c. Caregiver role strain related to increasing care needs, AMB wife stating, “He is just getting too heavy for me to lift”

Which statement would be considered true regarding goals/expected outcomes? Select all that apply.

a. They motivate the client and nurse by providing a sense of achievement when met.

b. They are broad overarching statements.

c. They form criteria that will be used in evaluation.

d. They provide a guide for selecting nursing interventions.

e. They describe a potential change in patient health status.

a. They motivate the client and nurse by providing a sense of achievement when met.

c. They form criteria that will be used in evaluation.

d. They provide a guide for selecting nursing interventions.

e. They describe a potential change in patient health status.

The nurse in an acute care facility is preparing to discharge an older client to an extended care facility. Which objective(s) does the nurse address in preparation for a comprehensive discharge process for this client? Select all that apply.

a. Maintain interagency communication

b. Determine level of family involvement

c. Share information about financial status

d. Activities for maintaining functional ability

e. Current ability to perform self-care needs

a. Maintain interagency communication

A nurse is overheard complaining about the time used to develop patients’ plans of care. What information does the nurse manager share with the nurse about the importance of the process? Select all that apply.

a. Ensures that provided care is complete

b. Supports of continuity of care among nurses and between shifts

c. Promotes the efficient use of nursing efforts and care activities

d. Provides nurses with a guide for assessment and documentation

e. Meets the requirements set by accrediting agencies regarding care

a. Ensures that provided care is complete b. Supports of continuity of care among nurses and between shifts c. Promotes the efficient use of nursing efforts and care activities d. Provides nurses with a guide for assessment and documentation e. Meets the requirements set by accrediting agencies regarding care

Newly hired nurses on an acute care unit are encouraged to use computerized care planning in providing patient care. Which advantage(s) exist from this process? Select all that apply.

a. The computer stores nursing diagnoses, medical diagnoses, and individualized interventions.

b. The computer generates a diagnosis and desired outcome after the patient’s assessment is entered.

c. The computer is capable of generating a list of suggested interventions, the nursing diagnosis, and goals.

d. The computer promotes the development and refinement of nursing intuition, insight, or expertise.

e. The computer prompts the nurse to consider a variety of actions and decreases overlooking common and important interventions.

c. The computer is capable of generating a list of suggested interventions, the nursing diagnosis, and goals.

e. The computer prompts the nurse to consider a variety of actions and decreases overlooking common and important interventions.

The nurse is providing care for a patient after a total-knee replacement. The patient is to remain in acute care for two days. When developing an individualized plan of care for this patient, which goal(s) set by the nurse are considered to be short term? Select all that apply. a. Patient will ambulate 10 feet with assistance 5 hours after surgery. b. Patient will exhibit the ability to use a walker when ambulating. c. Patient will understand the signs of infection at the surgery site. d. Patient will experience a pain level of 4 or below on a 0-to-10 scale. e. Patient will voice understanding of pain management at home.

a. Patient will ambulate 10 feet with assistance 5 hours after surgery.

b. Patient will exhibit the ability to use a walker when ambulating.

d. Patient will experience a pain level of 4 or below on a 0-to-10 scale.

The nurse is providing care for a hospitalized patient after surgery. Which statement(s) is an example of the need for ongoing planning? Select all that apply.

a. Patient completes daily hygiene activities without assistance.

b. Patient consumes 25% of daily diet due to continued reports of nausea.

c. Patient is able to perform dressing change only with verbal coaching and assistance.

d. Patient ambulates 10 of the 25 feet anticipated on second postop day.

e. Patient rates pain at a level of 3 on a 0-to-10 scale 1 hour after medicated.

b. Patient consumes 25% of daily diet due to continued reports of nausea.

c. Patient is able to perform dressing change only with verbal coaching and assistance.

d. Patient ambulates 10 of the 25 feet anticipated on second postop day.

The nurse recognizes which statement(s) about nursing interventions as being true? Select all that apply.

a. Writing of nursing interventions cannot be delegated to the licensed practical nurse/licensed vocational nurse (LPN/LVN).

b. The best nursing interventions are based on tradition.

c. Nursing interventions are individualized and culturally sensitive.

d. Standardized nursing interventions improve care for a specific client.

e. Evidence-based practice (EBP) must always be used for nursing interventions.

a. Writing of nursing interventions cannot be delegated to the licensed practical nurse/licensed vocational nurse (LPN/LVN).

c. Nursing interventions are individualized and culturally sensitive.

