Deck 9: Nursing Process

Question 1

The nurse is completing the charting after a patient suffered a fall.Which statement is appropriate for the nurse to include in the description of the incident?

A) The patient was found on the floor and his urinal was on the floor next to him.
B) The patient's nurse assistant always took her time to answer his call lights.
C) The patient probably urinated on the floor and slipped on the wet floor.
D) The patient is grouchy and inappropriate,always causing trouble for the nurses.

Answer 1

The patient was found on the floor and his urinal was on the floor next to him.

Question 2

The nurse is caring for a patient who came to the hospital with acute shortness of breath.What is the priority action of the nurse as the assessment process is started?

A) Pull the curtain around the bed and ensure patient privacy.
B) Listen to the patient's lung sounds and check the pulse oximetry level.
C) Tell the patient that the physician will be in shortly to start treatment.
D) Reassure the patient that the shortness of breath will be relieved shortly.

Answer 2

Listen to the patient's lung sounds and check the pulse oximetry level.

Question 3

A nurse is collecting data during the assessment of a patient.During the assessment,the nurse collects both subjective and objective data.Which information should the nurse consider as subjective data?

A) The patient's catheter drained 400 mL of urine during the last 8 hours.
B) The patient's incision is clean,dry,and intact with staples.
C) The patient reports having sharp,burning pain with urination.
D) The patient refused breakfast after vomiting 200 mL green emesis.

Answer 3

The patient reports having sharp,burning pain with urination.

Question 4

The nurse carefully enters a new patient's medical history and current medication list into the agency's electronic health record (EHR).Which step of the nursing process is being performed by the nurse?

A) Assessment
B) Implementation
C) Evaluation
D) Diagnosis

Question 5

The nurse is caring for a patient who has just arrived at the hospital with chest pain.Which is the most important question for the nurse to ask the patient?

A) "Did your family doctor tell you to come to the hospital?"
B) "When did your chest pain begin?"
C) "Do you have a family history of heart disease?"
D) "Did someone come to the hospital with you?"

Question 6

The nurse is caring for a patient who denies having any pain.The nurse notes that the patient is restless and the patient's hands are tightly clenched.The nurse also heard the patient moaning before walking into the room.What will the nurse take into consideration as the patient assessment is completed?

A) Unclear communication techniques
B) Unrealistic patient expectations
C) Inappropriate empathic response
D) Conflicting assessment findings

Question 7

The nurse becomes frustrated when a patient insists on taking herbal remedies rather than prescribed medications and spends certain hours of each day in prayer.The patient also prefers the care of the spiritualist healer over the attending physician.Which factor may be responsible for the nurse's frustration?

A) Cultural differences in health-related practices
B) Delay in the patient's psychosocial development
C) Impaired ability of the patient to cope with acute illness
D) Incorrect organization of health assessment findings

Question 8

The nurse is caring for a patient with sepsis.The nurse includes potential complications: septic shock in the plan of care.Why is this nursing diagnosis considered a collaborative problem?

A) The patient must be closely monitored in an intensive care unit.
B) The patient has a history of noncompliance with prescribed therapeutic regimens.
C) Prevention of septic shock is not a measurable patient outcome.
D) Both nursing and physician-prescribed interventions are required.

Question 9

Which question is the most appropriate for the nurse to use to start the health history assessment?

A) "Does your family doctor know that you are here?"
B) "Did you drive yourself to the hospital?"
C) "What brings you to the hospital today?"
D) "Did you give your insurance card to the receptionist?"

Question 10

The nurse is caring for a trauma patient who has just arrived to the emergency room.The nurse listens to the patient's lung sounds,palpates the patient's peripheral pulses,and obtains vital signs.What is the best description of the nurse's actions?

A) Establishing priorities for outcomes
B) Performing a physical examination
C) Demonstrating diagnostic reasoning
D) Setting time frames for interventions

Question 11

The nurse is caring for a patient who will be having surgery shortly.The patient requests that a religious bracelet be worn in the operating room to help ensure a good surgical outcome.Which is the most appropriate action of the nurse?

A) Call the operating room staff to determine if the bracelet can stay on during surgery.
B) Insist that the patient remove the bracelet and give it to a family member during surgery.
C) Notify the patient's surgeon of the patient's refusal to remove the bracelet before having surgery.
D) Remove the bracelet from the patient's wrist after sedating medication has been administered.

