NURSING RN NUR104 M5 quiz Questions and Answers
1
0 / 5 pts
A pre-operative client states “I do not know what to expect after surgery.” How
... [Show More] should the RN respond? Ask the healthcare provider to answer the client’s questions.
Assess the client’s knowledge of the planned procedure. Inform the charge nurse of the client’s knowledge deficit. Educate the client about what to expect after the procedure.
Question 2
5 / 5 pts
An immobile client reports a new, red, sore area on their heel. What assessment will the RN complete first?
Assess the client’s nutritional status. Assess the client’s self-care ability. Assess the client’s comfort level.
Assess the client’s skin surfaces.
Rationale: If a client reports possible skin integrity concerns, a full skin assessment should be conducted to determine if there are other areas of concern, first. Assessing nutrition, self-care ability and comfort are important, but the most important.
Question 3
5 / 5 pts
What is the primary reason the RN evaluates a client’s progress toward the identified outcome? It identifies whether the healthcare provider’s actions were effective.
It identifies if interventions were effective in meeting an outcome. It identifies what additional problems the client might have.
It identifies if the nurse-client relationship can be terminated.
Rationale: The evaluation step of the nursing process helps the RN identify whether the interventions implemented by the RN have caused the outcome to be met.
Question 4
5 / 5 pts
Which deliberate, systematic problem-solving approach is used by the RN to meet a person’s health care needs?
Critical thinking
Nursing process Reflective thinking Concept mapping
Rationale: The nursing process is a problem - solving approach to meet client and nursing needs. Components are assessment, diagnosis, planning, implementation, and evaluation. Critical thinking is a process of insightful thinking based on knowledge that displays a willingness to ask questions when developing solutions. Critical thinking enhances clinical decisions by the RN. RN’s use critical thinking for decisions related to the nursing process
IncorrectQuestion 5
0 / 5 pts
Which action by the RN demonstrates critical thinking for a client that has a NANDA-I nursing diagnosis of Deficient fluid volume?
Documenting a client’s intake and output for the previous 8 hours. Evaluating a client’s intake and output for the previous 24 hours. Adding additional fluids to the client’s tray to increase fluid intake.
Assessing a client’s understanding of fluid intake and providing education.
Rationale: Critical thinking requires the RN to use disciplined reasoning to discover a problem and formulate a solution. For a client who is fluid volume deficient, assessing their intake and understanding, combined with intervening with education signals higher level thinking, or critical thinking, required of the RN.
PartialQuestion 6
1.25 / 5 pts
What are characteristics of nursing diagnoses? Select all that apply.
They are prioritized based on Maslow’s Hierarchy.
They are focused on body systems and disease processes.
They are formed by recognizing patterns or data clusters.
They are developed by NANDA International (NANDA-I).
They are based on data obtained from client assessments.
Rationale: Nursing diagnoses are prioritized based on Maslow’s Hierarchy, formed by recognizing patterns of data, developed by NANDA lnternational, and are based on data obtained from a client assessment.
Question 7
5 / 5 pts
Which type of nursing diagnosis is used when there is a potential for a client problem to develop? Actual nursing diagnosis
Risk nursing diagnosis Wellness nursing diagnosis Syndrome nursing diagnosis
Rationale/ Feedback: A risk nursing diagnosis describes a problem that is likely to develop in a vulnerable client if the nurse and the client does not intervene. An actual nursing diagnosis the problem exists at the time of the assessment. A wellness nursing diagnosis identifies a health status but not a health problem. Syndrome nursing diagnosis represents a collection of nursing diagnoses that usually occur together.
IncorrectQuestion 8
0 / 5 pts
Which components are necessary for an actual nursing diagnosis statement? Select all that apply.
Diagnosis Interventions
Symptom Outcomes
Etiology
Rationale: The nursing diagnosis identified and approved by NANDA-I, includes a related to factor (etiology) and includes the defining characteristics (symptoms/as evidenced by).
Question 9
5 / 5 pts
Which component of a 3- part NANDA-I nursing diagnosis statement identifies the cause of the client problem?
Etiology Definition Symptom Intervention
Rationale: The etiology is the cause or the contributing factor believed to be at the root of the problem. The definition explains what the nursing diagnosis means. The symptom is the evidence the problem exists. The nursing interventions are individualized actions needed to achieve the desired outcome.
Question 10
5 / 5 pts
An RN has developed a plan of care for a client. Which nursing diagnostic statement requires revision? Fear related to spouse’s death as evidenced by client stating, “I don’t know how I will go on”.
Impaired comfort related to prolonged hospital stay as evidenced by irritability and asking to go home.
Dysfunctional gastrointestinal motility related to absence of bowel sounds as evidenced by immobility. Impaired bed mobility related to weakness as evidenced by client’s inability to change position in bed.
