1. The nurse who uses the nursing process will:
a. help reduce the obvious signs of discomfort.
b. help the patient adhere to the primary care
... [Show More] provider’s treatment protocol.
c. approach the patient’s disorder in a step-by-step method.
d. make all significant nursing care decisions involving patient care.
ANS: C
The nursing process is a collaborative process used throughout the patient’s stay. It is an organized method for identifying and meeting patient needs in a step-by-step manner.
DIF: Cognitive Level: Knowledge REF: p. 48 OBJ: Theory #1 TOP: Nursing Process KEY: Nursing Process Step: N/A MSC: NCLEX: N/A
2. A nurse will arrive at a nursing diagnosis through the nursing process step of:
a. planning.
b. evaluation.
c. research.
d. assessment.
ANS: D
As a result of the nursing assessmNenUtR, SaINnuGrTsBin.CgOdMiagnosis is established.
DIF: Cognitive Level: Comprehension REF: p. 50|Table 4-2
OBJ: Theory #2 TOP: Nursing Diagnosis KEY: Nursing Process Step: N/A MSC: NCLEX: N/A
3. In the collaborative process of delivering care based on the nursing process, the responsibility of the LPN/LVN is to:
a. collect data of health status.
b. select a nursing diagnosis.
c. organize data to help the RN evaluate patient progress.
d. prioritize nursing diagnoses for more effective care.
ANS: A
The LPN/LVN collects data of the patient’s health status to assist the RN in selecting a nursing diagnosis.
DIF: Cognitive Level: Comprehension REF: p. 49|Table 4-1
OBJ: Theory #2 TOP: Critical Thinking KEY: Nursing Process Step: N/A MSC: NCLEX: N/A
4. The participants of the planning stage of the nursing process during which the health goals are defined include:
a. the RN.
b. the health team led by the RN.
c. the health team, the patient, and the patient’s family.
d. the health team as directed by the physician.
ANS: C
The planning stage during which the health goals are defined are best shared by the entire health team, the patient, and the patient’s family for the optimum outcome.
DIF: Cognitive Level: Comprehension REF: p. 48 OBJ: Theory #1 TOP: Nursing Process KEY: Nursing Process Step: N/A MSC: NCLEX: N/A
5. When a resident in the nursing home complains of constipation, the nurse performs a digital rectal examination and finds a hard fecal mass. This is an example of:
a. implementation.
b. nursing diagnosis.
c. assessment.
d. evaluation.
ANS: C
The examination to confirm and affirm the complaint of constipation is an assessment.
DIF: Cognitive Level: Application REF: p. 48|Table 4-1 OBJ: Theory #1 TOP: Nursing Process
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
6. The nurse completing morning assessments on a patient who is sitting up in bed is told by the patient, “I’m having trouble breathNiUnRg—SINIGcTanB’.Ct OseMem to get enough air.” The best nursing
response is to:
a. notify the doctor as soon as he or she comes in later in the morning.
b. finish the vital signs for the assigned patients, and then notify the charge nurse.
c. reassure the patient, if his blood pressure and pulse are normal.
d. notify the charge nurse immediately of the patient’s statement.
ANS: B
The nurse should finish the assessment in order to confirm the complaint and inform the charge nurse.
DIF: Cognitive Level: Analysis REF: p. 50|Table 4-2
OBJ: Theory #1 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
7. The order in which the nursing process is approached is:
a. planning, assessment, implementation, nursing diagnosis, evaluation.
b. nursing diagnosis, evaluation, assessment, implementation, planning.
c. assessment, nursing diagnosis, planning, implementation, evaluation.
d. evaluation, nursing diagnosis, planning, implementation, assessment.
ANS: C
The order of assessment nursing diagnosis, planning, implementation, and evaluation sets up a basis for an organized approach to nursing care.
DIF: Cognitive Level: Knowledge REF: p. 49|Box 4-1
OBJ: Theory #1 TOP: Nursing Process KEY: Nursing Process Step: N/A MSC: NCLEX: N/A
8. Once the nursing plan has been initiated, the nursing care plan will:
a. stay in place until all nursing goals have been met.
b. change as the patient’s condition changes.
c. remain on the patient record to show progress.
d. be given to the patient for final approval.
ANS: B
The nursing care plan is always a work in progress and will change as the patient condition changes.
DIF: Cognitive Level: Comprehension REF: p. 50 OBJ: Theory #2 TOP: Nursing Process KEY: Nursing Process Step: N/A MSC: NCLEX: N/A
9. When a patient states, “I can’t walk very well,” the first problem-solving step would be to:
a. consider alternatives such as a wheelchair or walker.
b. find out what the problem is, such as weakness or poor balance.
c. choose the alternative with the best chance of success.
d. consider the outcomes of the choices, such as danger of falling with a walker.
ANS: B
Defining the problem clearly assists in the interventions to reduce the problem.
DIF: Cognitive Level: Analysis REF: p. 50 OBJ: Theory #5
TOP: Problem Solving
NURSINKGETYB:.CNOMursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
10. A student nurse can begin to develop critical thinking skills by means of:
a. working with a more experienced nurse.
b. questioning every statement made by instructors to be sure of its correctness.
c. memorizing class notes for tests and studying all night for big tests.
d. listening attentively and focusing on the speaker’s words and meaning.
ANS: D
Critical thinking involves foundation skills such as effective reading and writing and attentive listening.
