Nursig proccess
NAME THE STEPS OF THE NURSING PROCESS
ADPIE
assessment
diagnosis
planning
implementation
evaluation
The nurse is laboratory blood results will expect to observe which cation in the most abundance?
a. Sodium
b. Chloride
c. Potassium
d. Magnesium
a. Sodium
A parent calls the school nurse with questions regarding the recent school vision screening. Snellen chart examination revealed 20/60 for both eyes. Which response by the nurse is the best regarding the eye examination results?
a. Your child needs to see an ophthalmologist.
b. Your child is suffering from strabismus.
c. Your child may have presbyopia.
d. Your child has cataracts.
a. Your child needs to see an ophthalmologist.
When monitoring a patient who is taking hydrochlorothiazide, the nurse notes that which drug is most likely to cause a severe interaction with the diuretic?
a. Digoxin
B. Penicillin
C. Potassium supplements
D. Aspirin
a. Digoxin
Which nurse who was influential in the development of nursing in North America is regarded as the founder of American nursing?
A. Clara Barton
B. Lillian Wald
C. Lavina Dock
D. Florence Nightingale
D. Florence Nightingale
The nurse prescribes strategies and alternatives to attain expected outcome. Which standard of nursing practice is the nurse following?
a. Assessment
b. Diagnosis
c. Planning
d. Implementation
c. Planning
The nurse is assessing a patient and notes crackles in the lung bases and neck vein distention. Which action will the nurse take first?
a. Offer calcium-rich foods.
b. Administer diuretic.
c. Raise head of bed.
d. Increase fluids.
c. Raise head of bed.
The nurse is examining a female presenting with vaginal discharge. Which position will the nurse place the patient for proper examination?
a. Sitting
b. Lithotomy
c. Knee-chest
d. Dorsal recumbent
b. Lithotomy
The nurse will monitor a patient for signs and symptoms of hyperkalemia if the patient is taking which of these diuretics?
a. Hydrochlorothiazide
b. Furosemide
c. Acetazolamide
d. Spironolactone
d. Spironolactone
pH normal values
7.34-7.45
Which action indicates the nurse is using the nursing process in patient care?
a. Generates nursing knowledge for use in nursing practice.
b. Conceptualizes an aspect of nursing to predict nursing care.
c. Develops nursing care as a specific, distinct phenomenon.
d. Delivers nursing care using a systematic approach
d. Delivers nursing care using a systematic approach
diagnosis name of patient with sodium level of 155
hypernatreamia
During a routine physical examination of a 70-year-old patient, a blowing sound is auscultated over the carotid artery. Which assessment finding will the nurse report to the health care provider?
a. Bruit
b. Thrill
c. Phlebitis
d. Right-sided heart failure
a. Bruit
A patient is suffering from tendonitis of the knee. The nurse is reviewing the patient's
medication administration record and recognizes that which adjuvant medication is most
appropriate for this type of pain?
a. Antidepressant
b. Anticonvulsant
c. Corticosteroid
d. Local anesthesia
c. Corticosteroid
SBAR
The nurse is using critical thinking skills during thefirst phase of thenursing process. Which action indicates thenurse is in thefirst phase?
a. Completes a comprehensive database.
b. Identifies pertinent nursing diagnoses.
c. Intervenes based on priorities of patient care.
d. Determines whether outcomes have been achieved
a. Completes a comprehensive database.
When assessing a patient for signs of fluid overload, the nurse would expect to observe:
A.bounding pulse
B.flat neck veins
C.poor skin turgor
D.vesicular
A.bounding pulse
A nurse is caring for a group of patients. Which patient will the nurse see first?
a. An adult with an S4 heart sound
b. A young adult with an S3 heart sound
c. An adult with vesicular lung sounds in the lung periphery
d. A young adult with bronchovesicular breath sounds between the scapula posteriorly
a. An adult with an S4 heart sound
An older-adult patient is visiting the clinic after a fall during the night. The nurse obtains information on what medications the patient takes. Which medication most likely contributed to the patient's fall?
a. Melatonin
b. L-tryptophan
c. Benzodiazepine
d. Iron supplement
c. Benzodiazepine
A nurse is administering a pain medication to a patient. In addition to checking his identification bracelet, the nurse correctly verifies his identity by:
A. Asking the patient his name
B. Reading the patient's name on the sign over the bed
C. Asking the patient's roommate to verify his name
D. Asking, "Are you Mr. Brown?"
A. Asking the patient his name
The nurse is reviewing a patient’s database for significant changes and discovers that the patient has not voided in over 8 hours. The patient’s kidney function lab results are abnormal, and the patient’s oral intake has significantly decreased since previous shifts. Which step of the nursing process should the nurse proceed to after this review?
a. Diagnosis
b. Planning
c. Implementation
d. Evaluation
a. Diagnosis
Joshua is receiving furosemide and Digoxin, which laboratory data would be the most important to assess in planning the care for the client?
A.sodium
B. magnesium
C.potassium
d. calcium
C. potassium
A nurse is assessing a patient’s cranial nerve IX. Which items does the nurse gather before conducting the assessment? (Select all that apply.)
a. Vial of sugar
b. Snellen chart
c. Tongue blade
d. Ophthalmoscope
e. Lemon applicator
A, C, E
DM is a 62 year old African-American man who has had poorly controlled hypertension for the past 10 years, and now presents with signs of ankle edema, a low GFR and a serum creatinine of 2.5 mg/dL. The most effective drug for producing a diuresis and fall in blood pressure in DM is:
A. amlodipine
B. furosemide
C. hydrochlorothiazide
D. losartan
B. furosemide
A nurse has volunteered to give influenza immunizations at a local clinic. What level of care is the nurse demonstrating?
A. Tertiary
B. Secondary
C. Primary
D. Promotive
C. Primary