Fundamentals of Nursing NCLEX RN Exam Practice Q&A Set 5 | 75 Questions
1. 1. Question
Once a nurse assesses a client’s condition and identifies
... [Show More] appropriate nursing diagnoses, a:
o A. Plan is developed for nursing care.
o B. Physical assessment begins.
o C. List of priorities is determined.
o D. Review of the assessment is conducted with other team members.
Incorrect
Correct Answer: A. Plan is developed for nursing care.
The planning stage is where goals and outcomes are formulated that directly impact patient care based on EDP guidelines. These patient-specific goals and the attainment of such assist in ensuring a positive outcome. Nursing care plans are essential in this phase of goal setting.
• Option B: Assessment is the first step and involves critical thinking skills and data collection; subjective and objective. Subjective data involves verbal statements from the patient or caregiver. Objective data is measurable, tangible data such as vital signs, intake and output, and height and weight.
• Option C: A nursing diagnosis encompasses Maslow’s Hierarchy of Needs and helps to prioritize and plan care based on patient-centered outcomes. In 1943, Abraham Maslow developed a hierarchy based on basic fundamental needs innate for all individuals.
• Option D: Data may come from the patient directly or from primary caregivers who may or may not be direct relation family members. Friends can play a role in data collection. Electronic health records may populate data and assist in assessment.
2. 2. Question
Planning is a category of nursing behaviors in which:
• A. The nurse determines the health care needed for the client.
• B. The physician determines the plan of care for the client.
• C. Client-centered goals and expected outcomes are established.
• D. The client determines the care needed.
Incorrect
Correct Answer: C. Client-centered goals and expected outcomes are established.
The planning stage is where goals and outcomes are formulated that directly impact patient care based on EDP guidelines. These patient-specific goals and the attainment of such assist in ensuring a positive outcome.
• Option A: Nursing care plans are essential in this phase of goal setting. Care plans provide a course of direction for personalized care tailored to an individual’s unique needs. Overall condition and comorbid conditions play a role in the construction of a care plan.
• Option B: As explored by Salmond and Echevarria, healthcare is changing, and the traditional roles of nurses are transforming to meet the demands of this new healthcare environment. Nurses are in a position to promote change and impact patient delivery care models in the future.
• Option D: Care plans enhance communication, documentation, reimbursement, and continuity of care across the healthcare continuum. Critical thinking skills will play a vital role as nurses develop plans of care for these patient populations with multiple comorbidities and embrace this challenging healthcare arena.
3. 3. Question
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:
• A. Physician
• B. Non-Emergent, non-life-threatening needs
• C. Future well-being.
• D. Urgency of problems
Incorrect
Correct Answer: D. Urgency of problems
Triage of patients involves looking for signs of serious illness or injury. These emergency signs are connected to the Airway – Breathing – Circulation/Consciousness – Dehydration and are easily remembered as ABCD. If the client does not have any emergency signs, the health worker proceeds to assess the client for priority conditions. This should not take more than a few seconds. Some of these signs will have been noticed during the ABCD triage and others need to be rechecked.
• Option A: All clinical staff involved in the care of the sick should be prepared to carry out a rapid assessment to identify the few clients who are severely ill and require emergency treatment.
• Option B: Triage is the process of rapidly examining sick children when they first arrive in order to place them in one of the following categories: those with EMERGENCY SIGNS who require immediate emergency treatment; those with PRIORITY SIGNS who should be given priority in the queue so they can be rapidly assessed and treated without delay; and those who have no emergency or priority signs and are NON-URGENT cases. These clients can wait their turn in the queue for assessment and treatment. The majority of sick clients will be non-urgent and will not require emergency treatment.
• Option C: Ideally, all clients should be checked on their arrival by a person who is trained to assess how ill they are. This person decides whether the client will be seen immediately and receive life-saving treatment, or will be seen soon, or can safely wait for his or her turn to be examined.
4. 4. Question
A client-centered goal is a specific and measurable behavior or response that reflects a client’s:
• A. Desire for specific health care interventions.
• B. Highest possible level of wellness and independence in function.
• C. Physician’s goal for the specific client.
• D. Response when compared to another client with a similar problem.
Incorrect
Correct Answer: B. Highest possible level of wellness and independence in function.
Client-centered practices facilitate the development of strong therapeutic relationships and enable care providers to understand how to maximize clients’ strengths and minimize challenges in achieving treatment and recovery goals.
• Option A: Care providers negotiate between clients’ decisions and ongoing risk assessments. The care plan reflects safe practices and promotes interventions that minimize or reduce potential harms to the client.
• Option C: Client-centred care empowers clients, promoting autonomy, rights, voice, and self-determination in the treatment planning and recovery process and supports care plans that are developed in collaboration with clients, and allows clients to express their self-identified needs and choices.
• Option D: Client-centred care is about treating clients as they want to be treated, with knowledge about and respect for their values and personal priorities. Health care providers who take the time to get to know their clients can provide care that better addresses the needs of clients and improves their quality of care.