Question 12

The nurse is conducting an admission assessment for a patient who was brought to the hospital after having a seizure.Which question will the nurse ask to quickly focus on the patient's symptoms?

A) "Have you been to this hospital before?"
B) "How long did the seizure last?"
C) "Are you currently seeing a neurologist?"
D) "You don't abuse drugs,do you?"

Question 13

The nurse is caring for a toddler who will be having surgery.Which will provide the best primary source of information about how to comfort the child after surgery is completed?

A) Patient's chart
B) Patient
C) Parents
D) Surgeon

Question 14

The nurse has just completed an assessment for a patient.Which data will the nurse categorize as objective?

A) The patient felt less short of breath after receiving a nebulizer treatment.
B) The patient's lung sounds are diminished bilaterally with expiratory wheezes.
C) The patient worries that the insurance company will not pay the hospital bill.
D) The patient wonders if supplemental oxygen at home would be beneficial.

Question 15

Which nursing diagnosis is the highest priority for a patient with pneumonia?

A) Activity intolerance related to fatigue and shortness of breath
B) Knowledge deficit related to pneumonia risk factors
C) Pruritus related to side effects of prescribed medications
D) Impaired gas exchange related to alveolar inflammation and infection

Question 16

The nurse completes the assessment for a patient who has just been admitted to the hospital.The nurse carefully documents the patient's current drug list and asks about the use of any herbal supplements or over-the-counter medications.Which phase of the interview does this occur in?

A) Orientation
B) Working
C) Reasoning
D) Termination

Question 17

The nurse is assessing a patient with chest pain who has just come to the hospital.Which open-ended question will provide the nurse with helpful information about the patient's health status?

A) "How long have you been experiencing chest pain?"
B) "Do you have a family history of heart disease?"
C) "Are you having any difficulty breathing right now?"
D) "What does your chest pain feel like?"

Question 18

Every time the nurse asks the patient a question for the admission assessment,the patient's husband interrupts and answers the question for her.What is the best action of the nurse?

A) Enter the husband's responses into the patient's chart.
B) Request that the husband leave the room.
C) Complete the admission assessment after the husband has gone home.
D) Allow time for the patient to answer each question.

Question 19

Which statement by the nurse is an example of back-channeling?

A) "I completely understand.Can you tell me more?"
B) "When did you first seek health care for your symptoms?"
C) "I am sure the doctor will answer all of your questions shortly."
D) "Try not to worry.I'm sure that you will be just fine."

Question 20

The nurse is caring for a nonverbal patient who just had surgery.The nurse notes that the patient moans with position changes,the hands are clenched,and the skin is very sweaty.The nurse decides that the patient is in pain and decides to administer an analgesic.What is the correct term for this nursing action?

A) Setting priorities
B) Recognizing inconsistencies
C) Using empathy
D) Making inferences

Question 21

The nurse is caring for a patient with the nursing diagnosis constipation related to side effects of medications.Which is an appropriate goal for this patient?

A) "The patient will have a soft formed bowel movement by the end of the shift."
B) "The nursing assistant will ambulate the patient to the toilet as needed."
C) "The patient will not have any nausea,vomiting,or feeling of abdominal fullness."
D) "The nurse will palpate for abdominal distention and encourage oral fluid intake."

Question 22

Which nursing care order is an example of a standing order?

A) Monitor blood glucose level before meals and at bedtime.
B) Administer a soapsuds enema if no bowel movement for 3 days.
C) Instruct the patient how to self-administer insulin correctly.
D) Bathe the patient daily with application of moisturizer to all bony prominences.

Question 23

The nurse is preparing to insert an indwelling urinary catheter into the patient.Where will the nurse check to ensure that the packaging is sterile,intact,and not past the expiration date?

A) In the clean utility room immediately after removing the package from the shelf
B) At the patient's bedside after verifying the patient's name and birthdate
C) At the nurses' station after verifying the physician's order for the procedure
D) At the patient's bedside after performing careful perineal care for the patient

Question 24

Which actions by the nurse are examples of dependent nursing interventions for a postoperative patient?

A) Calculating the patient's fluid intake and output at the end of every shift
B) Encouraging fluid and fiber intake to prevent constipation from pain medications
C) Administering a mild stool softener daily to prevent constipation
D) Assessing the patient's abdomen for distention,bowel sounds,and passage of flatus
E) Reinserting of the patient's urinary catheter for retention of greater than 500 mL of urine

Question 25

The nurse is caring for a patient with the nursing diagnosis ineffective airway clearance related to narrowed airways and thick sputum.Which is an appropriate goal for this patient?

