- The student nurse correctly identifies which as a medical diagnosis ? (Select all that apply . )
- Acute pain
- Pneumonia
- Inability to tolerate activity
- Inability to clear airway
- Neuropathy , secondary to type 2 diabetes mellitus
2,5
A patient is admitted to a hospital for coronary artery bypass graft surgery . His wound continues to drain, and when he is discharged , home health nurses will visit to continue to care for him. Who is most likely responsible for coordinating the patient’s discharge plans?
1. RN team leader
2. Social worker
3. Case manager
4. Physician
3
- Which patient problem statement includes all appropriate components of an actual patient problem statement? ( Select all that apply.)
- Inefficient Oxygenation
- Potential Complication : Gastric Bleeding, related to gastric ulcer
- Fearfulness , related to separation from support system as evidenced by statements of being scared, pallor, and increased respirations
- Potential for Falling, related to confusion as evidenced by calling nurse by name of aunt
- Anxiousness, related to upcoming surgery as evidenced by the patient stating, am very worried that something is going to go wrong .”
3,5
Prolonged Infrequent or Difficulty With Bowel Elimination, related to the effects of analgesic medications on the bowel as evidenced by statements of straining to have a bowel movement and no bowel movement in 5 days is an example of which type of patient problem statement?
- An actual patient problem statement
- A potential patient problem statement
- A wellness patient problem statement
- A patient problem statement
1
Based on Maslow’s hierarchy of needs , which patient problem statement label has the highest priority ?
- Potential for Aspiration Into Airway
- Insufficient Knowledge
- Recent Onset of Pain
- Inability to Control Urination Due to Physical Stress
3
Which patient goal statement is best stated and contains necessary criteria ? ( Select all that apply .)
- The patient will identify the types of foods to include in a high -fiber diet.
- The nurse will teach the patient about constipation prevention .
- The nurse will increase total fluids during hospitalization .
- The patient will have a soft , formed bowel movement on the third day after surgery .
- The patient will ambulate 50 feet three times per day , with the assistance of 1, starting on postoperative day 1.
4,5
The patient is admitted to the hospital with an upper respiratory infection . The nurse writes the following problem statement : Potential for inadequate Fluid Volume , related to refusal to drink fluids , secondary to a sore throat . Which is the best patient goal statement for the patient ?
- The nurse will offer 2000 mL of fluids per day during hospitalization .
- The patient will experience a less sore throat in 8 hours . 3. The nurse will maintain an intravenous infusion of fluids for the ordered length of time .
- The patient will maintain adequate hydration as evidenced by moist mucous membranes, elastic skin turgor, and voiding of clear dilute urine.
4
A woman who has had four children comes to the clinic. She tells the nurse that when she laughs or coughs she loses control of some urine. Which nursing intervention is properly written in the care plan ?
- The nurse will teach the patient Kegel exercises .
- The patient will perform Kegel exercises 10 times a day with four to six repetitions each time .
- The nurse will teach the patient how to perform Kegel exercises 10 times a day with four to six repetitions each time .
- The patient will not experience stress incontinence after 2 months of performing Kegel exercises 10 times per day
3
A 14 -year -old patient is admitted to the emergency department with a possible medical diagnosis of acute appendicitis . Who should the nurse interview first when performing the assessment ?
- The patient’s parents
- The patient
- The physician
- The admissions nurse
2
Which statement by the student nurse best demonstrates knowledge of the nursing process when describing defining characteristics ?
- ” Defining characteristics are a description of the patient problem.”
- ” Defining characteristics tell how the nursing diagnosis was determined .”
3.” Defining characteristics are a cluster of clinical cues “ - “Defining characteristics are factors such as signs and symptoms that support the nursing diagnosis.
4
. Which phrases are most appropriate to use to connect the parts of a patient problem statement ?
- “Related to “ and “ due to”
- “Due to” and “as evidenced by
- “Related to “ and “as evidenced by
- “Due to “ and “as evidenced by “
3
What occurs during the last phase of the nursing process ?
