Question 1

When a nurse uses Maslow's Hierarchy of Needs to prioritize patient problems, which problem would be considered the highest priority?

Accepted Answer

The priority problem is one that is potentially life-threatening: shortness of breath. Physiologic or survival needs take priority over higher level needs. The problems mentioned in the other options do not threaten survival.

Question 2

During the assessment phase of the nursing process, the LPN/LVN is expected to

Accepted Answer

Data are collected as part of the assessment phase. This is the only option that relates to assessment.

Question 3

The patient's problem has been identified as insufficient intake of oral fluids. The best outcome statement is

Accepted Answer

An outcome may be attained by stating the problem in positive terms. It is always a statement of what the patient will do. Stating that the patient will request fluids when thirsty may not result in the desired intake. The remaining options are nurse centered.

Question 4

How does the LPN/LVN use nursing diagnosis in patient care?

Accepted Answer

The LPN/LVN uses the nursing diagnosis as the reference point for identifying patient problems that require intervention. The nursing diagnosis is not required by the LPN/LVN to set goals and outcomes, implement nursing interventions, or participate in data collection.

Question 5

Which of the following is the primary reason that LPN/LVNs are taught to use the nursing process?

Accepted Answer

The nursing process provides a structure for nurses to identify and respond to patient needs within the scope of nursing. Diagnosing disease is the domain of the physician. Reimbursement is not the primary purpose of the nursing process. Communication facilitation is not the primary purpose of the nursing process.

Question 6

The student nurse asks, "How does knowing the nursing diagnosis assist the LPN/LVN?" The best response is based on understanding that

Accepted Answer

The LPN/LVN uses the nursing diagnosis to identify a patient's problems. The other statements are false.

Question 7

The nursing care plan requires the nurse to ambulate the patient twice daily. The phase of the nursing process in which the nurse is participating is

Accepted Answer

Carrying out the care plan is termed implementation. Assessment involves data collection. Planning involves creation of the nursing care plan. Evaluation involves determining goal attainment.

Question 8

A student nurse asks, "What's the primary purpose of the evaluation phase of the nursing process?" The best response is

Accepted Answer

Data collection, with comparison of actual and desired patient outcomes, is the focus of the evaluation phase of the nursing process. The response "to establish a time frame for completion of goals" is initially part of the planning phase. Time frames for goal attainment may be revised during the evaluation phase, but this is not the primary purpose of evaluation. In the remaining options, evaluation is patient centered.

Question 9

A blood pressure of 110/70 at 8 PM is most accurately described as an example of

Accepted Answer

Objective data are sometimes called signs. Objective data can be verified. Subjective data are based on the patient's report. Planning data and reassessment data are not used as data classifications.

Question 10

Which of the following are considered subjective data?

Accepted Answer

Subjective data are based on the patient's report or opinion. This option is the only example of patient report.

Question 11

A nurse expresses difficulty deciding which nursing interventions to suggest for a patient with arthritic pain during an upcoming patient-centered conference. A peer suggests referring to the Nursing Interventions Classification (NIC) taxonomy. This would provide the nurse with information on

Accepted Answer

NIC standardizes, defines, and assists nurses in choosing the appropriate nursing interventions. It includes physical and psychosocial interventions, health promotion, illness treatment, and independent and collaborative interventions. NIC is not a basic text. NIC does not provide a measurement language. NIC does not give information about translating nursing diagnoses into nursing problems.

Question 12

The phases of the nursing process in which the LPN/LVN participates with the greatest degree of independence are

Accepted Answer

The LPN/LVN curriculum trains graduates to collect data and implement a variety of nursing interventions, making a high degree of independence possible in these areas. Goal setting, evaluation, and planning all require a greater degree of interdependence with the RN.

Question 13

"I feel like I can't catch my breath" is an example of

Accepted Answer

Subjective data are based on the patient's report or opinion. Objective data are data the nurse can verify. Effective data and evaluative data are not used as data classifications.

Question 14

The RN head nurse is having a busy day. When the LPN/LVN reports data she has collected, the RN states, "Incorporate that into the nursing care plan and write down the intervention you'd use. I'll cosign the entry." The LPN/LVN should

Accepted Answer

The RN is responsible for determining the nursing care plan. The LPN/LVN collects data that the RN may use to modify the plan, but the LPN/LVN may not independently modify the plan. If the LPN/LVN functions outside the identified scope of practice, he or she would be breaking the law. The remaining options do not directly address the problem at the time it occurs.

Question 15

Which of the following statements regarding short-term goals is accurate?

Accepted Answer

Short-term goals can usually be accomplished within hours or days, whereas long-term goals may take weeks.

Question 16

An LPN/LVN demonstrates to a new mother how to safely bathe her infant. This is an example of the phase of the nursing process called

Accepted Answer

Initiating teaching that is within the role of the LPN/LVN and supporting teaching by the RN are examples of implementation.

Question 17

Identify the outcome that would be appropriate to include in the nursing care plan of a patient who has undergone total knee replacement.

Accepted Answer

"The patient will transfer from the bed to a chair with the assistance of a walker and one staff member by the third postoperative day" contains the elements necessary for a well-written outcome. It is patient centered, realistic, measurable, and time referenced. "The patient will be stronger by (date)" is not measurable. The remaining options are nurse centered.

Question 18

When the LPN/LVN participates in the evaluation phase of the nursing process, she or he compares the patient's responses with the

Accepted Answer

The process of determining outcome attainment involves comparing actual patient outcomes with desired patient outcomes. The nursing orders are orders for treatments and medication written by a medical doctor or other health care provider with prescriptive authority. A nursing diagnosis is provided by the RN and is defined by the International Journal of Nursing Terminologies and Classifications as a clinical judgment about individual, family, or community responses to actual or potential health problems/life
processes. A nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable. The data collection is a systematic gathering and review of information about the patient, which is communicated to appropriate members of the health team.

Question 19

The LPN/LVN learns at report that a patient's priority problems are pain and inability to ambulate associated with arthritis. During the patient's bath, he becomes short of breath. The LPN/LVN should implement interventions based on

Accepted Answer

Status changes are a priority. Priorities may change rapidly, depending on the patient's condition. This change challenges survival and assumes priority over the other identified problems.

Question 20

A student nurse asks, "If RNs use a five-step nursing process and LPN/LVNs use a four-step process, what phase is missing?" The best response would be, "The phase of the nursing process that is the sole responsibility of the registered nurse is

Accepted Answer

The LPN/LVN participates in all phases of the nursing process with the exception of establishing a nursing diagnosis.

Quiz 12: The Nursing Process: Your Role