DIF: Cognitive Level: Comprehension REF: p. 50 OBJ: Theory #7 TOP: Critical Thinking KEY: Nursing Process Step: N/A MSC: NCLEX: N/A
11. When a nurse prioritizes the patient care, consideration is given to:
a. completing assessments before mid-shift.
b. considering situations that may result in an alteration of health.
c. assuming all health care activities for a group of patients.
d. identifying who can assist with the aspect of care.
ANS: B
Priority setting includes addressing health endangering situations and physiological needs first.
DIF: Cognitive Level: Comprehension REF: p. 53 OBJ: Theory #9 TOP: Priority Setting KEY: Nursing Process Step: N/A MSC: NCLEX: N/A
12. When the nurse checks to see whether a patient has had relief 45 minutes after administering pain medication, the nurse is performing a(n):
a. nursing diagnosis.
b. implementation.
c. assessment.
d. evaluation.
ANS: D
Evaluation is the step in which the nurse determines whether the plan and interventions are effective or need to be modified.
DIF: Cognitive Level: Comprehension REF: p. 49|Box 4-1 OBJ: Theory #2 TOP: Nursing Process
KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
13. The activity that is an implementation in the nursing care is:
a. checking the assigned patient’s blood pressure, pulse, and respiration.
b. changing the patient’s surgical dressing.
c. asking the patient to demonstrate how to give himself medication after teaching him.
d. discussing the patient with other team members to establish a care plan.
NURSINGTB.COM
ANS: B
Changing a dressing that is soiled is a nursing intervention performed to meet a patient’s need. Checking vital signs is assessment. Demonstrating medication administration is evaluation.
Discussing the patient with other team members is planning.
DIF: Cognitive Level: Comprehension REF: p. 49|Box 4-1
OBJ: Theory #2 TOP: Implementation KEY: Nursing Process Step: N/A MSC: NCLEX: N/A
14. Constant nursing assessments and evaluations of the patient will most likely result in:
a. the nursing care plan changing to reflect appropriate priorities.
b. small changes in the patient condition being overlooked.
c. cluttered and confusing documentation.
d. impeded problem solving.
ANS: A
Continued assessment and evaluation are necessary; reprioritizing and reorganizing activities occur in response to the patient’s changing condition.
DIF: Cognitive Level: Application REF: p. 50 OBJ: Theory #1 TOP: Nursing Process KEY: Nursing Process Step: N/A MSC: NCLEX: N/A
15. The effect of using a scientific problem-solving approach in nursing care will cause decision making to be:
a. slowed down considerably by the multiple steps.
b. rigid and nonpatient oriented.
c. improved nursing care outcomes.
d. unrelated to the nursing process.
ANS: C
A scientific problem-solving approach is most likely to result in positive patient outcomes.
DIF: Cognitive Level: Comprehension REF: p. 50 OBJ: Theory #3 TOP: Problem Solving KEY: Nursing Process Step: Planning MSC: NCLEX: N/A
16. An emergency room nurse will give first priority to the patient with the most critical need, which is the patient who:
a. is bleeding from a chin laceration.
b. complains of a productive cough.
c. has a fever of 102F.
d. complains of severe chest pain.
ANS: D
Because the chance of a bad outcome is highest for the patient with chest pain, it is most appropriate to assess this patient first.
DIF: Cognitive Level: Analysis REF: p. 53 OBJ: Theory #8 TOP: Critical Thinking KEY: Nursing Process Step: Assessment
MSC: NCLEX: N/A
NURSINGTB.COM
MULTIPLE RESPONSE
1. Activities considered to be aspects of the implementation step of the nursing process are: (Select all that apply.)
a. documentation of care given.
b. assembly of supplies.
c. analysis of data gathered.
d. modification of aspects of the plan.
e. evaluation of the patient response.
ANS: A, B
Documentation of care and assembly of supplies are nursing interventions performed during the implementation step of the nursing process.
DIF: Cognitive Level: Comprehension REF: p. 49|Table 4-1
OBJ: Theory #2 TOP: Nursing Process KEY: Nursing Process Step: N/A MSC: NCLEX: N/A
2. Descriptions of the activities involved in the nursing diagnosis step of the nursing process are: (Select all that apply.)
a. determination of potential health problems.
b. clustering of related assessments.
c. sharing of information with the patient and physician.
d. determination of desired outcomes.
e. evaluation of probable outcomes.
ANS: A, B
During the nursing diagnosis step, assessment data are analyzed and clustered to determine health problems, and appropriate nursing diagnoses are selected.
DIF: Cognitive Level: Comprehension REF: p. 49|Table 4-1
OBJ: Theory #1 TOP: Nursing Process KEY: Nursing Process Step: N/A MSC: NCLEX: N/A
3. Which of the following items could be the responsibility of the LPN/LVN for a patient’s plan of care? (Select all that apply.)
a. Collect data.
b. Perform nursing interventions.
c. Initiate the plan of care.
d. Assist the RN with evaluation of the patient’s response to nursing interventions.
e. Document nursing care.
ANS: A, B, D
Registered nurses are officially responsible for the initiation of nursing care plans for each patient, but the LPN/LVN assists with each part of the care plan. The LPN/LVN is often responsible for data collection to assist the RN with the assessment phase.
DIF: Cognitive Level: Comprehension REF: p. 49|Table 4-1
OBJ: Theory #2 TOP: Nursing Process KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
NURSINGTB.COM
COMPLETION
1. When the nurse constructs a nursing approach after careful judgment and sound reasoning, the nurse has used a system of .
ANS:
critical thinking
Critical thinking is a concept in which decisions are made using solidly based judgments and reasoning. [Show Less]