- The nurse gathers data to use in planning care .
- The nurse selects nursing interventions to achieve the desired outcomes .
- The nurse compares the desired outcome with the actual outcome .
- The nurse prioritizes nursing interventions .
4
Which statement best describes a patient problem statement ?
- Statement of the patient’s needs according to Maslow’s hierarchy
- Description of the patient’s disease process
- Listing of the required nursing interventions
- A patient’s health -related problem that can be treated by the nurse.
4
The patient is experiencing severe respiratory distress that is related to his chronic obstructive pulmonary disease . The patient is alert and oriented and is capable of answering questions . Which source of information is most accurate when performing a nursing history during the admission assessment ?
- The patient
- The patient’s wife
- The physician
- The medical record
1
The student nurse is correct in identifying which statement as objective data ? (Select all that apply .)
- “When walk to the mailbox , I get very short of breath .”
- “My legs ache when I climb stairs .
- 4 -cm Transverse abdominal incision
- Report of pain 6 on a scale of to 10
- B /P 178/90
3,5
A newborn has the nursing diagnosis of Potential for Inability to Regulate Body Temperature. What is the most accurate patient goal for this patient problem statement ?
- Parents state that they will keep the infant’s room warm.
- Parents state that they will wrap their infant in two blankets.
- Parents state that they will keep their infant’s temperature between 97.5 F and 98.6 °F.
- Parents state that they will be sure that their infant wears something on her head at home.
3
While giving a bath, the nurse notes skin breakdown on a patient’s coccyx . What part of the patient problem statement is this observation ?
- The patient problem statement
- The etiologic or related factor
- The patient goal
- The defining characteristic
2
Which example includes all appropriate components of a potential patient problem statement ? (Select all that apply.)
- Potential for Inability to Tolerate Activity
- Potential for Aspiration Into Airway , related to difficulty swallowing
- Potential Complication : Hemorrhage
- Potential for Inability to Clear Airway , related to accumulation of mucus in trachea
- Potential for Compromised Skin Integrity , related to immobility as evidenced by 2-cm abrasion
2,4
A nurse is caring for a client who is 24 hr postoperative following an inguinal hernia repair. The client is tolerating clear liquids well, has active bowel sounds, and is expressing a desire for “ real food.” The nurse tells the client, I will call the surgeon and ask for a change in diet.” The surgeon hears the nurse’s report and prescribes a full liquid diet. The nurse used which of the following levels of critical thinking?
A. Basic B. Commitment C. Complex D. Integrity
A
. A nurse receives a prescription for an antibiotic for a client who has cellulitis. The nurse checks the client’s medical record, discovers that the client is allergic to the antibiotic, and calls the provider to request a prescription for a different antibiotic . Which of the following critical thinking attitudes did the nurse demonstrate?
A. Fairness B. Responsibility C. Risk-taking D. Creativity
b
. A newly licensed nurse is considering strategies to improve critical thinking. Which of the following actions should the nurse take ? (Select all that apply .)
A. Find a mentor .
B. Use a journal to write about the outcomes of clinical judgments .
C. Review articles about evidence -based practice .
D. Limit consultations with other professionals involved in a client’s care .
E. Make quick decisions when unsure about a client’s needs.
a.b.c
A nurse is caring for a client who has a new prescription for antihypertensive medication. Prior to administering the medication, the nurse uses an electronic database to gather information about the medication and the effects it might have on this client. Which of the following components of critical thinking is the nurse using when he reviews the medication information?
A. Knowledge
B. Experience
C. Intuition
D. Competence
A
A nurse uses a head -to-toe approach to conduct a physical assessment of a client who will undergo surgery the following week. Which of the following critical thinking attitudes did the nurse demonstrate?
A. Confidence B. Perseverance C. Integrity D. Discipline
d
DO practice question online Book 1-10 chapter 5
