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- 1. Multiple Choice
The nurse repositions a client who has difficulty breathing. Which nursing action, when performed following the intervention, demonstrates evaluation?
Instructing the client the importance of mobility
Arranging the pillows behind the client's back
Checking the client's respiratory status
Changing the rate of flow for the oxygen delivery system
- 2. Multiple Choice
Which statement is correctly stated as an expected client outcome?
Client will ambulate safely.
Client will be able to safely walk down the hallway.
Nurse will assist the client with ambulation three times daily.
Client will ambulate with assistance to nurse's station on second postoperative day.
- 3. Multiple Choice
The nurse is caring for a one day postoperative client with a new colostomy. What nursing diagnosis would be the primary concern for the nurse?
Activity intolerance
Ineffective Health Maintenance
Impaired bowel elimination
Ineffective coping
- 4. Multiple Choice
One hour after receiving pain medication, a postoperative client reports intense pain. What is the nurse's most appropriate first action?
Discuss the frequency of pain medication orders with the client.
Assess the client to determine the cause of the pain
Consult with the healthcare provider for additional pain orders
Assist the client to reposition and splint the incision site
- 5. Multiple Choice
_______ assessments can be done with an initial assessment. They identify new or overlooked problems. They are important because they can "flag" existing problems.
Initial
Focused
On-going
Emergency
- 6. Multiple Choice
Time lapsed assessments compare current status to the ______data
Subjective
Projected
Objective
Baseline
- 7. Multiple Choice
_______ data is observable and measurable data that can be seen, heard, felt or measured by someone other than the person experiencing them
Objective
Subjective
- 8. Multiple Choice
_______ is the conscious and deliberate use of the five senses to gather data
Assessment
Interview
Observation
- 9. Multiple Choice
The _____ step of the nursing process interprets and analyzes data gathered
Assessment
Diagnosis
Implementation
Evaluation
- 10. Multiple Choice
Caring for a patient who presents with labored respirations, productive cough, and fever. What would be an appropriate nursing diagnosis for this patient? (select all that apply)
Bronchial pneumonia
Impaired gas exchange
Ineffective airway clearance
Potential complications: sepsis
Risk for septic shock
- 11. Multiple ChoiceWhich is not a method for observationSightSmellHearingVerbal
- 12. Multiple ChoiceT or F: When reporting, its okay to report opinions.TrueFalse
- 13. Multiple ChoiceWhich type of Observation is observed using the senses?SubjectiveObjective
- 14. Multiple ChoiceWho prepares patient care plans?NurseCNADoctorFacility administrator
- 15. Multiple ChoiceT or F: Abbreviations are used primarily in verbal communicationTrueFalse
- 16. Multiple ChoiceAn individualized plan for each resident. It is developed to help achieve goals of care. This plan list tasks that each member of the care team must performCare TrackerResident Care planResident Medical RecordADLs
- 17. Multiple ChoiceA permanent, confidential, legal collection of medical information that includes assessments, implementations, evaluations, management plans, and progress notes.Care TrackerResident Care planResident Medical RecordADLs
- 18. Multiple ChoiceReports are to be madeimmediatelythoroughlyaccuratelyall of the above
- 19. Multiple ChoiceAn observation using touch includes:wheezingrashchange in pulsewords spoken by a resident
- 20. Multiple ChoiceWhich is not included in care plans?level of independence in ADLstreatmentsstatement of issuesnone of the above
- 21. Multiple ChoiceWhat should you use to reference if you don't understand a term?Medical dictionaryInternetWebster's dictionarynone of the above
- 22. Multiple ChoiceWhat is the purpose of the nursing process?Assist family members to make healthcare decisions.Provide nurses with a framework to deliver comprehensive care.Help other healthcare professionals know what is going on with the client.Organize information so the nurse knows what is wrong with the client.
- 23. Multiple ChoiceWhat are the steps of the nursing process?Problem identification, care giving, collaboration and goal-setting.Planning intervention, re-evaluation, renewal and revision.Assessment, diagnosis, planning, intervention, evaluation.Assessment, goals, intervention, implementation, evaluation.
- 24. Multiple ChoiceAssessment includes:Subjective findingsPhysical findingsSocial informationAll of the above
- 25. Multiple ChoiceWhich of the following is objective data?Pain 5/10Temp 100.3Complaints of fatigueClient states "I am sleepy."
- 26. Multiple ChoiceWhich of the following are subjective?WBC 8,000X ray resultsComplains of hungerReport from surgeon
- 27. Multiple ChoiceAnalysis of subjective and objective data leads to which outcome?The cause of the surgeon's behavior.Information for the family.Conclusions about skills of nurse.Accurate nursing diagnosis.
- 28. Multiple ChoiceWhat is the North American Nursing Diagnosis Association (NANDA) responsible for?Determine independent nursing diagnosis and action.Support NLN in making new diagnosis.Establishing and determining new diagnosis for allied health.Developing criteria for collaborative practice between nursing and MD.
