1) What is a characteristic of the nursing process a. !s"ste#atic c. Inf$e%i&$e &. Goa$'oriente( (. Stagnant )) What is the or(er of the nursing process a. !ssessing* (iagnosing* i#p$e#enting* e+a$uating* p$anning &. !ssessing* (iagnosing* p$anning* i#p$e#enting* e+a$uating c. ,iagnosing * assessing* p$anning* i#p$e#enting* e+a$uating (. P$anning* (iagnosing* i#p$e#enting* assessing* e+a$uating -) Which approach to pro&$e# so$+ing tests an" nu#&er of so$utions unti$ one is foun( that .or/s for that particu$ar pro&$e# a. Intuition c. Scientific 0etho( &. Routine (. Tria$ an( error 1) Which #etho( of reasoning #o+es fro# genera$ princip$es to the co$$ection of specific (ata or infor#ation that confir#s or negate a h"pothesis a. ,e(ucti+e c. Insightfu$ &. In(ucti+e (. Rationa$ 2) ,uring the p$anning phase of the nursing process* .hich of the fo$$o.ing is the 3pro(uct4 (e+e$ope( a. Nursing care p$an c. Nursing histor" &. Nursing (iagnoses (. Nursing notes 5) Which range of app$ications (oes the nursing process ha+e a. 6roa( c. E%act &. ,istinct (. Narro. 7) O&8ecti+e (ata are a$so /no.n as9 a. Co+ert (ata c. O+ert ,ata &. Inferences (. S"#pto#s :) ,ata or infor#ation o&taine( fro# the assess#ent of a patient is pri#ari$" use( &" the nurse to9 a. !scertain the patient;s responses to hea$th pro&$e#s &. !ssist in constructing the ta%ono#" of nursing inter+entions. c. ,eter#ine the effecti+eness of the (octor;s or(ers. (. I(entif" the patient;s (isease process <) The pri#ar" source of (ata co$$ection in the assess#ent phase of the nursing process is the9 a. Chart c. (octor &. Patient (. fa#i$" 1=) What is an e%a#p$e of su&8ecti+e (ata a. Co$or of .oun( (rainage &. O(or of &reath c. Respiration of 11 &reaths>#inute (. The patient;s state#ent of 3I fee$ sic/ to #" sto#ach4 11) Which state#ent is a (ifference &et.een co#prehensi+e an( focuse( assess#ents a. Co#prehensi+e assess#ents can;t inc$u(e an" focuse( assess#ents. &. ?ocuse( assess#ents are #ore i#portant than co#prehensi+e assess#ents. c. ?ocuse( assess#ents are usua$$" ongoing an( concerning specific pro&$e#s (. O&8ecti+e (ata are inc$u(e( on$" in co#prehensi+e assess#ents 1)) T.o'"ear o$( @ason;s #other states 3@ason +o#ite( : ounces of his for#u$a this #orning.4 a. O&8ecti+e (ata fro# a pri#ar" source &. O&8ecti+e (ata fro# a secon(ar" source c. Su&8ecti+e (ata fro# a pri#ar" source (. Su&8ecti+e (ata fro# a secon(ar" source 1-) The nurse perfor#s a neuro$ogic e%a# on a patient. !fter the e%a#* .hich of the fo$$o.ing shou$( &e recor(e( as o&8ecti+e (ata9 a. A1 pate$$ar ref$e%es in &oth of the patient;s $egs &. Patients (escription of ringing in his ears c. Patients sensations of nu#&ness in his right ar# (. Patient;s state#ent* 3the roo# is spinning4 11) Which fin(ing o&taine( (uring an assess#ent is concerne( significant enough to reBuire i##e(iate co##unication to another #e#&er of the hea$th care tea# a. Change in a parent;s heart rate fro# 7) to := &. ,i#inishe( &reath soun(s in a patient .ith pre+ious$" nor#a$ &reath soun(s c. Re$ief note( &" a patient fro# prescri&e( nausea #e(ication (. Weight $oss of ) $& C1 /g) in a 112 $& C2) /g) fe#a$e patient 12) I#paire( gas e%change is $iste( in the N!N,! ta%ono#" un(er .hich of the fo$$o.ing hu#an response patterns a. Choosing c. e%changing &. Co##unicating (. re$ating 