Nursing Process
1. A nurse makes a home-care visit for a client who had a total hip replacement 1 week ago. During which of the 5 steps in the nursing process does the nurse determine whether outcomes of care are achieved?
1. Implementation
2. Evaluation
3. Planning
4. Analysis
2. evaluation.
2. When considering the nursing process, the word "observe" is to "assess" as the word "explore" is to which of the following words?
1. Plan
2. Analyze
3. Evaluate
4. Implement
2. analyze.
4. Which word best describes the role of the nurse when using the nursing process to meet the needs of the client holistically?
1. Teacher
2. Advocate
3. Surrogate
4. Counselor
2. Advocate
5. Which word is most closely associated with scientific principles?
1. Data
2. Problem
3. Rationale
4. Evaluation.
3. rationale.
7. A nurse teaches a client to use visualization to cope with chronic pain. Which step of the nursing process is associated with this nursing intervention?
1. Planning
2. Analysis
3. Evaluation
4. Implementation
4. Implementation
10. Which should the nurse do during the evaluation step of the nursing process?
1. Set the time frames for goals.
2. Revise a plan of care.
3. Determine priorities.
4. Establish outcomes.
2. Revise a plan of care
11. A client is admitted to a postop surgical unit after having abdominal surgery. During which step of the nursing process does the nurse determine which actions are required to meet the needs of this client?
1. Implementation
2. Assessment
3.Planning
4. Analysis
3. Planning
12. Which information supports the appropriateness of a nursing diagnosis?
1. Defining characteristics
2. Planned interventions
3. Diagnostic statement
4. Setting goals/outcomes.
1. Defining characteristics
13. Which is the primary goal of the assessment phase of the nursing process?
1. Build trust
2. Collect data
3. Establish goals
4. Validate the medical diagnosis.
2. Collect data
14. Which most directly influences the planning step of the nursing process.
1. Related factors
2. Diagnostic label
3. Secondary factors
4. Medical diagnosis
1. Related factors
3. Which statement is R/T the concept that is central to the nursing process?
1. It is dynamic rather than static.
2. It focuses on the role of the nurse.
3. It moves from the simple to the complex.
4. It is based on the client's medical problem.
1. the dynamic rather than static.
15. A nurse collects information about a client. Which should the nurse do next?
1.plan nursing interventions
2. Write client-centered goals.
3. Formulate nursing diagnosis
4. Determine significance of the data.
4. Determine the significance
16. When 2 nursing diagnosis appear closely related, which should the nurse do first to determine which diagnosis most accurately reflects the needs of the client?
1. Reassess the client
2. Examine the R/T factors
3. Analyze the secondary to factors
4. Review the defining characteristics
4. Review the defining characteristics
17. Which is the primary reason why a nurse performs a physical assessment of a newly admitted client?
1. Identify if the client is at risk for falls.
2. Ensure that the client's skin is totally intact.
3. Identify important information about the client.
4. Establish a therapeutic relationship with the client.
3. Identify important information about the client.
18. A nurse evaluates a client's response to a nebulizer treatment. To which aspect of the nursing process is this evaluation most directly related?
1. Goal
2. Problem
3. Etiology
4. Implementation
1. Goal
6. A pebble dropped into a pond causes ripples on the surface of the water. Which part of the nursing diagnosis is directly R/T this concept?
1. Defining Characteristics
2. Outcome criteria
3. Etiology.
4. Goal
3. Etiology.
9. A nurse is caring for a client with a fever. Which is a well-designed goal for this client?
1. The client will have a lower temperature.
2. The client will be taught how to take an accurate temperature.
3. The client will maintain fluid intake adequate to prevent hydration.
4. The client will be given aspirin every 8 hours whenever necessary.
3. The client will maintain fluid intake adequate to prevent dehydration.
19. A nurse concludes that a client's elevated temperature, pulse, and respirations are significant. Which step of the nursing process is being used when the nurse comes to this conclusion?
1. Implementation
2. Assessment
3. Evaluation
4. Analysis
2. Assessment
20. when the nurse considers the nursing process, the word "identify" is to "recognize" as the word "do" is to which of the following words?
1. Implement
2. Evaluate
3. Analyze
4. Plan
1. Implement
21. A nurse is collecting subjective data associated with a client's anxiety. Which assessment method should be used to collect this information?
1. Observing
2. Inspection
3. Auscultation
4. Interviewing
4. Interviewing
35. The nurse assess a client and collects a variety of data. identify the human response that is subjective data.
1. Nausea
2. Jaundice
3. Ecchymosis
4. Diaphoresis
5. Hypotension
1. Nausea
8. A nurse is caring for several clients. Which nursing action reflects the assessment step of the nursing process?
1. Taking a client's apical pulse rate every 2 hours after the client is admitted for an episode of chest pain.
2. Scheduling a client's fluid intake over 12 hours when the client has had a fluid restriction.
3. Examining a client for injury after a fall in the bathroom.
4. Obtaining a client's respiratory rate after a nebulizer treatment.
3. Examining a client for injury after a fall in the bathroom.
25. Which human response identified by the nurse is an example of objective data? SATA
1. Irregular radial pulse of 50 bpm
2. Wheezing on expiration
3. Temp of 99 degrees F.
4. Bradypnea
5. Vomiting
is 1-2-3-4-5
26. Place the following statements that reflect the analysis step of the nursing process in order in which they should be implemented.
1. Cluster data
2. Identify conclusions
3. Analyze clustered data
4. Communicate conclusion to other health team members.
5. Identify when additional data are needed to further validate clustered data.
1. Cluster data,3. Analyze clustered data. 5. Identify when additional data are needed to further validate clustered data. 3. Interpret clustered data. 2. Identify conclusions. 4. Communicate conclusion to other health team members.
28. The nurse is caring for a newly admitted client. Which actions are part of the Assessment phase?
Select all that apply.
1. Interview the client about current symptoms.
2. Measure the client's blood pressure and temperature.
3. Identify the client's priority nursing diagnosis.
4. Review the client's laboratory results.
5. Develop expected outcomes for the client.
1. Interview the client about current symptoms.
2. Measure the client's blood pressure and temperature.