Fundamentals of nursing final exam test bank new exam practice question and answers., Exams of Nursing

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Final Exam Chap 11 Question | The student is learning the steps of the nursing process. What is the first thing that the student should realize about the purpose of this process’? 1. Deliver care to a client in an organized way. 2. Implement a plan that is close to the medical model. 3. Identify client needs and deliver care to meet those needs. 4. Make sure that standardized care is available to clients. Correct Answer: 3 While conducting a dressing change. the nurse notes a new area of skin breakdown that was caused from the tape used to secure the dressing. In which phase of the nursing process is the nurse working? 1. Assessment 2. Diagnosis 3. Implementation 4. Evaluation Correct Answer: 1 Question 3 During an assessment, a clicnt who is not very talkative appears pale, diaphoretic, and restless in the bed, and says leave me alone. Which subjective data should the nurse document? 1. Restlessness 2. Leave me alone 3. Not talkative 4, Pale and diaphoretic Correct Answer: 2 Question 4 Family of a clicnt demonstrating confusion state that this is not the clicnts usual bchavior. How should the nurse document this data? 1. Inference 2. Subjective data 3. Objective data 4. Secondary subjective data Correct Answer: 3 Question 5 The nurse provides a back rub to a clicnt after administcring a pain medication with the hope that these two actions will help decrease the clients pain. Which phase of the nursing process is this nurse implementing? 1. Assessment 2. Diagnosis 3. Implementation 4. Evaluation Correct Answer: 3 Question 6 Anew client has been admitted to the care area. How soon should the nurse plan to complete a physical assessment on this patient? 1. 1 hour 2. 12 hours 3. 48 hours 4. 24 hours Correct Answer: 4 Question 7 The nurse is admitting an infant to the care area. The parents and grandmother are present. What should the nurse use as the best source of data for this client? 1. Medical record from the childbirth i) . Grandmother 3. Parents 4. Admitting physician Correct Answer: 3 Choice 1. The family is at the bedside. Choice 2. The TV pump is running on battery. Choice 3. The ECG monitor shows tachycardia. Choice 4. The client reports being restless. Choice 5. O2 tubing is not attached to wall regulator. Correct Answer: 3, 4, 5, 2,1 Question 12 During an initial interview, the client says I dont understand why I have to have surgery; Im really not that sick or in pain right now. How should the nurse respond to the clicnt? 1. Its OK to be worried. Surgery is a big step. 2. What kind of questions do you have about your surgery? 3. I think these are things you should be asking your doctor. 4. Have you had surgery before? Correct Answer: 2 Question 13 The nurse is completing a health history with a client who has complications from chronic asthma. Which open-ended question should the nurse usc’? 1. How would you describe your sleep pattern? 2. Can you describe your coughing pattern? 3. Is there anything that makes your breathing worse? 4. What medications are you on? Correct Answer: 1 Question 14 The nurse is assessing a client level of pain. Which open-ended question should the nurse use for this situation? 1. Is your pain worse at night? 2. What brought you to the clinic? 3. How has the pain impacted your life? 4. Youre feeling down about having pain, arent you? Correct Answer: 3 Question 15 Aclient is coming in to the clinic for the first time. In order for the nurse to allow the client the most comfort during the interview, what should the nurse do? 1. Sit next to the client, a few feet apart. i) . Sit behind a desk. 3. Stand at the side of the clients chair. 4. Stand at the counter to take notes during the interview. Correct Answer: 1 Question 16 A client in the emergency department has a non-lifethreatening wound. The unit is busy with other clicnts, familics, and people in the waiting room. How should the nurse conduct an interview with this client? 1. Have the client wait until the department quicts down, as the wound is not too scrious. 2. Tell the clicnt to wait in the waiting room and fill out the paperwork. 3. Draw curtains around the client and nurse to provide as much privacy as possible. 4. Make sure the clients back is to the rest of the room so as not to be heard by passersby. Correct Answer: 3 Question 17 A clicnt has been admitted for acute dehydration, secondary to nausca and diarrhea. When is the best time for the nurse to conduct this clients interview? 