15) It is i#portant to i(entif" the etio$og" Cris/ factors) of a nursing (iagnosis &ecause (oing so9 a. !ssists in organiDing nursing care of patients .ith si#i$ar (iagnosis. &. ,escri&e the patient;s hea$th pro&$e# or response in a fe. .or(s. c. Gi+es (irection to the reBuire( nursing inter+entions for the patient. (. In(icates the presence of a particu$ar hea$th pro&$e# in a patient. Page 2 of 6 17) The nurse (eter#ines that her patient;s un.i$$ingness to $oo/ at her #astecto#" scar* her refusa$ to see +isitors* an( her state#ent* 3I;# not the sa#e .o#an an"#ore4 see# to point to a (istur&ance in the patient;s &o(" i#age. This o&ser+ation is an e%a#p$e of9 a. ,eter#ining strengths an( .ea/nesses &. ,ifferentiating nursing fro# #e(ica$ (iagnoses. c. I(entif"ing gaps an( inconsistencies in (ata. (. RecogniDing a c$uster of significant (ata. 1:) 0r. 6ra($e"* a @eho+ah;s Witness* refuse( an" &$oo( transfusions (uring his surger"* &eca#e ane#ic after his operation* an( is no. tire(. 0r. 6ra($e" is #ore than $i/e$" e%periencing9 a. ! potentia$ Cris/) nursing (iagnosis. &. ! possi&$e nursing (iagnosis. c. We$$ness (iagnosis. (. !n actua$ nursing (iagnosis. 1<) The nurse (eter#ines that 0rs. Turner;s heart rate of 5= &eats>#inute #eans that she;s &ra("car(ic. This (eter#ination is an e%a#p$e of9 a. ! cue c. (ata c$ustering &. !n inference (. (ata s"nthesis )=) Using 0as$o.;s hierarch" of &asic hu#an nee(s* .hich of the fo$$o.ing nursing (iagnoses has the highest priorit" a. !n%iet" re$ate( to i#pen(ing surger"* as e+i(ence( &" inso#nia. &. I#paire( +er&a$ co##unication re$ate( to tracheosto#"* as e+i(ence &" ina&i$it" to spea/. c. Ineffecti+e &reathing pattern re$ate( to pain* as e+i(ence( &" shortness of &reath. (. Ris/ for in8ur" re$ate( to autoi##une ("sfunction )1) When e%a#ining a patient;s e"es* the nurse consi(ers the patients age. This action is an e%a#p$e of9 a. C$ustering (ata &. Co#paring (ata against stan(ar(s an( nor#s. c. ,eter#ining gaps in the (ata. (. ,ifferentiating cues an( inferences. ))) ?or#u$ating a nursing (iagnosis is a 8oint function of9 a. Patient an( fa#i$" c. Nurse an( (octor &. Nurse an( patient (. ,octor an( patient )-) Which of the fo$$o.ing is a nursing (iagnosis a. !n%iet" c. Heart fai$ure &. ,ia&etes (. 0"ocar(ia$ Infarction )1) The nurse sees a patient cr"ing an( (eter#ines fro# that o&ser+ation that the patient is e%perien' cing the nursing (iagnosis of ("sfunctiona$ grie+' ing. If the nurse has #a(e a (iagnostic error* it .ou$( #ost $i/e$" &e (ue to .hich of the fo$$o.ing reason a. I(entif"ing .ith the patient &. Genera$iDing fro# e%perience c. Eac/ of c$inica$ e%perience (. Pre#ature c$osure )2) Which state#ent in(icates the #ost appropriate nursing inter+entions to (eter#ine .hether the goa$ of 3The patient .i$$ (e#onstrate f$ui( &a$ance* as e+i(ence( &" tota$ f$ui( inta/e eBua$s tota$ f$ui( output4 has &een #et a. ,eter#ine the patient;s f$ui( preferences &" the en( of the shift. &. Instruct the patient to (rin/ 1*2== #E of f$ui( e+er"(a". c. 0easure an( recor( the patient;s tota$ f$ui( inta/e an( output e+er" shift. (. 