Question 1

The certified nursing assistant (CNA)is feeding a patient and notes that the patient is having difficulty swallowing.She reports this to the primary registered nurse.What should the nurse do first?
A) Assign the task to a more experienced CNA
B) Feed the patient herself
C) Assess the patient and place on NPO status
D) Call the primary care provider

Accepted Answer

Feeding a patient is a delegatable task that a CNA can perform.However,once it is reported to the registered nurse that the patient is having difficulty swallowing,this becomes a safety issue that the registered nurse must address.This circumstance is then no longer delegatable for any CNA regardless of experience.The first action by the nurse is to assess the patient and place the patient on NPO status until a primary provider is notified for further orders.

Question 2

Which of the following is a client outcome criterion?
A) Central venous catheter site infection does not occur (90% of cases).
B) Client will sit out of bed in the chair for 20 minutes three times per day.
C) Postoperative phlebitis does not occur (95% of cases).
D) Falls in the facility will reduce by 2% this quarter.

Accepted Answer

A client outcome criterion states the client health status or behaviors one wishes to effect."Client will sit out of bed ..." is a client outcome criterion.The other options are examples of organizational criteria used to evaluate the quality of care throughout the institution.

Question 3

Which statement by the nurse best demonstrates clear communication to nursing assistive personnel (NAP)about delegating a task?
A) "Record how the patient's intake and output of fluids, please"
B) "Take the patient's temperature, pulse, respirations, and blood pressure every 2 hours today."
C) "Take the patient's temperature every 4 hours; notify me if it is greater than 100.5°F (38.1°C)."
D) "Assist the patient with all of her meals so she will take in more calories."

Accepted Answer

Clear communication about a task (such as "Take the patient's temperature ...")tells the NAP exactly what the task is,the specific time at which it needs to be done,and the method for reporting the results to the registered nurse.The other options are vague and leave room for misinterpretation.

Question 4

Which task can be delegated to nursing assistive personnel (NAP)?
A) Turn and reposition the patient every 2 hours.
B) Assess the patient's skin condition.
C) Change pressure ulcer dressings every shift.
D) Apply hydrocolloid dressing to the pressure ulcer.

Accepted Answer

The nurse can delegate turning the client every 2 hours to the nursing assistive personnel.Assessing the client's skin condition,changing pressure ulcer dressings,and applying a hydrocolloid dressing to a pressure ulcer are all interventions that require nursing knowledge and judgment.

Question 5

The nurse is preparing to insert a Foley catheter for her patient.What is the best strategy for the nurse to use to perform this insertion in a timely and efficient manner?
A) Call another nurse to assist with the procedure
B) Gather all supplies and equipment before entering the patient room
C) Instruct and explain the procedure to the patient
D) Check the patient's schedule for the day for the most convenient time

Accepted Answer

Gathering all the supplies and equipment before entering a patient's room is the best strategy to ensure that work is completed in an efficient and timely manner.This strategy will also help in preventing stress to the patient that may occur when a nurse is interrupted by needing to go to a supply room to get a needed item.Healthcare resources are scarce and staffing may not be conducive or feasible in having extra personnel available.Instructing and explaining a procedure to a patient is good practice and usually completed prior to any procedure for the purpose of patient cooperation and understanding.This is will not usually assist the nurse in completing a procedure in an efficient and timely manner.

Question 6

When should the nurse collect evaluation data for this expected outcome? "Patient will maintain urine output of at least 30 mL/hour."
A) At the end of the shift
B) Every 24 hours
C) Every 4 hours
D) Every hour

Accepted Answer

The nurse should collect evaluation data as defined in the expected outcome.For instance,in this case,the nurse would check the patient's urine output every hour because the goal statement specifies an hourly rate (30 mL/hour).The unit of measurement in the goal guides how often the nurse would reassess the patient.