Rationale: A nursing diagnosis statement contains a nursing diagnosis, physiologic factor (related factor) and subjective/objective data (as evidence by).
Question 11
5 / 5 pts
Which statement by the student nurse indicates additional teaching about patient outcomes is necessary?
“The outcome includes a time estimate for attainment.”
“Outcomes must be realistic, measurable and culturally appropriate.”
“The outcome identifies what the nurse will do for the patient.” “Outcomes are used to modify the plan based on patient response.”
Rationale: Outcomes are patient-centered, must be observable, measurable, realistic, and culturally appropriate. The expected outcome also serves as a guide for selecting nursing interventions as well as a basis for evaluating and modifying the plan of care.
Question 12
5 / 5 pts
Which patient outcome is correctly written?
Patient will list dangers of smoking and will stop smoking.
Patient will have clear lung sounds in bilateral upper and lower lobes within 3 days. Patient will understand how to bathe her baby before being discharged home.
Patient will be offered 60 mL of fluid every 2 hours while awake.
Rationale: Outcomes are client-centered, must be observable, measurable, realistic, and culturally appropriate. The expected outcome also serves as a guide for selecting nursing interventions as well as a basis for evaluating and modifying the plan of care.
IncorrectQuestion 13
0 / 5 pts
Which is a characteristic of nursing interventions? Interventions are based on the nursing workload. Interventions identify a priority problem for the patient.
Interventions are consistent with standards of care. Interventions always require a medical order.
Rationale: Nursing interventions are actions that are consistent with standards of care and will assist the client to achieve the expected outcome.
IncorrectQuestion 14
0 / 5 pts
The RN develops a plan of care and includes which of the following as a dependent intervention? Reposition every 2 hours
Educate client
Administer medication Perform range of motion
Rationale: Dependent interventions require a provider order, and the order is carried out by the nurse. Independent nursing interventions do not require a health care provider order.
PartialQuestion 15
2.5 / 5 pts
After the interventions are completed, it is essential for the RN to complete which actions as part of the nursing process? Select all that apply.
Encourage the client to continue interventions.
Evaluate the effectiveness of the interventions.
Document that the interventions were completed. Develop new interventions for the client.
Delegate at least some interventions.
Rationale: After completing interventions, the RN needs to evaluate the effectiveness of the interventions in meeting the outcome. Also documentation is considered a last step in implementation and is appropriate.
Question 16
5 / 5 pts
Which action puts the RN at risk for legal liability when supervising health care staff? Collaborating with team members to plan care and share decision making.
Educating the nursing assistive personnel (NAP) to provide client teaching. Delegating tasks to staff based on job description and experience with task. Completing hourly rounds to ensure delegated tasks were completed.
Rationale: The 5 rights of delegation include right task, circumstance, person, communication, and supervision. The nursing assistive personnel (NAP) may not provide client teaching. It is out of their scope of practice.
Question 17
5 / 5 pts
Which activity can be delegated to the nursing assistive personal (NAP) by the RN?
Complete vital signs for a client prior to the RN’s medication administration. Assess the condition of the client’s abdominal dressing.
Determine if the client requires a laxative for constipation.
Assist the client to take medications if the RN brings to the bedside.
Rationale: The RN may not delegate assessments to the NAP but may delegate tasks if the NAP is qualified to complete the task.
Question 18
5 / 5 pts
The RN is caring for clients with the following NANDA-I nursing diagnoses. According to Maslow’s Hierarchy, which diagnoses relate to physiological needs? Select all that apply.
Risk for shock Social isolation
Readiness for enhanced hope
Constipation
Impaired gas exchange
Rationale: According to Maslow’s hierarchy, physiological needs are the highest priority, followed by safety, love and belonging, esteem and self-actualization.
Question 19
5 / 5 pts
Which outcome statement, written by the student RN, requires additional teaching?
The client will demonstrate how to correctly administer an insulin injection during this visit.
The client will increase understanding of their disease process by the end of this visit.
The client will ambulate to the nurse’s station and back with a steady gait by the end of the week. The client will have clear lung sounds over upper and lower lobes by the end of this week.
Rationale: Outcomes must be client specific, measurable and have a time frame for completion.
Question 20
5 / 5 pts
The RN has developed a plan of care for a client with Impaired skin integrity and the nursing assistive personnel (NAP) has turned and positioned the client every 2 hours. Which is the priority activity for the RN during the evaluation phase of the nursing process?
Evaluate the client for other problems.
Evaluate the client’s skin surfaces. Evaluate the NAP’s repositioning skill. Evaluate the client’s ability to position self.
Rationale: In the evaluation phase of the nursing process the RN determines whether the interventions were effective in meeting the planned outcome. The plan can be modified if the interventions were not
effective or more interventions can be added to the plan if supplementation is needed to achieve the outcome. [Show Less]