Medical, Pharmaceutical & Health Sciences
NursingFundamentals NursingNursing Active LearningPractice Set 6
NursingFundamentals NursingNursing Active LearningPractice Set 6Planning
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- Nursing, Theory, and Professional PracticeValues, Beliefs, and CaringCommunicationCritical Thinking in NursingIntroduction to the Nursing ProcessAssessmentNursing DiagnosisPlanningImplementation and EvaluationDocumentation, Electronic Health Records, and ReportingEthical and Legal ConsiderationsLeadership and ManagementEvidence-Based Practice and Nursing ResearchHealth Literacy and Patient EducationNursing InformaticsHealth and WellnessHuman Development: Conception through AdolescenceHuman Development Young Adult to Older AdultVital SignsHealth History and Physical AssessmentEthnicity and Cultural AssessmentSpiritual HealthPublic Health, Community Base, and Home Health CareHuman SexualitySafetyAsepsis and Infection ControlHygiene and Personal CareActivity, Immobility, and Safe MovementSkin Integrity and Wound CareNutritionCognitive and Sensory AlterationsStress and CopingSleepDiagnostic TestingMedication AdministrationPain ManagementPerioperative Nursing CareOxygenation and Tissue PerfusionFluid, Electrolytes, and Acid-Base BalanceBowel EliminationUrinary EliminationDeath and Loss
Question 1
Free
Multiple Choice
The nurse is caring for a patient who has undergone abdominal surgery. The patient stated prior to surgery that "I don't think I'll be able to handle this if I get a colostomy. I wouldn't know how to manage it." There is no "next of kin" listed in the patient's record. The patient is complaining of severe surgical pain. The nurse is correct when addressing which nursing diagnosis first?
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Pain
Alteration in body image
Knowledge deficit
Risk for falls
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Question 2
Free
Multiple Choice
Setting priorities among identified nursing diagnoses is the first step in the planning process. The nurse is responsible for:
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monitoring patient responses.
carrying out the physician's plan of care.
providing all interventions.
preventing interference from other disciplines.
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Question 3
Free
Multiple Choice
Which assessment made by the nurse should be addressed first?
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Reddened area to coccyx
Decreased urinary output
Shortness of breath
Drainage from surgical incision
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Question 4
Free
Multiple Choice
Which should the nurse address first?
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Pain
Hunger
Decreased self-esteem
Absence of pulse
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Question 5
Free
Multiple Choice
The nurse has a thorough understanding of the planning phase of the nursing process when stating:
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"Patients should be included in the planning process."
"Patient families should not interfere in the planning process."
"The planning process should focus on short-term goals only."
"Planning is the first phase of the nursing process."
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Question 6
Multiple Choice
Goals are broad statements of purpose that describe the aim of nursing care. As such, goals:
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are considered short term if achieved within a month of identification.
always have established time parameters, such as "long-term" or "short-term."
are mutually acceptable to the nurse, patient, and family.
can be vague to facilitate evaluation of achievement.
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Question 7
Multiple Choice
In developing the nursing care plan, the nurse creates goals:
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with the patient and possibly the family.
that the nurse wants the patient to achieve.
and actions needed to accomplish the goal.
that are aggressive to ensure success.
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Question 8
Multiple Choice
Which statement is correct regarding diversity considerations?
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The male gender may struggle less with health care terminology.
High numbers of minority populations do not understand health teachings.
Older adults have an easier time understanding health teachings because of life experience.
Disabilities have no impact on the development of patient care goals.
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Question 9
Multiple Choice
Which of the following is a correctly written example of a short-term goal?
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By attending the gym, the patient will lose 50 lb in 1 year.
In 6 months, patient will be able to ambulate 1 mile without shortness of breath.
Patient will be able to change his colostomy bag within 6 weeks of surgery.
With diet and exercise, the patient will lose 1 lb this week.
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Question 10
Multiple Choice
Which goal is written correctly for the nursing diagnosis of activity intolerance related to imbalance between oxygen supply and demand?
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Patient will walk 1 mile without shortness of breath.
Patient will ambulate 100 feet with no shortness of breath on third day after treatment.
Patient will climb stairs without shortness of breath by day 2 of hospital stay
Patient will tolerate activity.
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Question 11
Multiple Choice
The nurse recognizes which of the following as a barrier to achieving goals?
Choose correct answer/s
The effects of pain and/or clinical depression
Patient involvement in setting patient goals
Family involvement in setting patient goals
Realistic expectations of the patient's capabilities.
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Question 12
Multiple Choice
The nurse is caring for a patient who has had abdominal surgery but has developed a slight temperature. A patient-centered goal would be:
Choose correct answer/s
the patient's temperature will return to normal within 24 hours.
the nurse will medicate the patient for surgical pain every 4 hours.
skin integrity will be maintained until the patient is ambulatory.
the patient will ambulate 10 feet by post-op day 2.
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Question 13
Multiple Choice
An example of a measurable goal would be:
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"The patient will be able to lift 10 lb by the end of week one."
"The patient will be able to lift weights by the end of the week."
"The patient will be able to lift his normal weight amount."
"The patient will be able to life an acceptable amount of weight by week one."
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Question 14
Multiple Choice
The nurse is formulating the patient's care plan. In determining when to evaluate the patient's progress, the nurse is aware that evaluations:
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must be done at the end of every shift.
should be done at least every 24 hours.
depend on intervention and patient condition.
are always done at time of discharge.
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Question 15
Multiple Choice
The nurse knows that standardized care plans may be available and:
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need to be individualized for each patient.
are implemented without adjustment.
remove the need for nurse involvement.
do not require the use of nursing diagnoses.
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Question 16
Multiple Choice
Nursing interventions that originate from the physician or primary care provider orders are:
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dependent
independent
collaborative
Nursing Interventions Classifications
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Question 17
Multiple Choice
Medication administration is what type of nursing intervention?
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Independent
Dependent
Collaborative
Interdisciplinary
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Question 18
Multiple Choice
Dependent nursing interventions include:
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ordering heel protectors.
preadmission teaching.
medication reconciliation.
administer antipyretic medications as appropriate.
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Question 19
Multiple Choice
Physical therapy, home health care, and personal care are examples of:
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collaborative interventions.
dependent nursing interventions.
independent nursing interventions.
assessment data.
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Question 20
Multiple Choice
Discharge planning begins:
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the day before discharge.
upon admission.
prior to admission.
day of discharge.
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