0easure the specific gra+it" of the patient;s urine e+er" shift. )5) What is a (isa(+antage of stan(ar(iDe( nursing care p$ans a. ! nurse .ho uses a stan(ar(iDe( nursing care p$an #a" fin( it +er" ti#e consu#ing. &. ! stan(ar(iDe( nursing care p$an #a" not &e consistent .ith accepta&$e stan(ar(s of care. c. Consent of the patient is necessar" to use a stan(ar(iDe( nursing care p$an. (. The uniBue nee(s of the patient #a" not &e a((resse( in a stan(ar(iDe( nursing care p$an. )7) Which e%pecte( outco#e is correct$" .ritten a. 3the patient .i$$ &e $ess e(e#atous Cs.o$$en) in )1 hours4 &. The patient .i$$ (rin/ an a(eBuate a#ount of f$ui( (ai$"4 c. The patient .i$$ i(entif" a$$ high'sa$t" foo(s fro# a prepare( $ist &" (ischarge4 (. The patient .i$$ soon s$eep .e$$ through the night4 ):) In the p$anning phase of the nursing process* the nurse9 a. !na$"Des patients (ata &. Carries out nursing inter+entions c. ?or#u$ates a nursing (iagnosis (. I(entifies patient goa$s. )<) When shou$( (ischarge p$anning co##ence a. )1 hours after (ischarge &. The (a" &efore (ischarge c. Upon a(#ission (. When the patient (esires -=) Which patient .ou$( &enefit fro# a short'ter# goa$ a. 6i$$* .ho is ha+ing an appen(ecto#" to(a". &. 0ar"* .ho has e%tensi+e &urns o+er 2=F of her &o(". Page 3 of 6 c. Susan* .ho has suffere( a se+ere spina$ cor( in8ur". (. To((* .ho has heart fai$ure an( is a.aiting a transp$ant. -1) The scientific reason for se$ecting a specific nursing inter+ention supporte( &" c$inica$ research is ca$$e( a9 a. Criterion c. strateg" &. Rationa$e (. theor" -)) !n e%pecte( outco#e on a patient;s nursing care p$an rea(s9 3Patient .i$$ &e a&$e to transfer fro# the &e( to a .hee$chair .ithout assistance &" the en( of the .ee/.4 When the nurse e+a$uate( the patient;s progress* the patient .as a&$e to transfer fro# the &e( to a .hee$chair to go to the ph"sica$ therap" (epart#ent .ithout an" he$p fro# the nurse. Which of the fo$$o.ing .ou$( &e an appropriate e+a$uati+e state#ent for the nurse to p$ace on the patient;s nursing care p$an a. 3patient .as a&$e to transfer fro# the &e( to a .hee$chair .ithout assistance4 &. 3goa$ i#possi&$e to #easure4 c. 3Goa$ #etG patient .as a&$e to transfer fro# the &e( to a .hee$chair .ithout assistance. (. 3Goa$ not #et4 --) The nurse #anager e+a$uates the ne. I.H. s"ste# institute( in the faci$it" to ascertain .hether it has resu$te( in a (ecrease( inci(ence of ph$e&itis in patients .ith I.H. $ines. This is an e%a#p$e of .hat t"pe of e+a$uation a. Outco#e c. Process &. Peer (. Structure -1) In the e+a$uating phase of the nursing process* the nurse (oes .hich of the fo$$o.ing tas/s a. I(entifies a+ai$a&$e resources &. Carries out nursing inter+entions c. ?or#u$ates nursing (iagnoses (. 0easures goa$ achie+e#ent -2) !n e%pecte( outco#e on a patient;s care p$an rea(s9 3Patient .i$$ state se+en .arning signa$s of cancer &" (ischarge.4 When the nurse e+a$uates the patient;s progress* the patient is a&$e to state that a change in a .art or a #o$e* a sore that (oesn;t hea$ an( a change in &o.e$ or &$a((er ha&its are .arning signa$s of cancer. Which of the fo$$o.ing .ou$( &e an appropriate e+a$uati+e state#ent for the nurse to p$ace on the patient;s nursing care p$an a. 3Patient un(erstan(s the .arning signa$s of cancer4 &. 3Goa$ #etG patient cite( a change in a .art or a #o$e* a sore that (oesn;t hea$* an( a change in &o.e$ or &$a((er ha&its as .arning signa$s of cancer4. c. Goa$ not #et4 (. Goa$ partia$$" #etG patient a&$e to state on$" three .arning signa$s of cancer.4 -5) The goa$ or e%pecte( outco#e 3Patient .i$$ #aintain current .eight of 152 poun(s4 can &est &e e+a$uate( &" .hich of the fo$$o.ing #easures9 a. ,eter#ining the patient;s foo( preferences &. 