Critical Thinking
The nurse is using critical thinking skills during the first phase of the nursing process. Which action indicates the nurse is in the first phase?
A. Completes a comprehensive database
B. Identifies pertinent nursing diagnoses
C. Intervenes based on priorities of client care
D. Determines whether outcomes have been achieved
Answer
A. Completes a comprehensive database
The nurse has just finished removing a client’s dressing per the medical provider’s order. What would be the nurse’s next step in the nursing process?
A. Planning
B. Diagnosis
C. Evaluation
D. Assessment
C: Evaluation
An adult patient presents to the emergency department and is treated for hypothermia. What risk factor should the patient be assessed for?
A. Tobacco use
B. Homelessness
C. High carbohydrate diet
D. History of chronic respiratory disorder
Answer
B. Homelessness
Which unit positive environmental factors will most likely assist the nurse’s ability to set care priorities effectively?
A. The unit is short-staffed with one nurse absent.
B. A client is waiting for discharge instructions.
C. The nurse receives multiple non-urgent phone calls during medication pass.
D. Policy for conducting hourly rounds
Answer
D: Policy for conducting hourly rounds
A nurse is attempting to minimize the risk of future infection for a post-surgical client who is about to be discharged. Which technique will the nurse teach the client to best achieve this goal?
A. Sanitizing of eating utensils
B. Medical asepsis handwashing
C. Wound care using surgical asepsis
D. Limiting visitors during flu season
Answer
B: Medical asepsis handwashing
The nurse is critically thinking about the order in which to carry out the client's care. Which of the following is the correct order of the nursing process?
A. Assessment, diagnosis, planning, implementation, evaluation
B. Planning, diagnosis, assessment, implementation, evaluation
C. Assessment, planning, diagnosis, implementation, evaluation
D. Assessment, diagnosis, implementation, planning, evaluation
Answer
A. Assessment, diagnosis, planning, implementation, evaluation
The nurse determines that all of the expected outcomes have been achieved. Based on this knowledge, what is the nurse’s next action?
A. Modify the plan of care.
B. Continue the plan of care.
C. Terminate the plan of care.
D. Reevaluate the plan of care.
Answer
C: Terminate the plan of care.
When the nurse discovers a patient on the floor, the patient states, “I fell out of bed”. The nurse assesses the patient and then places the patient back in bed. Which action should the nurse take next?
a. Do nothing, no harm has occurred.
b. Notify the health care provider.
c. Complete an incident report.
d. Reassess the patient.
Answer
B
The nurse is planning care at the start of a shift. Which environmental factors should be considered when analyzing cues and generating solutions for priority-setting?
A. Equipment malfunction is identified, and solutions are in place
B. A float nurse is receiving orientation due to unfamiliar high-acuity patients.
C. Each client has a clearly outlined care plan.
D. A unit-wide infection control audit has been posted for review.
Answer
B. A float nurse is receiving orientation due to unfamiliar high-acuity patients.
A veteran is being discharged after surgical amputation of both lower extremities a week ago. Which type of collaborative care is of most significance to aid in the client's recovery?
A. Physical therapy
B. Occupational therapy
C. Dietician
D. Respiratory therapist
Answer
A. Physical therapy
Because the evaluation of the client's nursing care plan reflects lack of progress toward the goal. What action will the nurse take?
A. Assume a more accessible goal
B. Revise the nursing interventions
C. Adopt a different nursing diagnosis
D. Create a new evaluation.
Anwer
B. Revise the nursing interventions
The nurse is caring for the client with the following expected client outcome: "The patient will maintain adequate oxygenation by discharge." Which outcome criterion best indicates the goal is met?
A. Client no longer requires oxygen.
B. Client coughing and deep breathing every 1 hour.
C. Client identifies signs and symptoms of recurrence of infection.
D. Client taking antibiotic as ordered.
Answer
A: Client no longer requires oxygen.
The nurse is admitting an older adult to the surgical unit. What intervention is necessary when determining the safe use of side rails for this client?
a. Explain to the client the need to call for assistance when side rails are up.
b. Discuss whether the client is accepting of having the side rails up.
c. Assess the client’s ability to effectively follow instructions.
d. Always keeping the bed in its lowest position to the floor.
Answer
C: Assess the client’s ability to effectively follow instructions.
Which of the following is a dependent (collaborative) nursing action?
