Planning Nursing Care

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Question 1

Free

Multiple Choice

The nurse completes a thorough assessment of a patient and analyzes the data to identify nursing diagnoses. Which step will the nurse take next in the nursing process?

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Assessment

Diagnosis

Planning

Implementation

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Question 2

Free

Multiple Choice

A patient's plan of care includes the goal of increasing mobility this shift. As the patient is ambulating to the bathroom at the beginning of the shift, the patient suffers a fall. Which initial action will the nurse take next to revise the plan of care?

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Consult physical therapy.

Establish a new plan of care.

Set new priorities for the patient.

Assess the patient.

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Question 3

Free

Multiple Choice

Which information indicates a nurse has a good understanding of a goal?

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It is a statement describing the patient's accomplishments without a time restriction.

It is a realistic statement predicting any negative responses to treatments.

It is a broad statement describing a desired change in a patient's behavior.

It is a measurable change in a patient's physical state.

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Question 4

Free

Multiple Choice

A nurse is developing a care plan for a patient with a pelvic fracture on bed rest. Which goal statement is realistic for the nurse to assign to this patient?

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Patient will increase activity level this shift.

Patient will turn side to back to side with assistance every 2 hours.

Patient will use the walker correctly to ambulate to the bathroom as needed.

Patient will use a sliding board correctly to transfer to the bedside commode as needed.

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Question 5

Free

Multiple Choice

The following statements are on a patient's nursing care plan. Which statement will the nurse use as an outcome for a goal of care?

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The patient will verbalize a decreased pain level less than 3 on a 0 to 10 scale by the end of this shift.

The patient will demonstrate increased tolerance to activity over the next month.

The patient will understand needed dietary changes by discharge.

The patient will demonstrate increased mobility in 2 days.

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Question 6

Multiple Choice

A charge nurse is reviewing outcome statements using the SMART approach. Which patient outcome statement will the charge nurse praise to the new nurse?

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The patient will ambulate in hallways.

The nurse will monitor the patient's heart rhythm continuously this shift.

The patient will feed self at all mealtimes today without reports of shortness of breath.

The nurse will administer pain medication every 4 hours to keep the patient free from discomfort.

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Question 7

Multiple Choice

A nursing assessment for a patient with a spinal cord injury leads to several pertinent nursing diagnoses. Which nursing diagnosis is the highest priority for this patient?

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Risk for impaired skin integrity

Risk for infection

Spiritual distress

Reflex urinary incontinence

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Question 8

Multiple Choice

The new nurse is caring for six patients in this shift. After completing their assessments, the nurse asks where to begin in developing care plans for these patients. Which statement is an appropriate suggestion by another nurse?

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"Choose all the interventions and perform them in order of time needed for each one."

"Make sure you identify the scientific rationale for each intervention first."

"Decide on goals and outcomes you have chosen for the patients."

"Begin with the highest priority diagnoses, then select appropriate interventions."

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Question 9

Multiple Choice

A patient's son decides to stay at the bedside while his father is confused. When developing the plan of care for this patient, what should the nurse do?

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Individualize the care plan only according to the patient's needs.

Request that the son leave at bedtime, so the patient can rest.

Suggest that a female member of the family stay with the patient.

Involve the son in the plan of care as much as possible.

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Question 10

Multiple Choice

A nurse is caring for a patient with a nursing diagnosis of Constipation related to slowed gastrointestinal motility secondary to pain medications. Which outcome is most appropriate for the nurse to include in the plan of care?

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Patient will have one soft, formed bowel movement by end of shift.

Patient will walk unassisted to bathroom by the end of shift.

Patient will be offered laxatives or stool softeners this shift.

Patient will not take any pain medications this shift.

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Question 11

Multiple Choice

The nurse performs an intervention for a collaborative problem. Which type of intervention did the nurse perform?

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Dependent

Independent

Interdependent

Physician-initiated

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Question 12

Multiple Choice

A registered nurse administers pain medication to a patient suffering from fractured ribs. Which type of nursing intervention is this nurse implementing?

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Collaborative

Independent

Interdependent

Dependent

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Question 13

Multiple Choice

Which action indicates the nurse is using a PICOT question to improve care for a patient?

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Practices nursing based on the evidence presented in court

Implements interventions based on scientific research

Uses standardized care plans for all patients.

Plans care based on tradition

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Question 14

Multiple Choice

A nurse is developing a care plan. Which intervention is most appropriate for the nursing diagnostic statement Risk for loneliness related to impaired verbal communication?

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Provide the patient with a writing board each shift.

Obtain an interpreter for the patient as soon as possible.

Assist the patient in performing swallowing exercises each shift.

Ask the family to provide a sitter to remain with the patient at all times.

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Question 15

Multiple Choice

A nurse is completing a care plan. Which intervention is most appropriate for the nursing diagnostic statement Impaired skin integrity related to shearing forces?

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Administer pain medication every 4 hours as needed.

Turn the patient every 2 hours, even hours.

Monitor vital signs, especially rhythm.

Keep the bed side rails up at all times.

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Question 16

Multiple Choice

A patient has reduced muscle strength following a left-sided stroke and is at risk for falling. Which intervention is most appropriate for the nursing diagnostic statement Risk for falls?

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Keep all side rails down at all times.

Encourage patient to remain in bed most of the shift.

Place patient in room away from the nurses' station if possible.

Assist patient into and out of bed every 4 hours or as tolerated.

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Question 17

Multiple Choice

Which action will the nurse take after the plan of care for a patient is developed?

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Place the original copy in the chart, so it cannot be tampered with or revised.

Communicate the plan to all health care professionals involved in the patient's care.

File the plan of care in the administration office for legal examination.

Send the plan of care to quality assurance for review.

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Question 18

Multiple Choice

A hospital's wound nurse consultant made a recommendation for nurses on the unit about how to care for the patient's dressing changes. Which action should the nurses take next?

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Include dressing change instructions and frequency in the care plan.

Assume that the wound nurse will perform all dressing changes.

Request that the health care provider look at the wound.

Encourage the patient to perform the dressing changes.

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Question 19

Multiple Choice

A nurse is planning care for a patient with a nursing diagnosis of Impaired skin integrity. The patient needs many nursing interventions, including a dressing change, several intravenous antibiotics, and a walk. Which factors does the nurse consider when prioritizing interventions? (Select all that apply.)

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Rank all the patient's nursing diagnoses in order of priority.

Do not change priorities once they've been established.

Set priorities based solely on physiological factors.

Consider time as an influencing factor.

Utilize critical thinking.

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Question 20

Multiple Choice

A nurse is teaching the staff about the benefits of Nursing Outcomes Classification. Which information should the nurse include in the teaching session? (Select all that apply.)

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Includes seven domains for level 1

Uses an easy 3-point Likert scale

Adds objectivity to judging a patient's progress

Allows choice in which interventions to choose

Measures nursing care on a national and international level

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