MULTIPLE lCHOICE
1. The lnurse lcompletes lan ladmission ldatabase land lexplains lthat lthe lplan lof lcare land ldischarge lgoals lwill lbe ldeveloped
... [Show More] lwith lthe lpatient’s linput. lThe lpatient lstates, l“How lis lthis ldifferent lfrom lwhat lthe ldoctor ldoes?” lWhich lresponse lwould lbe lmost lappropriate lfor lthe lnurse lto lmake?
a. “The lrole lof lthe lnurse lis lto ladminister lmedications land lother ltreatments lprescribed lby lyour ldoctor.”
b. “The lnurse’s ljob lis lto lhelp lthe ldoctor lby lcollecting linformation land lcommunicating lany lproblems lthat loccur.” c. “Nurses lperform lmany lof lthe lsame lprocedures las lthe ldoctor, lbut lnurses lare lwith lthe lpatients lfor la llonger ltime lthan lthe ldoctor.”
d. “In laddition lto lcaring lfor lyou lwhile lyou lare lsick, lthe lnurses lwill lassist lyou lto ldevelop lan lindividualized lplan lto lmaintain lyour lhealth.”
ANS: lD
This lresponse lis lconsistent lwith lthe lAmerican lNurses lAssociation l(ANA) ldefinition lof lnursing, lwhich ldescribes lthe lrole lof lnurses lin lpromoting lhealth. lThe lother lresponses ldescribe lsome lof lthe ldependent land lcollaborative lfunctions lof lthe lnursing lrole lbut ldo lnot laccurately ldescribe lthe lnurse’s lrole lin lthe lhealth lcare lsystem.
DIF: Cognitive lLevel: lUnderstand l(comprehension) REF: l3
TOP: lNursing lProcess: lImplementation MSC: lNCLEX: lSafe land lEffective lCare lEnvironment
2. The lnurse ldescribes lto la lstudent lnurse lhow lto luse levidence-based lpractice lguidelines lwhen lcaring lfor lpatients. lWhich lstatement, lif lmade lby lthe lnurse, lwould lbe lthe lmost laccurate?
a. “Inferences lfrom lclinical lresearch lstudies lare lused las la lguide.”
b. “Patient lcare lis lbased lon lclinical ljudgment, lexperience, land ltraditions.”
c. “Data lare levaluated lto lshow lthat lthe lpatient loutcomes lare lconsistently lmet.”
d. “Recommendations lare lbased lon lresearch, lclinical lexpertise, land lpatient lpreferences.”
ANS: lD
Evidence-based lpractice l(EBP) lis lthe luse lof lthe lbest lresearch-based levidence lcombined lwith lclinician lexpertise. lClinical ljudgment lbased lon lthe lnurse’s lclinical lexperience lis lpart lof lEBP, lbut lclinical ldecision lmaking lshould lalso lincorporate lcurrent lresearch land lresearch-based lguidelines. lEvaluation lof lpatient loutcomes lis limportant, lbut linterventions lshould lbe lbased lon lresearch lfrom lrandomized lcontrol lstudies lwith la llarge lnumber lof lsubjects.
DIF: Cognitive lLevel: lRemember l(knowledge) REF: l15
TOP: lNursing lProcess: lPlanning MSC: lNCLEX: lSafe land lEffective lCare lEnvironment
3. The lnurse lteaches la lstudent lnurse labout lhow lto lapply lthe lnursing lprocess lwhen lproviding lpatient lcare. lWhich lstatement, lif lmade lby lthe lstudent lnurse, lindicates lthat lteaching lwas lsuccessful?
a. “The lnursing lprocess lis la lscientific-based lmethod lof ldiagnosing lthe lpatient’s lhealth lcare lproblems.”
b. “The lnursing lprocess lis la lproblem-solving ltool lused lto lidentify land ltreat lpatients’
health lcare lneeds.”
c. “The lnursing lprocess lis lused lprimarily lto lexplain lnursing linterventions lto lother lhealth lcare lprofessionals.”
d. “The lnursing lprocess lis lbased lon lnursing ltheory lthat lincorporates lthe lbiopsychosocial lnature lof lhumans.”
ANS: lB
The lnursing lprocess lis la lproblem-solving lapproach lto lthe lidentification land ltreatment lof lpatients’ lproblems. lDiagnosis lis lonly lone lphase lof lthe lnursing lprocess. lThe lprimary luse lof lthe lnursing lprocess lis lin lpatient lcare, lnot lto lestablish lnursing ltheory lor lexplain lnursing linterventions lto lother lhealth lcare lprofessionals.