1. As soon as the clicnt gets to the floor 2. After the client has settled in and been oriented to the room 3. When the family is available to help 4. After the client has been medicated Correct Answer: 2 Question 18 A nurse has been assigned a new clicnt who cannot speak English. How should the nurse facilitate communication with this client? 1. Have a member of the housckceping staff who speaks the same language translate. The nurse suspects that a clicnt with a history of injurics is a victim of abuse. What did the nurse use to come to this conclusion? 1. Observation of cucs 2. Validation 3. Inference 4. Judgment Correct Answer: 3 Question 23 The nurse is reviewing the nursing process with a first-ycar nursing student. What should the nurse explain as being the purpose of the diagnosis phase? Standard Text: Select all that apply. 1. Develop a list of problems. N . Identify client strengths. . Develop a plan. ow . Specify goals and outcomes. wv . Identify problems that can be prevented. Correct Answer: 1, 2,5 Question 24 The nurse decides to seek wound care alternatives for a clients stasis ulcer that is not healing after treatment for 2 weeks. In which phase of the nursing process is the nurse functioning? 1. Diagnosis 2. Implementation 3. Evaluation 4. Assessment Correct Answer: 3 Question 25 While preparing a client for a procedure, the nurse notes that the client has become unresponsive and respirations have become shallow. What type of assessment should the nurse complete at this time? 1. Initial assessment 2. Problem-focused assessment 3. Emergency assessment 4. Time-lapsed assessment Correct Answer: 3 Question 26 Unlicensed assistive personnel measure a newly admitted clients vital signs to be: temperature — 99.3(F), respirations = 26, pulse = 98 bpm, and blood pressure = 200/146. What should the nurse do to validate this data? 1. Retake the vital signs. 2. Call the physician. 3. Continue with the physical assessment as soon as possible. 4. Report the findings to the charge nurse. Correct Answer: 1 Question 27 A nurse is performing an initial assessment on a new admission. What information should the nurse consider as being a part of the database? Standard Text: Select all that apply. 1. Reports from physical therapy the client received as an outpatient 2. Documentation of the nurses physical assessment 3. Physicians orders 4. A list of current medications 5. Information about the clients cultural preferences 6. Discharge instructions Correct Answer: 1, 2,4, 5 Question 28 The nurse is conducting an interview with a new clicnt. Which actions indicate that the nurse is implementing effective communication guidelines? Standard Text: Select all that apply. 1. Looking directly at the client to ensure good eye contact 2. Managing the conversation to avoid periods of silence on 4.“How is your family responding to the diagnosis? Correct Answer: 3 The use of a conceptual or theoretical framework for collecting and organizing assessment data ensures which of the following? 1.Correlation of the data with other members of the health care team 2.Demonstration of cost-effective care 3.Utilization of creativity and intuition in creating a plan of care 4.Collection of all necessary information for a thorough appraisal Correct Answer: 4 Question 29 Nursing activities that represent the various characteristics of the nursing process includes the nurses: Standard Text: Select all that apply. 1. Notifying the surgeon that a postoperative client is experiencing an increase in temperature. i) . Advocating for a client who is mentally incapable of expressing her needs. 3. Deciding to increase a clients nasal oxygen based on his current pulse oxygenation levels. 4. Documenting all clicnts pain level responses after the administration of pain medication. 5. Attending in-services on a new hydraulic lift to be used to support safe client care. Correct Answer: 1,2,3.4 Chap 12 Question | After an assessment, the nurse reviews the List of clicnt problems. For which problems should the nurse create nursing diagnoses? 1. The ones that the nurse is licensed to treat 2. The ones that address other health professionals interventions 3. The ones that focus on the clients primary illness 4. The ones that have standardized care available Correct Answer: 1 Question 2 A client comes to the clinic seeking information and education regarding healthy lifestyles and cating habits. Which type of diagnosis should the nurse selcet for this client? 1. Risk nursing diagnosis 2. Syndrome diagnosis 3. Wellness diagnosis 4. Actual diagnosis Correct Answer: 3 Question 3 Aclient who has been in a wheelchair for several years is currently experiencing problems with skin breakdown and urinary retention in addition to depression. Which diagnosis should the nurse select for this client? 