0onitoring (ietar" inta/e for each #ea$ c. Restricting high'ca$orie foo( (. Weighing the patient on the sa#e sca$e -7) ! Bua$it" assurance nurse sen(s a Buestionnaire to patients after (ischarge to (eter#ine their $e+e$ of satisfaction .ith the nursing care the" recei+e( in the faci$it". What t"pe of nursing au(it is this a. Concurrent c. retrospecti+e &. Outco#e (. ter#ina$ -:) The nurse #a/es the fo$$o.ing entr" in the patient;s recor(9 3Goa$ not #etG patient refuses to atten( s#o/ing cessation changes.4 6ecause this goa$ hasn;t &een #et* the nurse shou$(9 a. ,e+e$op a co#p$ete$" ne. nursing care p$an &. !ssign the patient to a #ore e%perience( nurse c. CritiBue the steps in+o$+e( in the (e+e$op#ent of the goa$. (. Transfer the patient to another faci$it" -<) The nurse #anager e+a$uates the Bua$it" of the nursing care p$an (e+e$ope( for the patients on the nursing unit. This is an e%a#p$e of .hich t"pe of e+a$uation a. Outco#e c. Process &. Peer (. Structure 1=) Which state#ent regar(ing Bua$it" i#pro+e#ent is true a. Inherent in Bua$it" i#pro+e#ent is the notion that so#e processes in a faci$it" can;t &e i#pro+e(. &. Iua$it" i#pro+e#ent is a continuous process use( to e+a$uate the nee(s an( e%pectations of custo#ers. c. Iua$it" i#pro+e#ent esta&$ishes criteria use( to reco##en( punish#ent for i(entifie( (eficiencies. (. The focus of t Bua$it" i#pro+e#ent is pri#ari$" on the nursing an( #e(ica$ staffs of a faci$it". 11) In the i#p$e#enting phase of the nursing process* the nurse (oes .hich of the fo$$o.ing tas/s a. ,eter#ines the patient;s hea$th status. &. I(entifies a+ai$a&$e resources Page 4 of 6 c. 0easures goa$ achie+e#ent (. Puts the nursing care p$an into action 1)) Co$$a&orati+e nursing inter+entions9 a. !re &ase( on the .ritten instructions of another professiona$. &. !re (eter#ine( so$e$" &" the nurse an( patient. c. Ref$ect the o+er$apping responsi&i$ities of hea$th care personne$. (. ReBuire super+ision &" the (octor. 1-) Which nurse #ight nee( assistance .hen i#p$e#enting the (escri&e( nursing inter+ention a. !stri(* .ho has to insert nasogastric tu&e in patientG a proce(ure she has perfor#e( nu#erous ti#es &. 6i$$* .ho has to transfer a patient to a stretcherG the patient is in great pain c. 0ar"* a #e#&er of the I.H. tea#* .ho has to start an I.H. on a patient reBuiring I.H. anti&iotics. (. Sharon* .ho .eighs 11= E&s C2= /g)* an( has to position a patient .ho .eighs <: E&s C12/g). 11) When (eter#ining the teaching strateg" that is &est suite( to the patient an( the #ateria$ to &e $earne(* .hich inter+ention s/i$$ is the nurse using a. Cogniti+e c. interpersona$ &. Effecti+e (. ps"cho#otor 12) ! group of nurses* (octors* an( a hea$th care a(#inistrator co$$a&orate to (etai$ the actions nurses are a&$e to e%ecute .hen a patient is un(ergoing I.H. heparin therap". this e%a#p$e &est (escri&es9 a. ! critica$ path.a" &. ! protoco$ c. ! stan(ar(iDe( nursing care p$an (. !n in(epen(ent nursing action 15) When assessing a patient;s $e+e$ of pain* .hich t"pe of nursing inter+ention is the nurse perfor#ing a. Co$$a&orati+e c. In(epen(ent &. ,epen(ent (. Professiona$ 17) Which of the fo$$o.ing is a true state#ent .ith regar( to (e$egation of nursing inter+entions to un$icense( assisti+e personne$ CU!P) a. ! U!P (eter#ines .hich nursing inter+entions can &e (e$egate(. &. ,e$egation of nursing inter+entions to U!P resi(es .ith the (octor. c. Rare$" shou$( a nurse (e$egate nursing inter+entions to U!P. (. The nurse is responsi&$e an( accounta&$e for the outco#e. 1:) When a nurse an( a respirator" therapist (eter#ine that 1 hour prior to each #ea$ is the i(ea$ to#e for a patient;s respirator" therap"* .hich t"pe of nursing inter+ention is the nurse perfor#ing a. Co(epen(ent c. In(epen(ent &. Co$$a&orati+e (. professiona$ 1<) ,epen(ent nursing inter+entions9 a. !re actions for .hich the nurse isn;t accounta&$e &. !re in(i+i(ua$iDe( for the patient &" nurses. c. !re pri#ari$" co$$egia$ in nature (. Nee( to &e c$arifie( &" the nurse if Buestiona&$e. 2=) When reassuring a patient (uring an unco#forta&$e proce(ure* .hich inter+ention s/i$$ is the nurse using a. Cogniti+e c. interpersona$ &. Effecti+e (. ps"cho#otor 21) Which of the fo$$o.ing &eha+iors &" the nurse* Pau$a S#ith* (e#onstrates that she un(erstan(s the e$e#ents of effecti+e charting a. She (ocu#ents gi+ing a patient;s #e(ication after a(#inistering the #e(ication. &. She (ocu#ents the fo$$o.ing a&out her patient9 3appetite goo( this #orning4 c. She signs her charting as fo$$o.s9 P. S#ith (. She .rites in the nurse;s notes .ith no. ) penci$. 2)) The t"pe of patient recor( in .hich each #e#&er of the hea$th care tea# or (epart#ent #a/es notations a&out hea$th pro&$e#s that are integrate( throughout the patient;s chart is a9 a. Co#puter recor( &. ,epart#ent recor( c. Pro&$e#'oriente( #e(ica$ recor( (. Source'oriente( #e(ica$ recor( 2-) What is a (isa(+antage of co#puteriDe( (ocu#entation of the nursing process a. !ccurac" c. $egi&i$it" &. concern of pri+ac" (. rapi( co##unication 21) Which nursing (ocu#entation entr" ref$ects potentia$ $ega$ ris/ a. 3Patient;s &reath soun(s are c$ear an( eBua$ &i$atera$$".4 &. 3Patient;s right antecu&ita$ space has nee($e trac/s.4 c. 3Patient;s statesG 3I;# happ" that I;# going ho#e to(a"4 (. 3Patient transferre( fro# the &e( to chair .ith one assist.4 Page 5 of 6 22) What shou$( the nurse (o after #a/ing a charting error in the nurse;s notes a. ,ra. a $ine through the error an( .rite 3error4 an( her initia$s a&o+e it. &. O&$iterate the #ista/e .ith &$ac/ fe$t pen c. Recop" the page of nurses; notes an( start o+er. (. Report the inci(ent i##e(iate$" to the hea( nurse. 25) ,uring a change'of'shift report* it .ou$( &e i#portant for the nurse re$inBuishing responsi&i$it" for care of the patient to co##unicate .hich of the fo$$o.ing facts to the nurse assu#ing responsi&i$it" for care of the patient a. That the patient ha( a nasogastric tu&e re#o+e( ) hours ago. &. That the patient state(* 30" pain is #uch &etter to(a" that "ester(a"4 c. That the patients &ariu# ene#a perfor#e( - (a"s ago .as negati+e. (. That the patient;s fa#i$" ca#e to +isit this #orning. 27) ! patient;s participation .ou$( #ost $i/e$" &e encourage( in9 a. Change'of'shift report &. Nursing care conference c. Nursing groun( roun(s (. Staff #eeting 2:) In(epen(ent nursing inter+entions a. !$so /no.n as stan(ing or(ers &. !re initiate( &ase( on the nurse;s o.n /no.