Nursing Process – 1 - Practice questions PDF

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NURSING PROCESS – 1 1. Once a nurse assesses a client’s condition and identifies appropriate nursing diagnoses, a: 1. Plan is developed for nursing care. 2. Physical assessment begins 3. List of priorities is determined. 4. Review of the assessment is conducted with other team members.

2.

Planning is a category of nursing behaviors in which: 1. 2. 3. 4.

The nurse determines the health care needed for the client. The Physician determines the plan of care for the client. Client-centered goals and expected outcomes are established. The client determines the care needed.

3. Priorities are established to help the nurse anticipate and sequence nursing interventions when a client has multiple problems or alterations. Priorities are determined by the client’s: 1. 2. 3. 4.

Physician Nonemergent, non-life threatening needs Future well-being. Urgency of problems

4. A client centered goal is a specific and measurable behavior or response that reflects a client’s: 1. 2. 3. 4.

Desire for specific health care interventions Highest possible level of wellness and independence in function. Physician’s goal for the specific client. Response when compared to another client with a like problem.

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5.

For clients to participate in goal setting, they should be: 1. Alert and have some degree of independence. 2. Ambulatory and mobile. 3. Able to speak and write.

4. Able to read and write.

6. The nurse writes an expected outcome statement in measurable terms. An example is: 1. 2. 3. 4.

7.

Client Client Client Client

will will will will

have less pain. be pain free. report pain acuity less than 4 on a scale of 0-10. take pain medication every 4 hours around the clock.

As goals, outcomes, and interventions are developed, the nurse must: 1. Be in charge of all care and planning for the client. 2. Be aware of and committed to accepted standards of practice from nursing and other disciples. 3. Not change the plan of care for the client. 4. Be in control of all interventions for the client.

8.

When establishing realistic goals, the nurse:

1. Bases the goals on the nurse’s personal knowledge. 2. Knows the resources of the health care facility, family, and the client. 3. Must have a client who is physically and emotionally stable. 4. Must have the client’s cooperation. 9. To initiate an intervention the nurse must be competent in three areas, which include: 1. 1. 2. 3. 4.

Knowledge, function, and specific skills Experience, advanced education, and skills. Skills, finances, and leadership. Leadership, autonomy, and skills.

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10. Collaborative interventions are therapies that require: 1. Physician and nurse interventions. 2. Nurse and client interventions.

3. Client and Physician intervention. 4. Multiple health care professionals.

11. Well formulated, client-centered goals should: 1. 2. 3. 4.

Meet immediate client needs. Include preventative health care. Include rehabilitation needs. All of the above.

12. The following statement appears on the nursing care plan for an immunosuppressed client: The client will remain free from infection throughout hospitalization. This statement is an example of a (an): 1. 2. 3. 4.

Nursing diagnosis Short-term goal Long-term goal Expected outcome

13. The following statements appear on a nursing care plan for a client after a mastectomy: Incision site approximated; absence of drainage or prolonged erythema at incision site; and client remains afebrile. These statements are examples of: 1. 2. 3. 4.

Nursing interventions Short-term goals Long-term goals Expected outcomes.

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14. The planning step of the nursing process includes which of the following activities? 1. 2. 3. 4.

Assessing and diagnosing Evaluating goal achievement. Performing nursing actions and documenting them. Setting goals and selecting interventions.

15. The nursing care plan is: 1. 2. 3. 4.

A A A A

written guideline for implementation and evaluation. documentation of client care. projection of potential alterations in client behaviors tool to set goals and project outcomes.

16. After determining a nursing diagnosis of acute pain, the nurse develops the following appropriate client-centered goal: 1. 2. 3. 4.

Encourage client to implement guided imagery when pain begins. Determine effect of pain intensity on client function. Administer analgesic 30 minutes before physical therapy treatment. Pain intensity reported as a 3 or less during hospital stay.

17. When developing a nursing care plan for a client with a fractured right tibia, the nurse includes in the plan of care independent nursing interventions, including: 1. 2. 3. 4.

