Exam for Unit II- Chapters 4-9. Ch 4 The Nursing Process-Critical Thinking and Decision Making; Documentation; Communication and Relationships; Health and Wellness; Ethnic, Cultural, and Spiritual Aspects PDF

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Exam for Unit II- Chapters 4-9. Ch 4 The Nursing Process-Critical Thinking and Decision Making; Documentation; Communication and Relationships; Health and Wellness; Ethnic, Cultural, and Spiritual Aspects...

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Cour PNSG2030: Nursing Fundamentals se Test Fundamentals Unit II Exam Spring 2021 Start 1/19/21 9:04 AM ed



Question 1

After completing the initial head-to-toe shift assessment, the nurse determines that no changes are needed in the client’s plan of care. Which evaluation process supports the nurse’s decision? Answer a. s: Reviewing

the effectiveness of previously initiated nursing interventions b.

Recognizing that the client may be discharged from the hospital during this shift c.

Using the knowledge that the client received a comprehensive health assessment d.

Referring to the facility’s general plan of client care for the current shift 

Question 2

At the staff education meeting, the nurse explains that it is important to use four senses (sight, touch, hearing, and smell) to determine whether a patient is exhibiting signs of illness or injury. These signs of illness or injury are Answer a. s: Hidden. b.

Subjective. c.

Reported by the patient. .

Measurable. 

Question 3

While caring for a newly admitted client, the registered nurse (RN) gathers information by interviewing the client to obtain a health history and reviewing the

results of laboratory and diagnostic tests. Which step in the nursing process did this nurse complete? Answer a. s: Planning b.

Implementa tion c.

Evaluation d.

Assessment 

Question 4

The nurse is performing a shift assessment on a client. Which information should the nurse identify as objective data? Answer a. s: The

client complains of feeling nauseated b.

The client demonstrates facial grimacing c.

The client complains of visual disturbances d.

The client reports feelings of depression 

Question 5

The LPN/LVN assists the RN in completing an admission history with a confused client. Which information should be identified as secondary information? Answer a. s: The

client reports a history of chest pain.

b.

The client verbalizes anxiety about hospitalization. c.

The client complains of chronic

constipation. d.

The client’s spouse reports experiencing marital issues. 

Question 6

The nurse reviews problems identified for a client. Which problem should the nurse list as a priority? Answer a. s: Ambulates

with a cane

b.

Is separated from the spouse c.

Has irregular heart rhythm d.

Is unable to use a new glucose meter 

Question 7

A client has hyperactive bowel sounds, diarrhea, nausea, vomiting, and has lost five pounds over the last week. Which type of nursing diagnostic statement should be created for this client? Answer a. s: Wellnes

s b.

Threepart c.

Syndro me d.

Twopart 

Question 8

A hospitalized client with diabetes is being treated for an infected diabetic foot wound. Which would be an appropriate short-term goal for this client? Answers:

a.

No further evidence of skin breakdown on the feet b.

Wound is healed c.

Demonstrates correct technique for self-injection of insulin d.

Wears footwear in the home at all times



Answer Feedback:

This is correct. Long-term goals are not expected to be met before the pa time of discharge or transfer to another level of care. They may be met i

Response Feedback:

This is correct. Long-term goals are not expected to be met before the p the time of discharge or transfer to another level of care. They may be

Question 9

The nurse meets with the physical and occupational therapist to plan care for a client with nerve damage caused by a back injury. Which type of intervention will be listed on the plan of care? Answer a. s: Dependen

t b.

Collaborati ve c.

Direct d.

Independe nt 

Question 10

The nurse is planning interventions for a client experiencing nausea and vomiting after receiving chemotherapy. Which intervention is individualized for this client? Answers:

a.

Provide 8 ounces enriched milkshake mid-morning and mid-afternoon b.

Encourage fluids c.

Avoid taking fluids while eating meals

d.

Monitor intake and output and daily weights Answer Feedback: Response Feedback:



This is incorrect. Monitoring intake and output and daily weights are gen individualized for the client. Incorre ct.

Question 11 0 out of 1.11111 points

A client has a critical pathway to be used for providing care. Which should the nurse keep in mind when following this plan of care? Selected Answer: Answers:

a.

Uses nursing intervention (NIC) and outcome (NOC) statements a.

Uses nursing intervention (NIC) and outcome (NOC) statements b.

Coordinates nursing problems with medical diagnoses c.

Care is based upon the day of hospitalization d.

Provides areas for other disciplines to document interventions Answer Feedback: Response Feedback:



This is incorrect. Computerized care plans utilize standardized taxonom such as NIC and NOC. Incorre ct.

Question 12 0 out of 1.11111 points

The nursing student is preparing a care plan for an assigned client. What should the nurse include that is least likely to be placed on an individualized plan of care for the same client? Selected Answer: Answers:

a.

Numbered day of hospitalization a.

Numbered day of hospitalization b.

Impact of laboratory data on selection of an intervention c.

Consistent use of nursing taxonomy d.