Question 7

The second-year nursing student is in her clinical rotation on a medical-surgical unit.What is the most appropriate strategy that the student can use to assist her in organizing and prioritizing patient care for the day?
A) Ask the nurse what tasks need to be completed for the day
B) Make a time-sequenced "to do" list for her activities for the day
C) Ask the instructor what needs to be completed for the day
D) Ask the patient what needs to be completed for the day

Accepted Answer

Because a nurse will be providing care for more than one patient on each shift,it is important to make a time-sequenced work plan or work sheet to prioritize patient care for the day.Many institutions have forms that can be used or one may need to write his/her own list of "things to do" in the order of need of completion.This is the best strategy this student can use.Asking the nurse or instructor will not assist the student in developing her own strategy for the future or in staying organized throughout the day.The patient is not a reliable source as not every patient is aware of what needs to be "completed" for the day.

Question 8

Which statement accurately describes delegation?
A) Transferring authority to another person to perform a task in a selected situation
B) Collaborating with other caregivers to make decisions and plan care
C) Scheduling treatments and activities with other departments
D) Performing a planned intervention from a critical pathway

Accepted Answer

Delegation is the transfer to another person of the authority to perform a task in a selected situation-the person delegating retains accountability for the outcome of the activity.Collaboration is described as working with other caregivers to plan,make decisions,and perform interventions.Coordination of care involves scheduling treatments and activities with other departments.Implementation is the process of performing planned interventions.

Question 9

The nurse reviews a nursing order for a patient who is 4 days post-operative after hip surgery.It reads: Assist patient in bathing each morning.The nurse assesses the patient and notes that the patient is independent in bathing.What should the nurse do next?
A) Assist with the bath as ordered
B) Delegate the bath to the nursing assistant
C) Discontinue the nursing order on the plan of care
D) Collaborate with the nurse who originally wrote the order

Accepted Answer

After assessing and evaluating patient progress,the nurse will use her conclusions about goal achievement to decide whether to continue,modify,or discontinue the nursing order on the plan of care.In this item,the nurse has assessed patient independence and therefore can discontinue this nursing order from the plan of care.

Question 10

A physician orders an indwelling urinary catheter for a client who is mildly confused and has been combative.How should the nurse proceed?
A) Ask a colleague for help, because the nurse cannot safely perform the procedure alone.
B) Gather the equipment and prepare it before informing the client about the procedure.
C) Obtain an order to restrain the client before inserting the urinary catheter.
D) Inform the primary provider that the nurse cannot perform the procedure because the client is confused.

Accepted Answer

Before the nurse begins a procedure,she should review the care plan and look at the orders critically.Because this client is confused,she should ask a colleague to assist with the procedure to prevent undue stress for the client and nurse.The client should be informed about the procedure before the nurse gathers the equipment.Gathering the equipment and bringing it into the room before explaining the procedure might cause the client anxiety.Restraining the client should be done only as a last resort and to prevent client injury.Informing the primary provider that the procedure cannot be performed because the client is confused is inappropriate because the procedure can very likely be done with assistance.

Question 11

Which type of client-centered evaluation is performed at specific,scheduled times?
A) Intermittent
B) Ongoing
C) Terminal
D) Process

Accepted Answer

Intermittent evaluation is performed at specific times; it enables the nurse to judge the progress toward goal achievement and to modify the plan of care as needed.Ongoing evaluation is performed while implementing,immediately after an intervention,or with each client contact; these are not necessarily scheduled events.Terminal evaluation is performed at the time of discharge.It describes the client's health status and progress toward goals at that time.Process evaluation focuses on the manner in which care is given.It may be performed at specific times,but it is not considered a client-centered evaluation.

Question 12

Which of the following is the most valid criterion for determining the status of a patient's anxiety at discharge? The patient:
A) Has a relaxed facial expression
B) Reports that he feels more relaxed today
C) Shows no physiological signs of anxiety (e.g., pallor)
D) Asks no further questions about home care

Accepted Answer

A criterion is considered valid when it measures what it is intended to measure.Because anxiety is subjective (perceived by the patient),the best measure of anxiety is what the patient says about it.A relaxed facial expression and other physiological signs might or might not show the level of anxiety.Relaxation might occur,for example,because the patient is sleeping or falling asleep.The fact that a patient is not asking questions about his surgery could mean that he has adequate knowledge about the topic; it would not indicate the presence or absence of anxiety.All of the options except what the patient states could be measuring something other than anxiety.

