Deck 1: Critical Thinking and the Nursing Process

Question 1

The nurse is caring for a patient with the diagnosis of Fluid Volume Excess.Which information should the LPN/LVN use to determine if care was effective?

A) Restrict the patient's fluid intake.
B) Measure the patient's daily weight.
C) Teach the patient to monitor fluid balance.
D) Discuss the patient's care plan with the RN.

Answer 1

Measure the patient's daily weight.

Question 2

The nurse is determining diagnoses appropriate for a patient recovering from surgery.Which nursing diagnoses should the nurse identify as the highest priority for this patient?

A) Acute pain
B) Impaired mobility
C) Deficient knowledge
D) Impaired skin integrity

Answer 2

Acute pain

Question 3

The RN implements an intervention to improve a patient's appetite.After implementing the intervention for two meals,the LPN/LVN notes no improvement in the patient's eating.What action should the LPN/LVN take?

A) Develop a new plan of care.
B) Revise the patient outcome to one that is achievable.
C) Collaborate on a new nursing diagnosis with the RN.
D) Provide data to the RN to assist in evaluation of the plan.

Answer 3

Provide data to the RN to assist in evaluation of the plan.

Question 4

After receiving morning report,which patient should the licensed practical nurse/licensed vocational nurse (LPN/LVN)assess first?

A) A patient who needs discharge teaching
B) A patient who needs assistance to ambulate
C) A patient who states, "No one cares about me."
D) A patient who has a temperature of 106°F (41.1°C)

Question 5

A patient with a newly fractured femur reports a pain level of 8/10,and analgesic medication is not due for another 50 minutes.Which actions should the nurse take?

A) Reposition the patient.
B) Give the medication in 30 minutes.
C) Notify the registered nurse (RN) or physician.
D) Tell the patient it is too early for pain medication.

Question 6

The nurse is caring for a patient with a painful back injury that occurred 6 months ago.Which three-part nursing diagnosis should the nurse use to guide this patient's care?

A) Pain as evidenced by herniated lumbar disk
B) Acute pain related to inability to sit as evidenced by muscle spasms
C) Chronic pain related to muscle spasms as evidenced by patient pain rating of 8 and difficulty walking
D) Acute pain related to patient pain rating of 6 as evidenced by muscle spasms and nerve compression

Question 7

The nurse is using the nursing process when caring for a patient.In which order should the nurse implement this process?

A) Nursing diagnosis, intervention, rationale, evaluation, planning
B) Data collection, intervention, nursing diagnosis, rationale, evaluation
C) Assessment, nursing diagnosis, planning, implementation, evaluation
D) Data collection, evaluation, nursing diagnosis, implementation, rationale

Question 8

During a class discussion,two nursing students demonstrated intellectual courage.What action did the nursing students perform?

A) Considered being in the other person's situation
B) Expected proof that the use of restraints is safe
C) Conducted additional research on the use of restraints in patient care
D) Listened to each other's point of view regarding the use of patient restraints

Question 9

The nursing instructor is planning a teaching session on critical thinking for students.What should the instructor say when explaining critical thinking?

A) "Collect data concerning the patient's problem."
B) "Think of different ways to help relieve a patient's problem."
C) "Determine if an action worked to eliminate a patient problem."
D) "Use knowledge and skills to make the best decision for patient care."

Question 10

While caring for a patient 4 hours after a surgical procedure,the LPN/LVN notes serosanguineous drainage on the patient's dressing.Which statement should the nurse use to document the finding?

A) "Normal drainage noted."
B) "Moderate drainage recently noted."
C) "Scant serosanguineous drainage seen on dressing."
D) "Pale pink drainage, 2 cm by 1 cm, noted on dressing."

Question 11

The nursing staff is planning a celebratory dinner and cake for a newly licensed practical nurse.Which of the new nurse's human needs is supported by these actions?

A) Self-esteem
B) Physiological
C) Self-actualization
D) Safety and security

Question 12

The nurse is identifying outcomes for a patient with a Fluid Volume Deficit.Which outcome should the nurse use to guide the patient's care?

A) Patient's fluid intake will be measured daily.
B) Patient's intake will be 3000 mL daily.
C) Fluids will be at the bedside for the patient.
D) Fluids the patient likes will be at the bedside.

Question 13

The nurse is planning care and setting goals for a newly admitted patient.Who should the nurse include when conducting these nursing actions?

A) Patient
B) Nurse manager
C) Patient's family members
D) Patient's health care provider (HCP)

Question 14

A RN delegates a patient care assignment to the LPN/LVN.Which phase of the nursing process should the LPN/LVN perform independently?

A) Assessment
B) Planning care
C) Implementation
D) Nursing diagnosis

Question 15

The nurse is reviewing data collected during patient care.Which data should the nurse document as objective?

A) Patient is pleasant.
B) Urine output is 300 mL.
C) "It has been a good day."
D) Patient's appetite is poor.

Question 16

During morning report,the LPN/LVN is assigned a group of patients.Which patient should the LPN/LVN see first?