DIF: Cognitive lLevel: lUnderstand l(comprehension) REF: l5
TOP: lNursing lProcess: lImplementation MSC: lNCLEX: lSafe land lEffective lCare lEnvironment
4. A lpatient lhas lbeen ladmitted lto lthe lhospital lfor lsurgery land ltells lthe lnurse, l“I ldo lnot lfeel lcomfortable lleaving lmy lchildren lwith lmy lparents.” lWhich laction lshould lthe lnurse ltake lnext?
a. Reassure lthe lpatient lthat lthese lfeelings lare lcommon lfor lparents.
b. Have lthe lpatient lcall lthe lchildren lto lensure lthat lthey lare ldoing lwell.
c. Gather lmore ldata labout lthe lpatient’s lfeelings labout lthe lchild-care larrangements.
d. Call lthe lpatient’s lparents lto ldetermine lwhether ladequate lchild lcare lis lbeing lprovided.
ANS: lC
Because la lcomplete lassessment lis lnecessary lin lorder lto lidentify la lproblem land lchoose lan lappropriate lintervention, lthe lnurse’s lfirst laction lshould lbe lto lobtain lmore linformation. lThe lother lactions lmay lbe lappropriate, lbut lmore lassessment lis lneeded lbefore lthe lbest lintervention lcan lbe lchosen.
DIF: Cognitive lLevel: lApply l(application) REF: 6
OBJ: l l lSpecial lQuestions: lPrioritization TOP: lNursing lProcess: lAssessment lMSC: lNCLEX: lPsychosocial lIntegrity
5. A lpatient lwho lis lparalyzed lon lthe lleft lside lof lthe lbody lafter la lstroke ldevelops la lpressure lulcer lon lthe lleft lhip. lWhich lnursing ldiagnosis lis lmost lappropriate?
a. Impaired lphysical lmobility lrelated lto lleft-sided lparalysis
b. Risk lfor limpaired ltissue lintegrity lrelated lto lleft-sided lweakness
c. Impaired lskin lintegrity lrelated lto laltered lcirculation land lpressure
d. Ineffective ltissue lperfusion lrelated lto linability lto lmove lindependently
ANS: lC
The lpatient’s lmajor lproblem lis lthe limpaired lskin lintegrity las ldemonstrated lby lthe lpresence lof la lpressure lulcer. lThe lnurse lis lable lto ltreat lthe lcause lof laltered lcirculation land lpressure lby lfrequently lrepositioning lthe lpatient. lAlthough lleft-sided lweakness lis la lproblem lfor lthe lpatient, lthe lnurse lcannot ltreat lthe lweakness. lThe l“risk lfor” ldiagnosis lis lnot lappropriate lfor lthis lpatient, lwho lalready lhas limpaired ltissue lintegrity. lThe lpatient ldoes lhave lineffective ltissue lperfusion, lbut lthe limpaired lskin lintegrity ldiagnosis lindicates lmore lclearly lwhat lthe lhealth lproblem lis.
DIF: Cognitive lLevel: lApply l(application) REF: 7
TOP: lNursing lProcess: lDiagnosis MSC: lNCLEX: lPhysiological lIntegrity
6. A lpatient lwith la lbacterial linfection lhas la lnursing ldiagnosis lof ldeficient lfluid lvolume lrelated lto lexcessive ldiaphoresis. lWhich loutcome lwould lthe lnurse lrecognize las lappropriate lfor lthis lpatient?
a. Patient lhas la lbalanced lintake land loutput.
b. Patient’s lbedding lis lchanged lwhen lit lbecomes ldamp.
c. Patient lunderstands lthe lneed lfor lincreased lfluid lintake.
d. Patient’s lskin lremains lcool land ldry lthroughout lhospitalization.
ANS: lA
This lstatement lgives lmeasurable ldata lshowing lresolution lof lthe lproblem lof ldeficient lfluid lvolume lthat lwas lidentified lin lthe lnursing ldiagnosis lstatement. lThe lother lstatements lwould lnot lindicate lthat lthe lproblem lof ldeficient lfluid lvolume lwas lresolved.