Question 13

The nurse works with the respiratory therapist to administer a patient's breathing treatments.He reports the patient's breathing status and tolerance of the treatment to the primary care provider.The nurse then discusses with the patient the options for further treatment.This is an example of:
A) Delegation
B) Collaboration
C) Coordination of care
D) Supervision of care

Accepted Answer

Collaboration means working with other caregivers to plan,make decisions,and perform interventions.Delegation is the transfer to another person of the authority to perform a task in a selected situation.Coordination of care involves scheduling treatments and activities with other departments,putting together all the patient data to obtain "the big picture." Supervision is the process of directing,guiding,and influencing the outcome of an individual's performance of an activity or task.

Question 14

Before inserting a nasogastric tube,the nurse reassures the client.Reassuring the client requires which type of nursing skill?
A) Psychomotor
B) Interpersonal
C) Cognitive
D) Critical thinking

Accepted Answer

Reassuring the client is an interpersonal skill.Inserting the nasogastric tube requires psychomotor skills.Checking catheter placement after insertion requires cognitive and psychomotor skills.Assessing whether there is an indication for the nasogastric tube requires critical thinking skills.

Question 15

A psychiatrist prescribes oral aripiprazole 10 mg daily for a client with schizophrenia.This medication is unfamiliar to the nurse,and she cannot find it in the hospital formulary or other references.How should she proceed?
A) Administer the medication as ordered.
B) Hold the medication and notify the prescriber.
C) Consult with a pharmacist before administering it.
D) Ask the patient's RN for information about the medication.

Accepted Answer

The nurse must recognize when she does not have the knowledge or skill needed to implement an order.Because the nurse is unfamiliar with the medication,that does not mean she should hold it and delay patient treatment.It is wisest to first consult with the pharmacist for information before administering the medication to ensure safe practice.Administering the medication as ordered,without knowing its expected actions and side effects,at the least prevents adequate reassessment; at the most,it is dangerous.Holding the medication and notifying the prescriber prevents the client from receiving timely treatment-many drugs are less effective if a consistent schedule is not maintained.Asking another nurse to administer the medication is also unsafe because it cannot be assumed that the other nurse has the correct knowledge.In addition,the nurse caring for the client must assess for adverse reactions to the medication.

Question 16

The nurse reviews the patient chart and sees a physician prescription for a new medication.The nurse is able to clearly read the medication name but the dose is not legible.What is the best action by the nurse?
A) Contact the physician for clarification.
B) Ask another nurse to read the order.
C) Ask the unit secretary to read the order.
D) Contact the pharmacist to read the order.

Accepted Answer

As a nurse,you are obligated ethically and legally to clarify or question orders that you believe to be unclear,incorrect,or inappropriate.In this case,the nurse should contact the physician to clarify the order,as it is not legible.It is inappropriate to ask the secretary or another nurse to read the order as they may read it incorrectly.

Question 17

The nurse is caring for a client who was newly diagnosed with type 2 diabetes mellitus.Which intervention by the nurse best promotes client cooperation with the treatment plan?
A) Teaching the client that he must lose weight to control his blood sugar
B) Informing the client that he must exercise at least three times per week
C) Explaining to the client that he must come to the diabetic clinic weekly
D) Determining the client's main concerns about his diabetes

Accepted Answer

Determining the client's main concerns promotes cooperation with the treatment regimen.For example,if the client is concerned about paying for diabetic monitoring equipment,he may disregard any teaching about the procedure.Although it is often important for a diabetic client to exercise and lose weight to control blood sugar levels,the client must want to do both.He will not exercise or lose weight simply because he is told to do so.The nurse must assess the client's support systems and resources,not merely tell him he must come to the diabetic clinic weekly.Some clients do not have access to transportation and,therefore,could not come to the clinic without social service intervention.Remember that knowledge does not necessarily change behavior.