Generic nursing diagnoses based upon the primary health problem 

Question 13

The nurse is preparing to instruct a client on how to change an ostomy appliance. What should be addressed prior to beginning this teaching session to ensure optimal learning occurs? Answer a. s: Turn

off the television b.

Address lower level needs c.

Complete morning care d.

Invite family to participate 

Question 14

A nurse receives an order from the physician for an intravenous (IV) antibiotic to be administered to a patient who has experienced development of pneumonia. The nurse remembers that the patient has an allergy to another medication in the same family of antibiotics. The nurse should Answer a. s: Follow

the physician’s orders and administer the IV.

b.

Call the laboratory for clarification. c.

Notify the physician of the potential for the patient to have a reaction to the ordered antibiotic. d.

Retest the patient for allergies. 

Question 15

While caring for a patient who is complaining of abdominal pain, the nurse determines that the top priority is to manage the patient’s pain with medication. This step in the

nursing process is called Answer a. s: Implementat

ion. b.

Planning. c.

Diagnosis. d.

Assessment. 

Question 16

A nurse is caring for a patient who has a broken leg. When the patient complains of pain, the nurse administers additional pain medication. When the nurse medicates the patient, he or she is performing a step in the nursing process that is called Answer a. s: Planning. b.

Implementat ion. c.

Evaluation. d.

Assessment. 

Question 17

A nurse is caring for a patient with asthma who is having difficulty breathing. The nurse notifies the respiratory therapist, who administers treatment. After the treatment, the nurse reflects on the results to determine whether the goal of relief has been accomplished. When the nurse determines whether the goal has been met, he or she is performing a step in the nursing process called Answer a. s: Implementat

ion. b.

Planning. c.

Evaluation. d.

Diagnosis. 

Question 18

A nurse is performing a shift assessment on a patient. While collecting objective and subjective data, the nurse identifies as objective data that Answer a. s: The

patient reports feelings of depression. b.

The patient demonstrates facial grimacing. c.

The patient complains of feeling nauseated. d.

The patient complains of visual disturbances. 

Question 19

While performing a thorough physical assessment on a patient, the licensed practical nurse (LPN) begins collecting primary data. An example of primary data is that Answer a. s: The

patient’s spouse reports the patient has difficulty sleeping. b.

The patient’s caregiver complains of feeling overwhelmed. c.

The patient reports a history of chronic obstructive pulmonary disease. d.

The patient’s daughter appears anxious about the patient’s hospitalization. 

Question 20

The health-care team member responsible for performing a patient assessment and formulating nursing diagnoses is

Answer a. s: The

licensed practical nurse (LPN). b.

The registered nurse (RN). c.

The medical doctor (MD). d.

The unlicensed assistive personnel (UAP). 

Question 21

A licensed practical nurse (LPN) has formulated four nursing diagnoses for her patient. The priority nursing diagnosis would be Answer a. s: Altered

nutrition.

b.

Chronic low selfesteem. c.

Risk for infection. d.

Ineffective airway clearance. 

Question 22

A nursing instructor explains that a complete nursing diagnosis may be a one-part, two-part, or three-part statement. Three-part statements are often called PES statements, which stands for Answer a. s: Pathogen,

etymology, and symptoms. b.

Problem, etiology, and signs and symptoms. c.

Problems, evaluations, and solutions. d.

Prognoses, examination, and

solution. 

Question 23

A nurse assesses a patient’s urine and notices that it is dark yellow, concentrated, and lower in volume than normal. The nurse decides to put the patient on intake and output measurement because the patient has a risk for imbalanced fluid volume. This is an example of a(n) Answer a. s: Dependent

intervention. b.

Independent intervention. c.

Collaborative intervention. d.

Indirect intervention. 

Question 24

A nursing instructor is explaining the initial steps of most nursing interventions. The instructor recognizes that additional explanation is required when a student nurse states: Answer s:

a.

“You should always carry out the physician’s order as quickly as possible without question.” b.

“You should always think critically about the order to make sure the patient’s condition has not changed in such a way that the order might no longer be appropriate.” c.

“You should always check the chart to be certain of a physician’s or other health-care provider’s order.” d.

“You should always explain the procedure to the patient using words the patient understands.” 

Question 25

The nurse discovers a client lying on the floor. Which should the nurse write when completing an incident report?

Answer s:

a.

“Found client lying face down on the floor beside the bed.” b.

“Client accidentally fell out of bed onto the floor.” c.

“Client fell out of bed onto the floor.” d.

“Heard client fall from the bed to the floor.” 

Question 26

While documenting in a client’s chart, the nurse realizes that it is the wrong chart. What should the nurse do? Answer a. s: Write

over the incorrect letters.

b.

Use correction tape to blank out the mistaken entry. c.

Use correction fluid to blank out the mistaken entry. d.

Write “mistaken entry” and place initials just above incorrect entry. 

Question 27

The nursing instructor is reviewing the different types of charting methods with the class. Which should the instructor explain for the acronym SOAPIER? Answer a. s: Subjective

data, Objective data, Assessment data, Plan, Intervention, Evaluation, Results b.

