The nursing process guides client care in which of the following manners?
Select one:
a. It individualizes client care based on their priority nursing needs.
b. It provides a framework to systematically develop nursing policies.
c. It helps nurses to make decisions about which provider orders to implement.
d. It limits the number of client problems that the nurse manages at one time.
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Drag and drop the intervention according to its type.
Applying a specialized
Collaborative wound vac
Administering pain
Dependent medication
Elevating the head of the
Independent bed
Applying a specialized wound vac
Elevating the head of the bed
Administering pain medication
Question 3
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The nursing is planing care for a client and writes a goal and several outcome statements.
When writing SMART outcome statements the S stands for?
Select one:
a. Specific
b. Sensitive
c. Superficial
d. Subjective
Question 4
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The nurse is preparing to administer an enema to a client who has constipation. As the
nurse explains the procedure, the client states, "The doctor din't tell me I need an enema."
Which of the following nursing actions is most appropriate?
Select one:
a. Check the medical record to verify the order.
b. Inform the charge nurse that the client refused the enema.
c. Assure the client the enema is needed.
d. Explain to the client the provider ordered the enema.
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The nursing student is preparing for clinical and is applying nursing process to create a
concept map. How should the nursing define each component of a nursing diagnosis?
Drag and drop the correct definition to each element of a nursing diagnosis.
Precise definition of a
patient's response to health
Nursing Diagnosis problems within the
domain of nursing
Etiological or
Related Factor causative factor
Defining Characteristics Observable
assessment cues
Etiological or causative factor
Precise definition of a patient's response to health problems within the domain of nursing
Observable assessment cues
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The nurse is caring for a client and obtains the following data:
Label each finding as subjective or objective.
Answer 1Choose...SubjectiveObjective
Temperature 101.1 F
Answer 2Choose...SubjectiveObjective
Blood Pressure 120/80
Answer 3Choose...SubjectiveObjective
"Pain 6/10"
Answer 4Choose...SubjectiveObjective
Headache
Question 7
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The nursing student is completing clinical paperwork and has identified several relevant
nursing diagnosis problem statements. Which problem statement should be identified as
the priority for the client?
Select one:
a. Risk for Self-care Deficit
b. Pain
c. Imbalanced Nutrition: More than body requirements
d. Impaired Gas Exchange
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The nurse is caring for a client with an intravenous (IV) catheter. At the beginning of the
shift, the nurse asks if the patient feels pain when the site is palpated. This is an example
of:
Select one:
a. Prevention
b. Evaluation
c. Assessment
d. Planning
Question 9
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The nurse is preparing to conduct an admission assessment. Which of the following
questions by the nurse best promotes this discussion?
Select one:
a. "Why are you here today?"
b. "Do you want to tell me about your health problems?"
c. "Tell me about your medical issues?"
d. "What brought you to the hospital today?"
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The nurse formulates strategies and alternatives to attain expected outcomes. Which
phase of the nursing process is the nurse completing?
Select one:
a. Assessment
b. Implementation
c. Diagnosis
d. Planning
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A new nurse asks the preceptor to describe the primary purpose of evaluation. Which
statement made by the nursing preceptor is most accurate?
Select one:
a. “During evaluation, you determine when to downsize staffing on nursing units.”
b. “Evaluation eliminates unnecessary paperwork and care planning.”
c. “An evaluation helps you determine whether all nursing interventions were completed.”
d. “Nurses use evaluation to determine the effectiveness of nursing care.”
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The nurse is planning care for a newly admitted elderly client. The nurse identifies a
nursing diagnosis for the client. Which of the following is a correctly stated nursing
diagnosis?
Select one:
a. Impaired skin integrity related to decreased protein consumption as evidenced by decreased intake of
food and fluids, decreased mobility (patient needs assistance to get out of bed and uses a cane), dry
skin, and fatigue.
b. Impaired skin integrity related to thin skin and immobility
c. Impaired skin integrity related to impaired physical mobility as evidenced by decreased intake, dry
skin and decreased mobility.
d. Impaired skin integrity as evidenced by dermatitis and rash.
Question 13
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As the nurse bathes the client, he/she notes his skin color and integrity, his ability to
respond to simple directions, and his muscle tone. Which statement best describes why
continuing to collect data is important?
Select one:
a. It validates nursing patient outcome indicators.
b. It enables to nurse to revise the plan of care appropriately.
c. It is difficult to collect all necessary data upon admission.
d. It is required by the primary medical provider.
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The nursing student is providing care to clients during the clinical day. Which of the
following is the priority for the nursing student to implement?
Select one:
a. Apply ice to the knee
b. Administer oxygen
c. Bathe the client
d. Administer pain medication
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The nurse is completing a client's history and physical examination. Which information
should the nurse consider subjective data?
Select one:
a. Nausea
b. Cyanosis
c. Blood pressure
d. Bruising
Question 16
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A nurse is caring for a patient with a nursing diagnosis of Constipation related to slowed
gastrointestinal motility secondary to pain medications. Which outcome statement
is most appropriate for the nurse to include in the plan of care?