A) A patient scheduled for magnetic resonance imaging (MRI) due to back pain
B) A patient reporting constipation and stomach cramps
C) A 2-day postsurgical patient reporting pain at a level of 6
D) A patient with pneumonia who is short of breath and anxious

Question 17

The nurse is determining a patient's problems.What step of the nursing process is the nurse performing?

A) Assessment
B) Outcome planning
C) Nursing diagnosis
D) Nursing intervention

Question 18

The nurse suspects a patient is experiencing adverse effects to a newly prescribed antihypertensive medication.After being informed that the effects are expected,the nurse remains concerned and conducts an Internet search on the patient's manifestations.Which critical thinking behavior did the nurse implement?

A) Sense of justice
B) Intellectual courage
C) Intellectual empathy
D) Intellectual perseverance

Question 19

The nurse is caring for a patient who is scheduled for surgery.Which data should the nurse collect to identify safety and security needs?

A) Meal patterns
B) Sleep patterns
C) Anxiety about surgery
D) Effectiveness of pain medication

Question 20

The LPN/LVN is reviewing a patient's list of nursing diagnoses.Which diagnoses should the LPN/LVN identify as a priority for this patient?

A) Anxiety
B) Constipation
C) Deficient fluid volume
D) Ineffective airway clearance

Question 21

The nurse identifies the diagnosis Potential for Ineffective Gas Exchange as appropriate for a patient with pneumonia.Which independent nursing actions should the nurse plan for this problem? (Select all that apply.)

A) Apply oxygen, 2 liters, per nasal cannula.
B) Turn and reposition in bed every 2 hours.
C) Coach to deep breathe and cough every hour.
D) Administer intramuscular antibiotic medication.
E) Encourage to drink 240 mL of fluid every 2 hours.

Question 22

The nurse approaches a person in a restaurant who appears to be experiencing respiratory distress.Which action should the nurse perform first?

A) Diagnose the problem.
B) Help the person lie down.
C) Gather data from other people.
D) Collect data about the person's condition.

Question 23

While being taught to apply a topical medication,the patient begins to vomit.Which action should the nurse take to meet the patient's human needs?

A) Provide a clean gown before resuming the teaching.
B) Position an emesis basin for patient use while teaching.
C) Provide medication prescribed for nausea and vomiting.
D) Wait for the vomiting to stop and begin the teaching session again.

Question 24

After collecting data the nurse identifies diagnoses to guide the patient's care.Which diagnoses did the nurse document correctly? (Select all that apply.)

A) Diabetes
B) Acute pain
C) Pancreatitis
D) Activity intolerance
E) Impaired physical mobility

Question 25

A patient with a history of respiratory disease is recovering from total hip replacement surgery.In which order should the nurse address the patient's diagnoses? (Place in order from 1 to 4.)

A) _____ Acute pain related to surgery
B) _____ Risk for injury related to unsteady gait
C) _____ Deficient knowledge related to use of a walker
D) _____ Impaired gas exchange related to compromised respiratory system

Question 26

The nurse is planning a patient's care based on Maslow's hierarchy of needs.Which human need should the nurse identify as requiring his or her immediate attention?

A) Heart rate 38 and irregular
B) Plans to return to college in a year
C) Needs walker adjusted to safely ambulate
D) Desire to learn how to self-inject medication

Question 27

The nurse is caring for a patient recovering from a stroke.Use the nursing process to order the observations made or actions performed while caring for this patient (A-E).

A) Hand grasp absent left hand
B) Alteration in Cerebral Perfusion
C) The patient flexed left thumb and index finger.
D) Coached to squeeze rubber ball placed in left hand.
E) The patient will be able to self-feed using left hand.

Question 28

A patient with a family history of diabetes is experiencing high blood glucose levels,confusion,an unsteady gait,and dehydration.Which nursing diagnoses should the nurse identify as appropriate for this patient's care? (Select all that apply.)

A) Diabetes
B) Dehydration
C) Risk for falls
D) Hyperglycemia
E) Deficient fluid volume

Question 29

The nurse is preparing to determine if a patient is meeting planned outcomes.What measurable information should the nurse use to make this determination?

A) P-E-S format
B) Objective observations
C) Subjective terminology
D) Open-ended time frames

Question 30

The nurse finishes collecting data on a patient with injuries from a motor vehicle crash.Which data should the nurse document as objective? (Select all that apply.)

A) Patient in no acute distress
B) "I can't believe I wrecked my car."
C) Complains of pain when moving arms
D) Oxygen saturation level 92% on room air
E) Mid-forehead wound 3 cm long, oozing blood

Question 31

The nurse identifies the diagnosis Fluid Volume Overload as appropriate for a patient with heart failure.Which collected data should the nurse use to provide evidence for this diagnosis?

A) Skin warm to the touch
B) Oriented to person only
C) Respiratory rate 20 and shallow
D) +3 pitting edema of both feet and ankles

Question 32

After identifying nursing diagnoses,the nurse plans outcomes for a patient with gastroesophageal reflux disease.Which outcome should the nurse use to evaluate this patient's care?

A) The patient will have less heartburn.
B) The patient will sleep through the night.
C) The patient's esophageal burning will resolve 30 minutes after taking oral antacids.
D) The patient will state that burning only occurs when eating foods high in acid content.