DIF: Cognitive lLevel: lApply l(application) REF: 7
TOP: lNursing lProcess: lPlanning MSC: lNCLEX: lPhysiological lIntegrity
7. A lnurse lasks lthe lpatient lif lpain lwas lrelieved lafter lreceiving lmedication. lWhat lis lthe lpurpose lof lthe levaluation lphase lof lthe lnursing lprocess?
a. To ldetermine lif linterventions lhave lbeen leffective lin lmeeting lpatient loutcomes
b. To ldocument lthe lnursing lcare lplan lin lthe lprogress lnotes lof lthe lmedical lrecord
c. To ldecide lwhether lthe lpatient’s lhealth lproblems lhave lbeen lcompletely lresolved
d. To lestablish lif lthe lpatient lagrees lthat lthe lnursing lcare lprovided lwas lsatisfactory
ANS: lA
Evaluation lconsists lof ldetermining lwhether lthe ldesired lpatient loutcomes lhave lbeen lmet land lwhether lthe lnursing linterventions lwere lappropriate. lThe lother lresponses ldo lnot ldescribe lthe levaluation lphase.
DIF: l l lCognitive lLevel: lUnderstand l(comprehension) REF: l5
TOP: lNursing lProcess: lEvaluation MSC: lNCLEX: lSafe land lEffective lCare lEnvironment
8. The lnurse linterviews la lpatient lwhile lcompleting lthe lhealth lhistory land lphysical lexamination. lWhat lis lthe lpurpose lof lthe lassessment lphase lof lthe lnursing lprocess?
a. To lteach linterventions lthat lrelieve lhealth lproblems
b. To luse lpatient ldata lto levaluate lpatient lcare loutcomes
c. To lobtain ldata lwith lwhich lto ldiagnose lpatient lproblems
d. To lhelp lthe lpatient lidentify lrealistic loutcomes lfor lhealth lproblems
ANS: lC
During lthe lassessment lphase, lthe lnurse lgathers linformation labout lthe lpatient lto ldiagnose lpatient lproblems. lThe lother lresponses lare lexamples lof lthe lplanning, lintervention, land levaluation lphases lof lthe lnursing lprocess.
DIF: l l lCognitive lLevel: lUnderstand l(comprehension) REF: l5
TOP: lNursing lProcess: lAssessment MSC: lNCLEX: lSafe land lEffective lCare lEnvironment
9. Which lnursing ldiagnosis lstatement lis lwritten lcorrectly?
a. Altered ltissue lperfusion lrelated lto lheart lfailure
b. Risk lfor limpaired ltissue lintegrity lrelated lto lsacral lredness
c. Ineffective lcoping lrelated lto lresponse lto lbiopsy ltest lresults
d. Altered lurinary lelimination lrelated lto lurinary ltract linfection
ANS: lC
This ldiagnosis lstatement lincludes la lNANDA lnursing ldiagnosis land lan letiology lthat ldescribes la lpatient’s lresponse lto la lhealth lproblem lthat lcan lbe ltreated lby lnursing. lThe luse lof la lmedical ldiagnosis las lan letiology l(as lin lthe lresponses lbeginning l“Altered ltissue lperfusion” land l“Altered lurinary lelimination”) lis lnot lappropriate. lThe lresponse lbeginning l“Risk lfor limpaired ltissue lintegrity” luses lthe ldefining lcharacteristic las lthe letiology.
DIF: Cognitive lLevel: lUnderstand l(comprehension) REF: l7
TOP: lNursing lProcess: lDiagnosis MSC: lNCLEX: lSafe land lEffective lCare lEnvironment
10. The lnurse ladmits la lpatient lto lthe lhospital land ldevelops la lplan lof lcare. lWhat lcomponents lshould lthe lnurse linclude lin lthe lnursing ldiagnosis lstatement?
a. The lproblem land lthe lsuggested lpatient lgoals lor loutcomes
b. The lproblem lwith lpossible lcauses land lthe lplanned linterventions
c. The lproblem, lits lcause, land lobjective ldata lthat lsupport lthe lproblem
d. The lproblem lwith lan letiology land lthe lsigns land lsymptoms lof lthe lproblem
ANS: lD
When lwriting lnursing ldiagnoses, lthis lformat lshould lbe lused: lproblem, letiology, land lsigns land lsymptoms. lThe lsubjective, las lwell las lobjective, ldata lshould lbe lincluded lin lthe ldefining lcharacteristics. lInterventions land loutcomes lare lnot lincluded lin lthe lnursing ldiagnosis lstatement.