$e(ge an( s/i$$. c. Consist pri#ari$" of hea$th e(ucation. (. Re$ate (irect$" to the patient;s (isease process. 2<) Using the nursing process he$ps pro+i(e patient care that is9 a. In(i+i(ua$iDe( c. stan(ar(iDe( &. Repetitious (. unortho(o% 5=) In the e+a$uation process* the nurse shou$(9 a. 6e certain that the (iagnosis is a#ena&$e to #e(ica$ care. &. Ha+e three other nurses confor# the accurac" of the (iagnosis. c. Eoo/ for patterns an( (e+iations fro# nor#a$. (. Use on$" su&8ecti+e (ata to infer pro&$e#s. 51) The e+a$uati+e state#ent 3!t =-==* patient state(* Jit is easier to &reathe;* rate( pain a J- on sca$e of 1 to 1=. !n( coughe( effecti+e$"4 is #issing .hich of the fo$$o.ing e$e#ents a. Conc$usion c. outco#e &. ,ecision (. supporting (ata 5)) The hea( nurse .ants to (eter#ine the siDe an( $ocation of the nursing station inf$uences the (e$i+er" of nursing care on the unit. This is an e%a#p$e of .hich t"pe of e+a$uation a. Outco#e c. process &. Peer (. structure 5-) Which state#ent (oes not (escri&e an appropriate gui(e$ine for .riting a nursing (iagnosis a. State the (iagnosis in ter#s of a pro&$e#* not a nee(. &. Use of #e(ica$ ter#ino$og" to (escri&e the pro&a&$e cause of the patient;s response. c. Use nursing ter#ino$og" to (escri&e the patient response. (. Use state#ents that assist in p$anning the in(epen(ent nursing inter+entions. 51) The e+a$uation phase of the nursing process. a. Changes continua$$" &. ,irects the e%pecte( patient outco#es c. Is a sta&$e* s"ste#atic #etho( of (e+e$oping nursing care p$ans. (. Isn;t a$.a"s necessar" 52) Which of the fo$$o.ing state#ents a&out the ter# nursing process is true a. Use( on$" in the Unite( States &. It originate( .ith ?$orence Nightinga$e c. It .as first use( &" E"(ia Ha$$ in 1<22 (. Was initiate( &" the Nationa$ Eeague for Nursing in 1<:-. 55) Cho$e$ithiasis is a9 a. Co$$a&orati+e pro&$e# c. Nursing (iagnosis &. 0e(ica$ (iagnosis (. Potentia$ pro&$e# SITUATION: Gar" Ste$$ato is a )2'"ear'o$( #a$e .ho has &een +o#iting an( ha+ing (iarrhea for 1: hours Question 67 70 relate to this situation 57) Which state#ent is the #ost appropriate goa$ for a nursing (iagnosis of (iarrhea a. 3The patient .i$$ e%perience (ecrease( freBuent$" of &o.e$ e+acuation.4 &. 3The patient .i$$ pro+i(e a stoo$ speci#en for cu$ture an( sensiti+it".4 c. 3The patient .i$$ recei+e anti(iarhea$ #e(ication.4 (. 3The patient .i$$ sa+e a$$ stoo$s for inspection &" the nurse.4 5:) Which of the fo$$o.ing is the #ost i#portant purpose of p$anning care .ith this patient a. ,e+e$op#ent of a stan(ar(iDe( nursing care p$an &. E%pansion of the current ta%ono#" of nursing (iagnosis c. Pro+ision of in(i+i(ua$iDe( patient care. (. Incorporation of &oth nursing an( #e(ica$ (iagnoses in patient care. Page 6 of 6 5<) When se$ecting appropriate nursing inter+entions for 0r. Ste$$ato* the nurse #ust re#e#&er that nursing inter+entions shou$( &e9 a. !chie+a&$e .ith resources a+ai$a&$e to the nurse an( patient &. Carrie( out un(er the super+ision of a (octor. c. Chosen (isregar(ing the patient;s +a$ues an( &e$iefs. (. Oriente( pri#ari$" to.ar( tas/s an( #echanica$ proce(ures. 7=) Where .ou$( the nurse #ost $i/e$" fin( 0r. Ste$$ato;s +ita$ signs in a source'oriente( #e(ica$ recor( a. Graphic sheet &. ,iagnostic report c. nurse;s notes (. ,octor;s progress notes