- 29. Multiple ChoiceTypes of nursing diagnosis are?RiskPossibleActualAll of the above
- 30. Multiple ChoiceThe planning stage of the nursing process involves:Outcomes and goalsGoals, outcomes, and interventionsInterventions based on medical diagnosis.Goals based on medical diagnosis.
- 31. Multiple ChoiceWhich of the following is a well written goal?Will reduce his risk of falls by correct use of his walker each time him ambulates.The nurse will teach the patient the to use a walker within 2 days.The patient will use his cane correctly by 2 pm today.The patient will demonstrate safe use of his walker during ambulation down the hallway by 2 pm today.
- 32. Multiple ChoiceClient outcomes include which of the following?Actions of the client to accomplish goals.Cues clustered to enhance diagnostic goals.List of unit policies and procedures.Staff credentials and goals for renewal.
- 33. Multiple ChoiceWhich of the following is true about interventions?They assist with data collection.Connect patient goals and outcomes.They are broadly applied to all patients.Improve relationship between nursing staff and allied health.
- 34. Multiple ChoiceDuring the evaluation stage,Determine progress toward goals completion.Assess outcomes for completion.Edit nursing care plan.All of the above
- 35. Multiple ChoiceIf the client has not completed the plan, but the goal is still relevantCreate a new plan.Initiate new interventions.Reassess in 24 hours.Adjust diagnosis to suit outcome.
- 36. Multiple Choice
The stem part of the nursing diagnosis statement guides the nurse in developing which other part of the nursing care plan?
goal/outcome
intervention
evaluation
etiology
- 37. Multiple Choice
The purpose of stating a two part diagnosis created after identifying a relationship between the health problem (stem) and factors related to the health problem (etiology) is to:
individualize the plan of nursing care for the patient.
include both dependent and independent nursing functions.
compare the patient’s problems to accepted standards.
use a functional category approach to organize the assessment data.
- 38. Multiple Choice
What are two types of nursing diagnosis?
direct and indirect
independent and collaborative
actual and potential
independent and dependent
- 39. Multiple Choice
Name the steps of the nursing process
assessment, diagnosis, planning, intervention, evaluation
assessment, diagnosis, planning, implementation, evaluation
acknowledge, decision-making, planning, implementation, evaluation
assessment, decision-making, planning, intervention, evaluation
- 40. Multiple Choice
Which of the following are valid sources for patient assessment data?
patient's family
medical record/chart
healthcare team
All of the above
- 41. Multiple Choice
The medical diagnosis is never included as a part of the nursing diagnosis.
True
False
- 42. Multiple Choice
Which of the following terms defines the "patient's response to a disease or medical condition"?
nursing diagnosis
medical diagnosis
interventions
medical diagnosis
- 43. Multiple Choice
The implementation phase of the nursing care plan should include:
evaluation of the nursing care plan
patient teaching
identifying a nursing diagnosis
selection of the nursing diagnosis
- 44. Multiple Choice
Goals and outcomes should be:
written after determining patient interventions
written before developing a nursing diagnosis
evaluated based on doctor's orders
evaluated and labeled as met, unmet, partially met
- 45. Multiple Choice
Which option best reflects nursing activities that occur within the implementation phase of the nursing process?
Obtaining the patient’s subjective rating of pain one hour after analgesia is given
Administering a dose of analgesia to a patient experiencing pain
Determining criteria that will reflect successful pain relief activities
Modifying the outcome after assessing reaction to the analgesia
- 46. Multiple Choice
Which of the following will help the nurse prioritize needs?
identifying a problem, cause of the problem, and defining characteristics
ensuring assessment data is thorough and complete
utilization of Maslow's Hierarchy
assessment, teaching, and evaluation
- 47. Multiple Choice
Which of the following is a well written nursing diagnosis statement?
Risk for infection R/T infection via surgical incision
Altered oral mucous embranes R/T forceful trauma during oral suctioning
Breathing pattern, ineffective, R/T retained secretions secondary to pulmonary edema
Decreased caloric intake R/T alteration in nutrition
- 48. Multiple Choice
The nurse understands the following statement " The patient will reduce his risk of falls by correct use of his walker each time him ambulates" is an example of...
nursing diagnosis
outcome
goal
intervention
- 49. Multiple Choice
If the client has not completed the care plan, but the goal is still relevant...
create a new plan
reassess in 24 hours
initiate new interventions
adjust diagnosis to suit the outcome
- 50. Multiple Choice
Which of the following is objective data?
client reports a fever
itching
headache
temp of 99.1
- 51. Multiple Choice
It is important to document: (select all that apply)
only what the patient tells you
what you as the nurse observe
what you as the nurse interpret or infer from the data collected
nursing history and physical assessment
- 52. Multiple Choice
What is the first and most critical step in the nursing process, and accuracy of the data collected affects all other phases of the nursing process
Planning
Assessment
Diagnosis
Evaluating
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