A. Head to toe assessment
B. Measuring vital signs
C. Implementing physical therapy orders
D. Assisting with a bed bath
Answer
C: Implementing physical therapy orders
A nurse is preparing a client for a transfer to a step-down unit to monitor the cardiac function. To foster a client centered approach, which step should the nurse take first?
A. Develop cultural skills
B. Understand organization policies
C. Learning about the client's world view
D. Assess the client's understanding of the medical decision
Answer
D. Assess the client's understanding of the medical decision
A nurse is caring for a client with a nursing diagnosis of Constipation to pain medications. Which outcome is most appropriate for the nurse to include in the plan of care?
A. Client will have one soft, formed bowel movement by end of shift.
B. client will walk unassisted to bathroom by the end of shift.
C. Client will be offered laxatives or stool softeners this shift.
D. Client will not take any pain medications this shift.
Answer
A. Client will have one soft, formed bowel movement by end of shift.
The nurse is trying to determine why a client is not following the plan of care. Which client statements should the nurse identify as potential factors interfering with following the plan of care and causing the client to be noncompliant? (Select all that apply)
A. "I don't drive so I was unable to fill my prescription."
B. "I consult the list of low sodium foods when preparing meals."
C. "My social security check does not come until next week."
D. "I dropped the strips for my finger-stick blood glucose testing in the bath water."
E. "My daughter helps me with my range of motion exercises every morning and afternoon."
Correct
a, c, d
The nurse is caring for a client who suddenly becomes confused and tries to remove an intravenous (IV) infusion. Which priority action will the nurse take to minimize the client’s risk for injury?
a. Assess the client.
b. Gather restraint supplies.
c. Try alternatives to restraint.
d. Call the health care provider for a restraint order.
Answer
a. assess the client
Based on Maslow's Hierarchy of Needs, which nursing diagnosis should have the highest priority for any client?
A. Impaired Physical Mobility
B. Ineffective Breathing Pattern
C. Disturbed Sensory Perception
D. Self-Care Deficit
Answer
B. Ineffective Breathing Pattern
A client's daughter asks the nurse why her mother is being transferred to a long-term care facility. What is the nurse best response?
A. Your mother has an inoperable brain tumor
B. This client has been hospitalized for weeks
C. I will call the medical provider in charge of the client's care
D. I cannot talk to you right now about anything
Answer
C. I will call the medical provider in charge of your mother's care
Question: A nurse is caring for a group of clients. Which client will the nurse see first?
A. A client who has just returned from outside "for a smoke" who needs a temperature taken
B. A postoperative client whose blood pressure dropped from 128/70 to 90/60
C. A 27-year-old male client whose blood pressure went from 124/70 to 130/74
D. An older adult with a temperature of 96.2F
Answer
B. A postoperative client whose blood pressure dropped from 128/70 to 90/60
Which of the following client goal is written correctly according to the SMART format for the nursing process?
a. "The client will maintain an oxygen saturation level less than 95% on room air within 48 hours of initiating airway clearance interventions."
b. "The client will use of the incentive spirometer 10 times per hour"
c. "The client will verbalize 3 methods to reduce the risk of respiratory infection by end of teaching session today."
d. "The client will consume at least 75% of each meal
Answer
C: "The client will verbalize 3 methods to reduce the risk of respiratory infection by end of teaching session today."
A client is admitted and is placed on fall precautions. The nurse teaches the client and family about fall precautions. Which action will the nurse take in accordance with hospital policy?
A. Check on the client once a shift.
B. Encourage visitors in the early evening.
C. Place all four side rails in the “up” position.
D. Keep the client on fall risk until discharge.
Answer
D: Keep the client on fall risk until discharge.
Which of these findings in a plan of care should the registered nurse revise because it lacks the characteristic of critical thinking and the nursing process?
A. Nurse's assumptions about hospital discharge
B. Identification of five different nursing diagnoses
C. Client's reactions to diagnostic testing
D. Documentation of client's ability to cope with loss
Answer
A. Nurse's assumptions about hospital discharge
Which of the following statements reflects a client's acceptance of the discharge home with family?
A. "I need risk management to get involved with my case due to my fall."
B. "I hope my discharge goes well."
C. "I need to contact my family to let them know I am leaving in one hour."
D. "I think I need to speak to the doctor about staying an extra day."
Answer
C. "I need to contact my family to let them know I am leaving in one hour."