Deck 2: Critical Thinking and Nursing Process

Question 1

Upon a patient's admission to the facility,the nurse collects the following data: patient's temperature is 100° F,oxygen saturation is 89%,frothy mucus is expectorated,and the patient's chest feels tight.The nurse correctly identifies tightness in the chest as:

A)judgmental.
B)objective data.
C)subjective data.
D)drawing a conclusion.

Answer 1

subjective data.

Question 2

The nurse writes an intervention for the goal: Patient will sleep for 5 hours uninterrupted each night.The best nursing intervention is:

A)medicate with sedative each night.
B)offer warm fluids frequently.
C)arrange for a large meal at supper.
D)discourage daytime napping.

Answer 2

discourage daytime napping.

Question 3

The nurse explains that,in addition to the NANDA stem and etiology,the complete nursing diagnosis should include:

A)a time reference for meeting the need.
B)a designation of what the patient should do.
C)signs and symptoms of the problem assessed.
D)a specifically worded medical diagnosis.

Answer 3

signs and symptoms of the problem assessed.

Question 4

During the admission process,the nurse receives orders for the patient to have arterial blood gases (ABGs)drawn.Which finding from the patient's history may cause concern?

A)Taking ginkgo biloba for the last 6 months
B)Having an increased hematocrit (Hct) level during the last physical exam
C)Being diabetic for 10 years
D)Having a decreased white blood cell (WBC) count

Question 5

The nurse who has recently moved from Louisiana to Texas is uncertain about the LPN/LVN's role in applying the nursing process.The most appropriate source for the nurse to consult is:

A)hospital policies.
B)the Texas State Board of Nursing.
C)rules and regulations of the Louisiana Nurse Practice Act.
D)the National Association of Practical Nurse Education and Service.

Question 6

The nurse's assessment reveals edema of both feet and ankles.The best documentation of these findings is:

A)pitting edema present in both feet and ankles.
B)edema in both feet and ankles approximately 4 mm deep.
C)4 mm pitting edema quickly resolving.
D)bilateral pitting edema in feet and ankles: 4 mm deep resolving in 3 seconds.

Question 7

The nurse adds a nursing order to the care plan related to a patient with a nursing diagnosis of Nutrition: less than body requirement related to nausea and vomiting.The statement that is a nursing order is:

A)medicate with an antiemetic before each meal.
B)offer crackers and iced drink before each meal.
C)change diet to clear liquids.
D)give nothing by mouth until nausea subsides.

Question 8

Basic to the ability to apply critical thinking,the nurse must have:

A)unshakable beliefs and values.
B)an open attitude.
C)the ability to disregard evidence inconsistent with set goals.
D)the ability to recognize the perfect solution.

Question 9

The newly admitted patient is describing his recent symptoms to the nurse.The nurse is aware that the source of this information is considered:

A)primary.
B)objective.
C)secondary.
D)complete.

Question 10

The nurse explains to a patient that inclusion of potential problems in the nursing care plan:

A)alerts nursing staff to prevent potential complications.
B)reminds the family of potential problems.
C)broadens the assessment of the caregiver.
D)educates the patient to aspects of her health.

Question 11

The nursing student demonstrates an understanding of the Health Insurance Portability and Accountability Act (HIPAA)by:

A)using the patient's full name only on clinical assignments submitted to the instructor.
B)using the facility printer to copy lab reports on an assigned patient.
C)shredding any documents that the student has been using that contain identifying patient information before leaving the clinical facility.
D)asking the patient for permission to copy lab and diagnostic reports for educational purposes.

Question 12

The RN has chosen the nursing diagnosis of Risk for impaired skin integrity related to immobility.The correct goal/outcome statement for the diagnosis would be:

A)patient will sit in chair at bedside for 15 minutes after each meal.
B)nurse will assist patient to chair every shift.
C)nurse will assess skin and record condition every shift.
D)patient will change position frequently.

Question 13

Because the evaluation of the nursing care plan reflects lack of progress toward the goal,the nurse will confer with the patient to plan a:

A)more accessible goal.
B)revision of interventions.
C)different nursing diagnosis.
D)new evaluation.

Question 14

The nursing team prioritizing the nursing diagnoses of an overweight hospital patient will select as the highest priority the nursing diagnosis of:

A)Risk for dehydration related to vomiting.
B)Activity intolerance related to shortness of breath.
C)Knowledge deficit related to weight reduction diet.
D)Altered self-image related to excessive weight.

Question 15

To assess skin turgor,the nurse would:

A)examine mucous membranes of the mouth.
B)compare limbs for similar color.
C)pinch skinfold on chest for tenting.
D)palpate ankles for evidence of pitting edema.

