Question 1

When percussing the patient's abdomen,the nurse anticipates a note that is:

Accepted Answer

Tympanic notes are anticipated over an air-filled organ such as the stomach.

Question 2

The nurse assisting with prioritizing nursing diagnoses would select which of the following as the highest priority?

Accepted Answer

Without a clear airway,no need exists for the other diagnoses.

Question 3

The nurse notes the previous 24-hour urine output was 950 ml,well below the normal of 1500 ml.An effective nursing order to remedy the impending dehydration would be to:

Accepted Answer

The statement is clear and measurable and relates directly to the potential of dehydration.The other options are vague and have no measurement criteria.

Question 4

The documentation entry that reflects objective data is:

Accepted Answer

Objective data are data that are observable and measurable.

Question 5

The nursing process is based on:

Accepted Answer

The nursing process assesses the needs of the patient to establish goals and to carry out nursing implementations.

Question 6

The nurse uses palpation for the purpose of:

Accepted Answer

Palpation is a method of touching the patient to obtain information about symptoms and signs such as skin temperature,condition,and pain.

Question 7

The nurse is aware of the goal that reads,"The patient will eat at least 50% of all meals." The nurse has observed the patient eating over 50% of all meals for 2 days.The evaluation statement should read:

Accepted Answer

The evaluation statement should reflect the actual outcome compared with the expected outcome,with the qualifying statement of goal met,goal not met,goal partially met.

Question 8

An example of a complete nursing diagnosis is:

Accepted Answer

A complete nursing diagnosis includes diagnosis,related to and exhibited by problem,cause,and signs and symptoms (PES).

Question 9

The best example of a nursing order is:

Accepted Answer

Nursing orders should include a specific description of what,where,when,how much,how long,and how the order should be carried out.

Question 10

The nursing care plan is initiated by the:

Accepted Answer

The LPN/LVN may contribute to the nursing care plan,but the care plan itself must be initiated by an RN.

Question 11

The patient will maintain an adequate nutritional state without nausea or vomiting is an example of a nursing:

Accepted Answer

Goals should be stated in terms of observable patient outcomes.

Question 12

Nursing interventions classifications (NIC)are:

Accepted Answer

NIC is a standardized list of nursing implementations divided into seven domains.The nurse selects those that pertain to the patient and then implements them.

Question 13

The patient complains of a headache.This information would be classified as:

Accepted Answer

Subjective data are reported by the patient or family and cannot be observed.

Question 14

When the postsurgical patient complains of shortness of breath,the nurse should immediately:

Accepted Answer

Although all these options will be eventually performed,the initial implementation should be to raise the head of the bed to ease breathing,perform a focused assessment with vital signs and oxygen concentration,and then inform the charge nurse about the patient's symptoms and your assessment findings.

Question 15

Nursing outcome classification (NOC)is a method of classifying a nursing:

Accepted Answer

NOC is a new classification system for outcomes that are amenable to nursing implementations.

Question 16

Data collection consists of:

Accepted Answer

Diagnostic tests supply general information that can be helpful in identifying general areas in which a patient might have a health care problem.Patient records provide valuable information regarding the medical history and present illness.Physical assessment can provide information concerning the patient's current needs.

Question 17

The primary purpose of incorporating the nursing process into the care of patients is to:

Accepted Answer

The goal of the nursing process is to alleviate,minimize,or prevent actual or potential health problems and direct nursing care,not medical care.

Question 18

The five steps of the nursing process,in the correct order,are:

Accepted Answer

The nursing process is a systematic method of providing care to patients.Each phase is dependent on the other phases.

Question 19

Standardized care plans are:

Accepted Answer

Clinical pathways are standard care plAnswer developed to set daily care priorities,schedule achievement outcomes,and reduce length of hospital stay.

Question 20

When a patient plan of care has been written,it:

Accepted Answer

The care plan should reflect the current needs of the patient.

Quiz 12: The Nursing Process and Critical Thinking