Apply a cold pack to the tibia. Elevate the leg 5 inches above the heart. Perform range of motion to right leg every 4 hours. Administer aspirin 325 mg every 4 hours as needed.

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18. Which of the following nursing interventions are written correctly? (Select all that apply.) 1. 2. 3. 4.

Apply continuous passive motion machine during day. Perform neurovascular checks. Elevate head of bed 30 degrees before meals. Change dressing once a shift.

19. A client’s wound is not healing and appears to be worsening with the current treatment. The nurse first considers: 1. Notifying the physician. 2. Calling the wound care nurse 3. Changing the wound care treatment.

4. Consulting with another nurse.

20. When calling the nurse consultant about a difficult client-centered problem, the primary nurse is sure to report the following: 1. 2. 3. 4.

Length of time the current treatment has been in place. The spouse’s reaction to the client’s dressing change. Client’s concern about the current treatment. Physician’s reluctance to change the current treatment plan.

21. The primary nurse asked a clinical nurse specialist (CNS) to consult on a difficult nursing problem. The primary nurse is obligated to: 1. 2. 3. 4.

Implement the specialist’s recommendations. Report the recommendations to the primary physician. Clarify the suggestions with the client and family members. Discuss and review advised strategies with CNS.

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22. After assessing the client, the nurse formulates the following diagnoses. Place them in order of priority, with the most important (classified as high) listed first. 1. 2. 3. 4.

Constipation Anticipated grieving Ineffective airway clearance Ineffective tissue perfusion.

23. The nurse is reviewing the critical paths of the clients on the nursing unit. In performing a variance analysis, which of the following would indicate the need for further action and analysis? 1. 2. 3. 4.

A client’s family attending a diabetic teaching session. Canceling physical therapy sessions on the weekend. Normal VS and absence of wound infection in a post-op client. A client demonstrating accurate medication administration following teaching.

24. The RN has received her client assignment for the day-shift. After making the initial rounds and assessing the clients, which client would the RN need to develop a care plan first? 1. 2. 3. 4.

A client who is ambulatory. A client, who has a fever, is diaphoretic and restless. A client scheduled for OT at 1300. A client who just had an appendectomy and has just received pain medication.

1. 2. 3. 4. 5. 6. 7. 8. 9.

A (1-10 from FON; Chapter 17) B D B A C B B A

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10. D 11. D (11-15 from FON SG, Chapter 17) 12. B 13. D 14. D 15. A 16. D. This is measurable and objective. (16-22 from Evolve website) 17. B. This does not require a physician’s order. (A & D require an order; C is not appropriate for a fractured tibia) 18. C. It is specific in what to do and when. 19. B. Calling in the wound care nurse as a consultant is appropriate because he or she is a specialist in the area of wound management. Professional and competent nurses recognize limitations and seek appropriate consultation. (a. This might be appropriate after deciding on a plan of action with the wound care nurse specialist. The nurse may need to

obtain orders for special wound care products. c. Unless the nurse is knowledgeable in wound management, this could delay wound healing. Also, the current wound management plan could have been ordered by the physician. d. Another nurse most likely will not be knowledgeable about wounds, and the primary nurse would know the history of the wound management plan.) 20. A. This gives the consulting nurse facts that will influence a new plan. (b, c, and d. These are all subjective and emotional issues/conclusions about the current treatment plan and may cause a bias in the decision of a new treatment plan by the nurse consultant.) 21. D. Because the primary nurse requested the consultation, it is important that they communicate and discuss recommendations. The primary nurse can then accept or reject the CNS recommendations. (a. Some of the recommendations may not be appropriate for this client. The primary nurse would know this information. A consultation requires review of the recommendations, but not immediate implementation. b. This would be appropriate after first talking with the CNS about recommended changes in the plan of care and the rationale. Then the primary nurse should call the physician. c. The client and family do not have the knowledge to determine whether new strategies are appropriate or not. Better to wait until the new plan of care is agreed upon by the primary nurse and physician before talking with the client and/or family.) Advertisements REPORT TH IS AD

22. C, D, A, B. 23. B. (23 & 24 from Saunders NCLEX, 3rd edition) 24. B. This clients needs are a priority.

NURSING PROCESS – 2 1. What are the steps in the nursing process?

