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
What is 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
What is 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
What is 2. Advocate
5. Which word is most closely associated with scientific principles?
1. Data
2. Problem
3. Rationale
4. Evaluation.
What is 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
What is 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.
What is 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
What is 3. Planning
12. Which information supports the appropriateness of a nursing diagnosis?
1. Defining characteristics
2. Planned interventions
3. Diagnostic statement
4. Related risk factors.
What is 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.
What is 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
What is 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.
What is 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.
What is 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
What is 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.
What is 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
What is 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
What is 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.
What is 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
What is 4. Analysis
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
What is 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
What is 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
What is 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.
What is 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?
1. Irregular radial pulse of 50 bpm
2. Wheezing on expiration
3. Temp of 99 degrees F.
4. Bradypnea
5. Vomiting
What 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. Interpret clustered data
4. Communicate conclusion to other health team members.
5. Identify when additional data are needed to further validate clustered data.
What is 1. Cluster 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. Which nursing action reflects an activity associated with the analysis step of the nursing process?
1. Formulating a plan of care
2. Identifying the client's potential risks.
3. Grouping data into meaningful relationships.
4. designing ways to minimize a client's stressors.
5. Making decisions about the effectiveness of client care.
What is 2. Identifying the client's potential risks and 3. Grouping data into meaningful relationships.