Symptoms, Objective, Assessment data, Plan, Intervention, Evaluation, Revision c.

Subjective data, Objective data, Assessment data, Plan, Intervention, Evaluation, Revision d.

Subjective data, Objective data, Assessment data, Problems, Intervention, Evaluation, Revision



Question 28

A health-care organization is considering focus charting. Which categories are commonly documented using this approach? Answer a. s: Subjective,

objective, assessment, plan b.

Abnormal findings and checklist c.

Problem, intervention, evaluation d.

Data, action, response 

Question 29

The nurse uses a cheat sheet to jot down pertinent client data while providing care. What should the nurse do with the sheet after documenting all client care? Answer s:

a.

Shred the paper. b.

Keep the paper for use the next day. c.

Throw it in the trash. d.

Give the paper to the next nurse during hand off communication. 

Question 30

A health-care facility uses narrative charting. What should the nurse remember when following this documentation approach? Answer a. s: It

focuses on data, action, and response. b.

It tells the client’s story. c.

It is the least time-consuming

documentation method. d.

It is the least thorough documentation method. 

Question 31

A client received a dose of intravenous pain medication before change of shift. After receiving the report, the oncoming nurse notes that the medication was not documented, provides another dose, and the client has a respiratory arrest. Who is most liable for this situation? Answer a. s: The

health-care provider who prescribed the medication

b.

The nurse who gave the first dose of medication c.

The nurse who gave the second dose of medication d.

The person who called the nurse away before documenting the medication 

Question 32

A nurse is educating a student nurse about the purpose of written documentation. The nurse recognizes that additional teaching is warranted when the student nurse states: Answer a. s: “The

purpose of written documentation is to serve as a record of accountability for accreditation.” b.

“The purpose of written documentation is to serve as a record of accountability for quality assurance.” c.

“The purpose of written documentation is to serve as a legal record for the health-care provider only.” d.

“The purpose of written documentation is to communicate pertinent data to the health-care team.” 

Question 33

A nurse is aware that the best method to ensure documentation accuracy

is to consistently chart Answer a. s: At

the completion of each shift. b.

Immediately after care is provided. c.

Immediately before providing care. d.

Within 4 hours of providing care. 

Question 34

A student nurse is caring for a patient who is on a clear liquid diet. The best example of nursing documentation related to this patient is: Answer a. s: “Average

intake of clear liquid diet noted.”

b.

“Patient swallowing clear liquids normally.” c.

“No complaints of nausea while on clear liquid diet.” d.

“Patient tolerates the clear liquid diet well.” 

Question 35

While bathing a patient, a nurse recognizes that the personal spacedistance zone that he or she is in when physically touching the patient is Selected Answer:

b.

Socialconsultative.

Answers:

a.

Intimate. b.

Social-

consultative. c.

Casualpersonal. d.

Public. 

Question 36

When interacting with patients, a nurse demonstrates a willingness to communicate by Answer a. s: Standing

over seated patients.

b.

Folding arms while talking to patients. c.

Slumping while talking to patients. d.

Leaning slightly forward toward patients. 

Question 37

When a nurse educates a patient about his medications, the patient tells the nurse that he should go back to nursing school because he does not know very much about medications. The style of communication that the patient is demonstrating is Answer s:

a.

Aggressi ve. b.

Passive. c.

Assertive . d.

Avoidant. 

Question 38

A nursing instructor teaches a class of student nurses that the most

effective communication style for nurses to practice is Answer a. s: Passive. b.

Avoidant. c.

Aggressi ve. d.

Assertive . 

Question 39

A nurse is caring for a patient who has end-stage renal disease and will require dialysis three times per week. The patient states, “I’m upset that I didn’t visit all the places I’d like to see. Now that I’m on dialysis, I won’t be able to.” The most therapeutic response by the nurse is: Answer s:

a.

“You are upset that it’s too late to visit places that you would like to see?” b.

“Don’t worry. You can still visit all of the places that you would like to see.” c.

“There are many people who feel exactly the same as you do.” d.

“I think you should visit the places you would like to see before it’s too late.” 

Question 40

A nurse is caring for a patient who has just been diagnosed with a brain tumor. The patient asks the nurse if she should choose to have surgery. The nurse’s most therapeutic response is: Answer s:

a.

“Tell me what you know about the surgery.” b.

“If I were you, I would definitely have the surgery.” c.

“Don’t worry. You will be fine if you don’t have surgery.” d.

“I would never decide against having surgery.” 

Question 41

A nurse is caring for a patient who develops dyspnea that does not improve with oxygen therapy and nebulizer treatment. The nurse immediately calls the patient’s primary health-care provider. This type of communication is called Answer s:

a.

Upward. b.

Downwar d. c.

Horizont al. d.

Bilateral. 

Question 42

A nurse observes a student nurse caring for a hearing-impaired patient. The nurse will intervene if the student nurse Answer a. s: Positions

himself or herself in front of the patient when speaking. b.

Speaks clearly without shouting. c.

Speaks directly to the ...