Question 18

Which of the following is the best example of the implementation phase of the nursing process?
A) Patient verbalizes pain is reduced from an 8 to a 3 after receiving pain medication.
B) Nurse observes that patient has a small, quarter-sized skin tear over coccyx area.
C) Nurse writes in the care plan: Patient requires 2 person assist with ambulation to bathroom.
D) Nurse inserts Foley catheter after reporting to physician patient's inability to void.

Accepted Answer

Implementation is the action phase of the nursing process.It involves thinking but the emphasis is on doing.During implementation,the nurse will perform or delegate planned interventions.In short,implementation is doing,delegating,and documenting.A patient verbalizing that pain is reduced after receiving pain medication is part of the evaluation phase.Observing or noticing a skin tear relates to assessment and evaluation of skin condition.Writing on the care plan of a patient requiring assistance to the bathroom is an example of assessment and planning.

Question 19

Which criterion might be used in structure evaluation?
A) "Staff refrains from sharing computer passwords."
B) "Healthcare provider washes hands with each client contact."
C) "A defibrillator is present on each client care area."
D) "Nurse verifies client identification before initiating care."

Accepted Answer

The criterion that states "A defibrillator is present on each client care area" is associated with structure evaluation."Refrains from sharing computer passwords," "Washes hands before each client contact," and "Verifies client identification before initiating care" are criteria associated with process evaluation.

Question 20

Who is responsible for evaluating the outcome of a task delegated to the nursing assistive personnel (NAP)?
A) Nurse who delegated the task
B) LPN working with the NAP
C) Unit nurse manager
D) Charge nurse for the shift

Accepted Answer

The nurse who delegates the task is responsible for supervising and evaluating the outcomes of tasks performed by the NAP.Another registered nurse,such as a staff nurse,nurse manager,or charge nurse,can answer questions and provide help,if necessary.

Quiz 7: Nursing Process: Implementation Evaluation

The certified nursing assistant (CNA) is feeding a patient and notes that the patient is having difficulty swallowing.She reports this to the primary registered nurse.What should the nurse do first?

Which of the following is a client outcome criterion?

Which statement by the nurse best demonstrates clear communication to nursing assistive personnel (NAP) about delegating a task?

Which task can be delegated to nursing assistive personnel (NAP) ?

The nurse is preparing to insert a Foley catheter for her patient.What is the best strategy for the nurse to use to perform this insertion in a timely and efficient manner?

When should the nurse collect evaluation data for this expected outcome? "Patient will maintain urine output of at least 30 mL/hour."

The second-year nursing student is in her clinical rotation on a medical-surgical unit.What is the most appropriate strategy that the student can use to assist her in organizing and prioritizing patient care for the day?

Which statement accurately describes delegation?

The nurse reviews a nursing order for a patient who is 4 days post-operative after hip surgery.It reads: Assist patient in bathing each morning.The nurse assesses the patient and notes that the patient is independent in bathing.What should the nurse do next?

A physician orders an indwelling urinary catheter for a client who is mildly confused and has been combative.How should the nurse proceed?

Which type of client-centered evaluation is performed at specific,scheduled times?

Which of the following is the most valid criterion for determining the status of a patient's anxiety at discharge? The patient:

The nurse works with the respiratory therapist to administer a patient's breathing treatments.He reports the patient's breathing status and tolerance of the treatment to the primary care provider.The nurse then discusses with the patient the options for further treatment.This is an example of:

Before inserting a nasogastric tube,the nurse reassures the client.Reassuring the client requires which type of nursing skill?

A psychiatrist prescribes oral aripiprazole 10 mg daily for a client with schizophrenia.This medication is unfamiliar to the nurse,and she cannot find it in the hospital formulary or other references.How should she proceed?

The nurse reviews the patient chart and sees a physician prescription for a new medication.The nurse is able to clearly read the medication name but the dose is not legible.What is the best action by the nurse?

The nurse is caring for a client who was newly diagnosed with type 2 diabetes mellitus.Which intervention by the nurse best promotes client cooperation with the treatment plan?

Which of the following is the best example of the implementation phase of the nursing process?

Which criterion might be used in structure evaluation?

Who is responsible for evaluating the outcome of a task delegated to the nursing assistive personnel (NAP) ?