DIF: Cognitive lLevel: lRemember l(knowledge) REF: l7
TOP: lNursing lProcess: lDiagnosis MSC: lNCLEX: lSafe land lEffective lCare lEnvironment
11. A lnurse lis lcaring lfor la lpatient lwith lheart lfailure. lWhich ltask lis lappropriate lfor lthe lnurse lto ldelegate lto lexperienced lunlicensed lassistive lpersonnel l(UAP)?
a. Monitor lfor lshortness lof lbreath lor lfatigue lafter lambulation.
b. Instruct lthe lpatient labout lthe lneed lto lalternate lactivity land lrest.
c. Obtain lthe lpatient’s lblood lpressure land lpulse lrate lafter lambulation.
d. Determine lwhether lthe lpatient lis lready lto lincrease lthe lactivity llevel.
ANS: lC
UAP leducation lincludes laccurate lvital lsign lmeasurement. lAssessment land lpatient lteaching lrequire lregistered lnurse leducation land lscope lof lpractice land lcannot lbe ldelegated.
DIF: Cognitive lLevel: lApply l(application) REF: 11
OBJ: l l lSpecial lQuestions: lDelegation TOP: lNursing lProcess: lPlanning lMSC: lNCLEX: lSafe land lEffective lCare lEnvironment
12. A lnurse lis lcaring lfor la lgroup lof lpatients lon lthe lmedical-surgical lunit lwith lthe lhelp lof lone lfloat lregistered lnurse l(RN), lone lunlicensed lassistive lpersonnel l(UAP), land lone llicensed lpractical/vocational lnurse l(LPN/LVN). lWhich lassignment, lif ldelegated lby lthe lnurse, lwould lbe linappropriate?
a. Measurement lof la lpatient’s lurine loutput lby lUAP
b. Administration lof loral lmedications lby lLPN/LVN
c. Check lfor lthe lpresence lof lbowel lsounds land lflatulence lby lUAP
d. Care lof la lpatient lwith ldiabetes lby lRN lwho lusually lworks lon lthe lpediatric lunit
ANS: lC
Assessment lrequires lRN leducation land lscope lof lpractice land lcannot lbe ldelegated lto lan lLPN/LVN lor lUAP. lThe lother lassignments lmade lby lthe lRN lare lappropriate.
DIF: Cognitive lLevel: lApply l(application) REF: 11
OBJ: l l lSpecial lQuestions: lDelegation TOP: lNursing lProcess: lPlanning lMSC: lNCLEX: lSafe land lEffective lCare lEnvironment
13. Which ltask lis lappropriate lfor lthe lnurse lto ldelegate lto la llicensed lpractical/vocational lnurse l(LPN/LVN)?
a. Complete lthe linitial ladmission lassessment land lplan lof lcare.
b. Document lteaching lcompleted lbefore la ldiagnostic lprocedure.
c. Instruct la lpatient labout llow-fat, lreduced lsodium ldietary lrestrictions.
d. Obtain lbedside lblood lglucose lon la lpatient lbefore linsulin ladministration.
ANS: lD
The leducation land lscope lof lpractice lof lthe lLPN/LVN linclude lactivities lsuch las lobtaining lglucose ltesting lusing la lfinger lstick. lPatient lteaching land lthe linitial lassessment land ldevelopment lof lthe lplan lof lcare lare lnursing lactions lthat lrequire lregistered lnurse leducation land lscope lof lpractice.
DIF: Cognitive lLevel: lApply l(application) REF: 11
OBJ: l l lSpecial lQuestions: lDelegation TOP: lNursing lProcess: lPlanning lMSC: lNCLEX: lSafe land lEffective lCare lEnvironment
14. A lnurse lis lassigned las la lcase lmanager lfor la lhospitalized lpatient lwith la lspinal lcord linjury. lThe lpatient lcan lexpect lthe lnurse lfunctioning lin lthis lrole lto lperform lwhich lactivity?
a. Care lfor lthe lpatient lduring lhospitalization lfor lthe linjuries.
b. Assist lthe lpatient lwith lhome lcare lactivities lduring lrecovery.
c. Determine lwhat lmedical lcare lthe lpatient lneeds lfor loptimal lrehabilitation.
d. Coordinate lthe lservices lthat lthe lpatient lreceives lin lthe lhospital land lat lhome.
ANS: lD
The lrole lof lthe lcase lmanager lis lto lcoordinate lthe lpatient’s lcare lthrough lmultiple lsettings land llevels lof lcare lto lallow lthe lmaximal lpatient lbenefit lat lthe lleast lcost. lThe lcase lmanager ldoes lnot lprovide ldirect lcare lin leither lthe lacute lor lhome lsetting. lThe lcase lmanager lcoordinates land ladvocates lfor lcare lbut ldoes lnot ldetermine lwhat lmedical lcare lis lneeded; lthat [Show Less]