The nurse completes the plan of care for a patient with a medical diagnosis of gall bladder disease. Which consideration(s) will the nurse use when selecting nursing interventions? Select all that apply.

a. Age of the patient

b. Abilities and preferences

c. Education levels of the nursing staff

d. Medical orders

e. General health status

a. Age of the patient

b. Abilities and preferences

c. Education levels of the nursing staff

d. Medical orders

e. General health status

The nurse is selecting nursing interventions for a patient with diabetes mellitus. Which available resource(s) does the nurse use to assist in the selection of interventions? Select all that apply.

a. A computer-generated list of standardized interventions

b. Self-generated interventions based on knowledge and experience

c. Traditional interventions that seem to have worked in the past

d. Only those interventions that agree with patient preferences

e. Suggested interventions from the facility policy and procedures

a. A computer-generated list of standardized interventions

b. Self-generated interventions based on knowledge and experience

Which description(s) are best related to the primary goal of evidence-based practice (EBP)? Select all that apply.

a. Presents the most effective treatments

b. Identifies the most cost-effective treatments

c. Includes all patient and family preferences

d. Creates standardized facility clinical pathways

e. Adds more studies to support an intervention

a. Presents the most effective treatments

b. Identifies the most cost-effective treatments

Which question(s) does the nurse ask oneself after the development and before the implementation of nursing interventions? Select all that apply.

a. Do I have the skills and knowledge to carry out the interventions?

b. Will any of the interventions interfere with medical prescriptions?

c. Have I explained the intervention enough to obtain patient support?

d. Does administration support expenses associated with the intervention?

e. What consequences might occur from performance of this intervention?

a. Do I have the skills and knowledge to carry out the interventions?

b. Will any of the interventions interfere with medical prescriptions?

e. What consequences might occur from performance of this intervention?

The nurse and the unlicensed assistive personnel (UAP) are providing care for various clients on a medical-surgical unit. For which client(s) can the nurse delegate to the UAP the task of bathing? Select all that apply.

a. A 75-year-old client who is newly admitted with a diagnosis of dehydration b. A 65-year-old client diagnosed with a stroke, whose BP is currently 189/90 mm Hg

c. A 92-year-old client with stable vital signs admitted with a urinary tract infection

d. A 56-year-old client with chronic renal failure, whose vital signs remain stable e. An 80-year-old client who is 2 days postoperative after repair of a hernia

a. A 75-year-old client who is newly admitted with a diagnosis of dehydration

c. A 92-year-old client with stable vital signs admitted with a urinary tract infection

d. A 56-year-old client with chronic renal failure, whose vital signs remain stable

e. An 80-year-old client who is 2 days postoperative after repair of a hernia

The nurse is providing care for various patients with the assistance of a licensed practical nurse/licensed vocational nurse (LPN/LVN). Which task(s) does the nurse delegate to the LPN/LVN? Select all that apply.

a. Administer oral pain medications.

b. Insert an indwelling urinary catheter.

c. Perform an admission assessment on a patient.

d. Establish a new teaching plan for a patient with diabetes.

e. Call a patient’s physician to validate a new prescription.

a. Administer oral pain medications.

b. Insert an indwelling urinary catheter.

The nurse is providing care for a patient after abdominal surgery and has just completed a prescribed dressing change. Which activities does the nurse perform soon after this task is completed? Select all that apply.

a. Assess the patient’s response to the procedure.

b. Provide patient teaching about the procedure.

c. Document the procedure in the nursing progress notes.

d. Ask if the patient is interested in helping with the next dressing change.

e. Provide a handout about the dressing changes after discharge.

a. Assess the patient’s response to the procedure

c. Document the procedure in the nursing progress notes.

. Which statement(s) or questions made by the nurse during the interview are appropriate? Select all that apply.

a. “You shouldn’t be smoking cigarettes; you have already had one heart attack.”

b. “Why don’t you take your blood pressure medications? Your blood pressure remains high.”

c. “I can see you are in pain. I will bring pain medication and complete the interview later.”

d. “If it is a good time for you, we can complete your interview now.”

e. “Have you noticed any changes in your ability to sleep or patterns of sleeping?”

c. “I can see you are in pain. I will bring pain medication and complete the interview later.”

d. “If it is a good time for you, we can complete your interview now.”

e. “Have you noticed any changes in your ability to sleep or patterns of sleeping?”

A _______________ care plan uses shapes and pictures to represent the steps in the nursing process.

mind-mapped

Using Maslow’s hierarchy of needs, rank the following nursing diagnoses in order of importance, beginning with the highest-priority diagnosis. (Enter using the following format: A, B, C, D.)

A. Anxiety B. Risk for infection C. Disturbed body image D. Sleep deprivation

D. 1.Sleep deprivation

B. 2.Risk for infection

A. 3.Anxiety

C. 4.Disturbed body image

Nurses use a five-step process in selecting the best nursing interventions for their patients. Using the five-step process, arrange the option numbers in the correct order of completion. (Enter using the following format: A, B, C, D.)

A. Review the desired outcomes/goals.

B. Identify several actions or interventions.

C. Individualize standardized interventions.

D. Review the nursing diagnosis.

E. Choose the best interventions for the patient.

D. Review the nursing diagnosis.

A. Review the desired outcomes/goals.

B. Identify several actions or interventions.

E. Choose the best interventions for the patient.

C. Individualize standardized interventions