A) "The patient will be resting comfortably by the morning."
B) "The patient's airway will remain clear throughout the night."
C) "The patient will not experience any feelings of shortness of breath or anxiety."
D) "The patient's respiratory rate and pulse will remain within normal limits."

Question 26

The extended care agency administers the flu vaccination to all of the patients who do not have contraindications to the injection.What is the reason that the nurses do not have to obtain orders from each patient's physician for vaccination each year?

A) The agency's medical director placed a standing order for patients to receive the flu vaccination yearly unless contraindicated.
B) The Centers for Disease Control and Prevention highly recommend yearly flu vaccinations for all individuals over the age of 65.
C) The State Licensing Board for extended care facilities requires annual flu vaccinations for all residents and staff.
D) The administrator of the agency has the authority to order annual flu vaccinations for all residents and staff.

Question 27

The nurse is caring for a patient who has been unable to have a bowel movement for the last 4 days after taking prescribed narcotic pain medication.Which nursing diagnosis is appropriate for this patient?

A) Risk for constipation related to irregular defecation habits
B) Perceived constipation related to expectation of daily bowel movements
C) Constipation related to side effects of pain medication
D) Impaired bowel elimination related to abdominal muscle weakness

Question 28

The nurse is caring for an unconscious patient.The nurse repositions the patient at least every 2 hours and ensures that all of the patient's bony prominences are padded.What is the rationale for these actions?

A) The nurse is following the standing orders listed in the patient's medical record.
B) The nurse realizes the potential for bedsores and acts to prevent their development.
C) The nurse identifies the patient care areas in which additional assistance is required.
D) Nursing regulations do not allow these care tasks to be delegated to unlicensed personnel.

Question 29

The nurse observed a postoperative patient trying to take her friend's narcotic pain pills in addition to the pain medication administered by the nurse.Which nursing diagnosis is the highest priority for this patient?

A) Health-seeking behaviors
B) Risk-prone health behavior
C) Readiness for enhanced comfort
D) Situational low self-esteem

Question 30

Which actions by the nurse are examples of independent nursing interventions for a postoperative patient?

A) Teaching patients with heart failure how to do accurate daily weights
B) Administering intravenous fluids when the patient is unable to eat or drink
C) Advancing a patient's diet from clear liquids to solid foods after surgery
D) Elevating the head of the patient's bed to facilitate use of the incentive spirometer
E) Switching the patient's injected pain medication to oral tablets before discharge

Question 31

A nurse is delegating care of patients to the certified nursing assistant (CNA)and a licensed practical nurse (LPN).Which task assignment indicates that the nurse needs additional education about delegation?

A) The LPN is assigned to change a sterile dressing.
B) The CNA is assigned to provide skin care.
C) The CNA is assigned to insert an indwelling urinary catheter.
D) The LPN is assigned to administer a soapsuds enema.

Question 32

The nurse enters the patient's room to begin teaching the patient about wound care management.The nurse notes that the patient is nauseated due to medication side effects.What are the priority actions of the nurse?

A) Begin teaching the patient about wound care management,taking care to avoid using terms that the patient might find upsetting.
B) Provide measures to relieve the patient's nausea and return to teach about wound care when the patient is feeling better.
C) Document in the patient's chart that teaching about wound care management was not done because the patient refused to learn.
D) Check the patient's order list to determine if antiemetic medication has been prescribed for the patient.
E) Apply a cold cloth to the patient's forehead and maintain a quiet,odor-free environment for the patient.

Question 33

The patient has a goal of maintaining urinary output of at least 30 mL/hour as part of the nursing care plan.However the patient's urinary output for the shift was only 20 mL/hour.What is the appropriate action of the nurse?

A) Contact the physician to obtain an order for diuretics to increase urinary output.
B) Reassess the patient to determine why the urinary output was less than 30 mL/hour.
C) Change the goal to: patient will maintain urinary output of at least 20 mL/hour.
D) Inform the patient that the urinary output goal for the shift was not met.

Question 34

Which nursing diagnosis is the highest priority for a patient with multiple sclerosis?

A) Chronic sorrow related to loss of independence
B) Disturbed sensory perception related to nerve cell damage
C) Risk for powerlessness related to impaired fine- and gross-motor skills
D) Risk for falls related to impaired mobility and sensation