2. Mr. Anderson says that his head has been hurting for 3 weeks. The nurse knows this is what kind of data? 1. Primary objective data 2. Primary subjective data 3. Secondary objective data

4. Secondary subjective data

3. Mr. Jones comes into the doctor’s office with his wife. During the initial interview with the nurse assessing the reason for the visit, the wife says that her husband has been feeling bad for three days. The nurse knows this is what type of data? 1. 2. 3. 4.

4.

Primary objective data Primary subjective data Secondary objective data Secondary subjective data

Pain is always which kind of symptom 1. Subjective 2. Objective

5.

Subjective or Objective? 1. 2. 3. 4. 5. 6. 7.

Feeling tired Feeling warm skin Seeing spots Seeing a rash A fever Needing to cough Hearing a cough

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6. The nurse needs to interview a client in the hospital room. What is the idea setting for this interview? 7.

What are the 5 types of Nursing Diagnoses?

8.

What is the Basic Three Part Statement format for a Nursing Diagnosis?

9.

What can a Nursing Diagnosis not ever have as the Etiology?

10. What is different about the format of a Risk Diagnosis compared to an Actual Diagnosis?

11. What is another name for “defining characteristics”? 12. What is the proper format of a Nursing Diagnosis that contains a medical diagnosis? 13. What kind of Nursing Diagnosis uses a One Part Statement? 14. How do you always start an intervention statement? 15. How do you always start an outcome or goal statement? 16. Outcome must always be Smart. What does this mean? 17. Which of these is a properly written outcome? 1. The nurse will assist the patient to the nurse’s station twice during this shift. 2. The client will walk unassisted to the bathroom. 3. The client will get out of bed into the chair for two hours today. 4. The client will be free of pain.

18. When does discharge planning begin? 19. What step in the nursing process does writing desired outcomes occur? Advertisements REPORT TH IS AD

20. Desired outcomes are based on what part of the Three Part Statement? 21. Interventions focus on what part of the Three Part Statement? 22. Which of the following is an not independent nursing intervention? 1. 2. 3. 4.

Keep the side rails raised x 2. Give a patient his medication Turn patient every 2 hours Take vital signs every 4 hours

23. What are the two things a nurse must do in the intervention step of the nursing process?

24. The CNA reports that the patient who is scheduled to be discharge at 11:00 has a blood pressure of 160/90. What is the nurses first action? 1. Check the medication list to see if there is any medication to give for high blood pressure 2. Check the blood pressure 3. Call the physician 4. Get the charge nurse

1. 2. 3. 4. 5. 6.

Assess, Diagnose, Plan, Implement, Evaluate B D A . Client in no pain, no TV or other interruptions, should be private, comfortable, seated eye level, at a comfortable distance according to culture, use laymen terminology, or translator as necessary 7. Actual, Risk, Wellness, Possible, Syndrome 8. Problem related to (r/t) Etiology as evidenced by (AEB) defining characteristics (or signs and symptoms) 9. A medical diagnosis

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10. A Risk Diagnosis does not have any defining characteristics, because if it did, it would be an actual problem, not a risk. It is a Two Part Statement. 11. Signs and symptoms. 12. Problem r/t Etiology, secondary to Medical Diagnosis, AEB S&S 13. Wellness, Syndrome 14. “The nurse will…” 15. “The patient will…” 16. Specific, Measurable, Appropriate, Realistic, Timely 17. C 18. Upon admission 19. Planning

20. Problem 21. Etiology 22. B, this is a dependent intervention because it must have a doctor’s order. 23. Do the intervention and document the intervention. 24. B. The nurse should always validate cues that seem out of the ordinary. Also in priority questions, the answer is normally an independent nursing intervention first....