Question 16

During the admission interview,when asked about pain,the patient responds,"No.I'm pretty wobbly." Which action by the nurse would be most appropriate?

A)Ask, "Did you hear me? I asked you about pain."
B)Say, "What do you mean 'wobbly'?"
C)Record the patient denied pain.
D)Record the patient stated he was wobbly.

Question 17

During the intake interview,the nurse notices that,although the patient denies pain,he is grimacing and holding his hand over his stomach.The nurse's best approach would be to:

A)examine the history closely for etiology of pain.
B)question the patient about having feelings of pain.
C)record that patient denies pain but seems to be having abdominal discomfort.
D)physically examine the patient's abdomen.

Question 18

The nurse explains that a fundamental basis for the nursing process is:

A)that basic needs must be met by the individual without assistance.
B)that patients and families appreciate an efficient health care system that functions without their input.
C)a focus on disease control.
D)that all persons have worth and dignity.

Question 19

The diabetic patient who had blood drawn for an HbA?c level says,"I don't know why they want to look at my hemoglobin." The most helpful reply by the nurse would be:

A)"The test is to evaluate your present level of blood sugar."
B)"The HbA1c provides information relative to blood sugar levels from the past 2 to 3 months."
C)"Hemoglobin levels and blood sugar levels are closely related."
D)"The HbA1c tells if you have type 1 or type 2 diabetes."

Question 20

The nurse performing an intake interview on a new resident to the long-term care facility detects the odor of acetone from the patient's breath.The assessment is done by:

A)inspection.
B)observation.
C)auscultation.
D)olfaction.

Question 21

Matching
Place the steps of the nursing process in their proper sequence.

Step: 3

A)Evaluation
B)Assessment
C)Implementation
D)Planning
E)Nursing diagnosis

Question 22

Matching
Place the steps of the nursing process in their proper sequence.

Step: 2

A)Evaluation
B)Assessment
C)Implementation
D)Planning
E)Nursing diagnosis

Question 23

Shortness of breath due to emphysema would be a major component of the _________ care plan.

Question 24

Matching
Place the steps of the nursing process in their proper sequence.

Step: 4

A)Evaluation
B)Assessment
C)Implementation
D)Planning
E)Nursing diagnosis

Question 25

Matching
Place the steps of the nursing process in their proper sequence.

Step: 1

A)Evaluation
B)Assessment
C)Implementation
D)Planning
E)Nursing diagnosis

Question 26

The nurse explains to the nursing student that the application of critical thinking to patient care involves: (Select all that apply.)

A)identification of a patient problem.
B)setting priorities.
C)concentrating on the patient rather than family needs.
D)use of logic and intuition.
E)expansion of thought beyond the obvious.

Question 27

The nurse is caring for a patient diagnosed with pneumonia.The patient has a BP 160/94,P 102,R 28,crackles in posterior lower lobes bilaterally,oxygen saturation 89%,and complains of shortness of breath upon exertion.The highest priority nursing diagnosis for this patient is:

A)Activity intolerance
B)Impaired gas exchange
C)Ineffective cardiopulmonary tissue perfusion
D)Self-care deficit: Bathing and hygiene

Question 28

The nurse demonstrates knowledge of the National Patient Safety Goals by performing patient care that includes: (Select all that apply.)

A)identifying the patient prior to medication administration by asking the patient to state his or her name.
B)reporting any sentinel event to the facility's quality assurance team.
C)assessing the patient's heart rate prior to administration of digoxin.
D)performing hand hygiene prior to performing a patient assessment.
E)documenting the appropriate time of medication administration.

Question 29

Matching
Place the steps of the nursing process in their proper sequence.

Step: 5

A)Evaluation
B)Assessment
C)Implementation
D)Planning
E)Nursing diagnosis

Question 30

The LPN/LVN adheres to facility policy regarding core measures by performing which interventions during patient care?

A)Administering the ordered amount of insulin to a patient with type 1 diabetes
B)Performing a thorough patient assessment upon admission to the health care facility
C)Documenting accurately and at appropriate intervals in the patient's record
D)Providing patient teaching regarding proper diet for the patient diagnosed with renal failure

Question 31

The nurse demonstrates application of the nursing process by: (Select all that apply.)

A)performing a head-to-toe assessment.
B)updating the patient care plan on a weekly basis.
C)evaluating if patient goals have been met.
D)determining if nursing interventions need to be changed based on lack of patient progress toward meeting goals.
E)ensuring that all personnel caring for the patient are implementing the care plan and working toward the same goals.

Question 32

The nursing student demonstrates knowledge of the proper use of the ___________ when determining that it is safe to administer meperidine (Demerol)and promethazine (Phenergan)together.