Select one:
a. Patient will have one soft, formed bowel movement each day.
b. Patient will not take any pain medications until he/she defecates.
c. Patient will walk unassisted to bathroom by the end of shift.
d. Patient will be offered laxatives or stool softeners this shift.
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The nursing student in the clinical setting is developing a concept map for a client. How
would the nursing student define each step of the nursing process?
Determine the
effectiveness of
Evaluation interventions.
Critically analyze data
Planning to determine priorities.
Collect and organize
Assessment data.
Providing client-
Implementation centered nursing care.
Collect and organize data.
Critically analyze data to determine priorities.
Providing client-centered nursing care.
Determine the effectiveness of interventions.
Question 18
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Nurses preform physical assessments by implementing specific techniques. Match each
technique with the appropriate example.
Answer 1Choose...Tap on an organPress on the abdomenLook at the skinListen to
Palpate lung sounds
Answer 2Choose...Tap on an organPress on the abdomenLook at the skinListen to
Percuss lung sounds
Answer 3Choose...Tap on an organPress on the abdomenLook at the skinListen to
Inspect lung sounds
Answer 4Choose...Tap on an organPress on the abdomenLook at the skinListen to
Auscultat
lung sounds
e
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The nursing student is writing goals and outcomes for a patient-specific concept map.
Which of the following is a goal?
Select one:
a. Patient will express fewer non-verbal signs of discomfort within 48 hours of surgery.
b. Patient will ambulate independently in 3 days.
c. Patient will walk with assistance from the bed to the chair three times a day on first post-operative
day.
d. Patient will ambulate 20 feet using a walker at least twice per day within 48 hours of surgery.
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The nurse is monitoring the client's progress on a new drug regimen. After administering
the first dose of the medication, the nurse documents the patient's therapeutic response to
the medication. Which phase of the nursing process is the nurse demonstrating?
Select one:
a. Evaluation
b. Nursing Diagnosis
c. Planning
d. Implementation
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A nurse is evaluating an expected outcome for a patient that states heart rate will be more
60 beats/min before 12/4. Which finding will alert the nurse that the goal has been met?
Select one:
a. Heart rate 62 beats/min on 12/3
b. Heart rate 78 beats/min on 12/4
c. Heart rate 45 beats/min on 12/4
d. Heart rate of 56 beats/min on 12/3
Question 22
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The nurse is providing care to a client. Which example of patient care is not the
responsibility of the nurse?
Select one:
a. Individualize plan of care for each client.
b. Monitor for changes in health status.
c. Promote safety and prevent harm.
d. Confirm the medical diagnosis.
Question 23
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The nurse administers a blood pressure medication. Forty-five minutes later the nurse
checks the patients blood pressure. This is an example of:
Select one:
a. Assessment
b. Planning
c. Prevention
d. Evaluation
Question 24
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The nurse administers the wrong medication to a client. Which of the following is the
priority action by the nurse?
Select one:
a. Call the medical provider.
b. Call pharmacy to report
c. Complete an incident report
d. Observe the client
Question 25
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The nursing student is creating a patient specific concept map for Mr. Jones. When
developing a problem-focused nursing diagnosis, which of the following is the problem
statement?
Select one:
a. Swelling
b. Impaired Physical Mobility
c. Incision Pain
d. Alteration in Fluid Volume
Question 26
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The nurse is receiving change-of-shift report. The nurse anticipates which of the following
activities first in delivering client care using the nursing process?
Select one:
a. Determine the effectiveness of interventions.
b. Critically analyze client data to determine priorities.
c. Collect and organize client data.
d. Set client-centered, measurable and realistic goals.
Question 27
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A nurse is implementing interventions for a group of patients. Which actions are nursing
interventions (independent interventions)? (Select all that apply.)
Select one or more:
a. Teach a patient medication side effects.
b. Transfer a patient to another room on the unit.
c. Prescribe antibiotics for a wound infection.
d. Reposition a patient who is on bed rest.
e. Order chest x-ray for suspected arm fracture.
Question 28
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Which of the following nurse is demonstrating the assessment stage of nursing process?
Select one:
a. The nurse who asks the client, "What happens when you get stung by a bee?"
b. The nurse who initiates isolation precautions as ordered by the medical provider.
c. The nurse who documents that pain medication was effective to relieve the client's pain.
d. The nurse who changes the bed linens when the client is incontinent of urine or stool.
Question 29
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A nurse is reviewing a patient’s care plan. Which of the following is an example of a nursing
intervention?
Select one:
a. The patient will ambulate at least 100 feet three times every shift using crutches correctly.
b. The patient was able to walk in the hallway twice every shift with crutches.
c. The patient is unable to bear weight on right lower extremity.
d. Impaired physical mobility related to inability to bear weight on right leg.
Question 30
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The nurse is planning care for a newly admitted client. Which of the following is not a
priority when planning care?
Select one:
a. Insurance
b. Culture
c. Age
d. Development