5. 5. Question
For clients to participate in goal setting, they should be:
• A. Alert and have some degree of independence.
• B. Ambulatory and mobile.
• C. Able to speak and write.
• D. Able to read and write.
Incorrect
Correct Answer: A. Alert and have some degree of independence.
Goal setting in nursing provides direction for planning nursing interventions and evaluating patient progress. The purpose of goal setting in nursing is to enable the patient and nurse to determine when the problem has been resolved and help motivate the patient and the nurse by providing a sense of achievement.
• Option B: In light of the potential benefits of patient participation in goal setting, a study by Baker, Rice, Zimmerman, Marshak, et. al. believes the following are needed: (1) patient and therapist education regarding the potential advantages of participation, (2) the enhancement of patient readiness to assume greater responsibility in their care, and (3) the development of models for use in achieving patient participation.
• Option C: Patient and therapist education is needed regarding methods for patient participation during initial goal-setting activities. In a study by Baker, Rice, Zimmerman, Marshak, et. al., the therapists stated that they believed that it is important to include patients in goal-setting activities and that outcomes will be improved if patients participate. Patients also indicated that participation is important to them.
• Option D: Patient participation in goal setting is emphasized in order to enhance patient management and the effectiveness of treatment. Participation should improve outcomes and could be used to identify benefits that may result from the treatment. These benefits include greater goal attainment, increased patient satisfaction, gains in function, better adherence to treatment regimens, decreased depression in patients, and reduced burnout rates among physical therapists.
6. 6. Question
The nurse writes an expected outcome statement in measurable terms. An example is:
• A. Client will have less pain.
• B. Client will be pain-free.
• C. Client will report pain acuity less than 4 on a scale of 0-10.
• D. Client will take pain medication every 4 hours around the clock.
Incorrect
Correct Answer: C. Client will report pain acuity less than 4 on a scale of 0-10.
When developing goals for patients, the nurse needs to look at several factors. Think back to the SMART goal criteria. In order to be specific, nurses focus on questions like ‘What is the problem? What is the response desired?’ To make it measurable, ‘How will the client look or behave if the healthy response is achieved? What can I see, hear, measure, observe?’
• Option A: One way to help nurses remember how to write goals is to make sure they are SMART. SMART goals are Specific, Measurable, Action-Oriented, Realistic, and Timely. ‘Specific’ refers to who, what, when, where, and why. ‘Measurable’ means that you can actually measure and evaluate the progress of that goal in a concrete way. ‘Action-oriented’ means there are actions that can be taken to reach the goal. ‘Realistic’ includes the ability to work on the goal, having the resources, attitudes, abilities, and skills to reach this goal, and how realistic it is to come to fruition. Finally, ‘Timely’ means that there is an end time frame or date at which the goal is going to be evaluated.
• Option B: Goal setting occurs in the third phase of the process, planning. Is the goal for nursing care to heal patients? To help them get better? To help them get well? While these are certainly at the forefront of nurses’ minds, how do you evaluate these statements? What if the definition of wellness is different from one person to another? This is why nursing goal statements that are patient-centered and measurable are so important.
• Option D: Considering action-oriented, ‘Are there steps and nursing interventions needed to reach that goal? Is this a realistic outcome for the patient? Have we considered all of the factors involved, including the client’s capabilities and limitations? Does the patient have what he or she needs to reach that goal?’ And finally, ‘Is it timely? When do we expect the goal to be reached?’
7. 7. Question
As goals, outcomes, and interventions are developed, the nurse must:
• A. Be in charge of all care and planning for the client.
• B. Be aware of and committed to accepted standards of practice from nursing and other disciples.
• C. Not change the plan of care for the client.
• D. Be in control of all interventions for the client.
Incorrect
Correct Answer: B. Be aware of and committed to accepted standards of practice from nursing and other disciples.
Whenever a healthcare provider intervenes or implements care, they must reassess or evaluate to ensure the desired outcome has been met. Reassessment may frequently be needed depending upon overall patient condition. The plan of care may be adapted based on new assessment data.
• Option A: Patients’ participation in decision-making in health care and treatment is not a new area, but currently it has become a political necessity in many countries and health care systems around the world. Emphasizing the importance of participation in the decision-making process motivates the service provider and the health care team to promote participation of patients in treatment decision-making.
• Option C: A review of some literature reveals that participation of patients in health care has been associated with improved treatment outcomes. Moreover, this participation causes improved control of diabetes, better physical functioning in rheumatic diseases, enhanced patients’ compliance with secondary preventive actions, and improvement in health of patients with myocardial infarction.
• Option D: With enhanced patient participation, and considering patients as equal partners in healthcare decision making patients are encouraged to actively participate in their own treatment process and follow their treatment plan and thus a better health maintenance service would be provided.
8. 8. Question
When establishing realistic goals, the nurse:
• A. Bases the goals on the nurse’s personal knowledge.
• B. Knows the resources of the health care facility, family, and the client.
• C. Must have a client who is physically and emotionally stable.
• D. Must have the client’s cooperation. [Show Less]