1. Syndrome diagnosis 2. Risk nursing diagnosis 3. Actual diagnosis 4. Wellness diagnosis Correct Answer: | Question 4 The nurse is preparing to write nursing diagnoses for a clicnt. What should the nurse recall about the NANDA label? 1. Must contain three components 2. Describes the health problem for which nursing therapy is given 3. Helps define medical diagnoses for nursing 4. Promotes a taxonomy of nursing Correct Answer: 4 Question 5 An experienced nurse has just walked into the room of a newly assigned client. Which observation should the nurse use to include a new nursing diagnosis in this clients plan of care? 1. The clients eyes are closed. 2. The clicnts skin is pale and mottled. 4. The nurse wont have to spend time going over the pathology of the clients discasc. Correct Answer: 1 Question 9 A client has been having pain without any clear pathology for cause. Which nursing diagnosis should the nurse identify as being the most appropriate for this client? 1. Pain due to unknown factors i) . Pain related to unknown etiology 3. Pain caused by psychosomatic condition 4. Pain manifested by clicnts report Correct Answer: 2 Question 10 A client is diagnosed with pneumonia and has been hospitalized for several days. Which nursing diagnosis should the nurse identify as a priority for this client? 1. Altered oral mucous membranes, related to dry mouth 2. Activity intolerance, related to oxygen supply imbalance 3. Knowledge deficit, related to medication regimen 4. Incffeetive airway clearance, related to inercased secretions Correct Answer: 4 Question | 1 The nurse is caring for a client recovering from a long and difficult childbirth experience. Which nursing diagnosis did the nurse write appropriately for this client? 1. Constipation, due to tissue trauma, manifested by no bowel movement for 2 days 2. Risk for infection, because of new incision, related to episiotomy 3. Ineffective breast-feeding, related to lack of motivation, secondary to exhaustion 4. Altered urinary climination, secondary to childbirth Correct Answer: 3 Question 12 The nurse is formulating a nursing diagnosis for a clicnt with a long. extensive history of psychiatric problems, beginning in childhood, who is being placed in a long-term, structured institutional environment. Which diagnosis indicates the clients problem is adequately described? 1. Chronic low self-esteem, related to factors too numerous to mention 2. Risk for self-harm, related to many psychiatric problems 3. Impaired social interaction, duc to long history of institutionalization 4. Altcration in thought processes, rclated to complex factors Correct Answer: 4 After communicating with the client and family, the nurse compares a clients problem list with identified nursing diagnoses. What action is the nurse performing to minimize diagnostic errors? 1. Understanding what is normal vs. what is not normal 2. Verifying 3. Consulting resources 4. Basing diagnoses on patterns Correct Answer: 2 Question 14 After formulating several diagnoses, the nurse does not understand the reason for some of the discrepancies in the clients lab values and diagnostic tests, when comparing to norms and standards. Which action should the nurse take? 1. Verify the information with the client. i) . Compare all findings to the national norms and standards. 3. Consult other professionals and colleagues. 4. Improve critical thinking skills so answers come more easily. Correct Answer: 3 Question 15 The nurse has completed the initial assessment of a client and has analyzed and clustered the data. What should the nurse complete next in the diagnostic process? 1. Formulate a diagnosis. 2. Verify the data. Question 19 The nurse has formulated a nursing diagnosis of Impaired skin integrity related to poor hygienic practice, secondary to current living conditions for a clicnt. Which data did the nurse use to support this diagnosis? Standard Text: Select all that apply. 1. The client has dry, cracked skin. 2. The client has one large and several smaller open, ulcerated areas on his right leg. 3. The client does not drive. 4. The client states that he does not use alcohol or drugs. 5. The clients clothes are soiled. 6. The client has obvious body odor. Correct Answer: 1, 2, 5,6 Question 20 The nurse is reviewing information about the formulation of nursing diagnoses. What should the nurse identify as the area in which nursing diagnoses differ from medical diagnoses and collaborative problems? 1. Mental status of the client 2. Chronic nature of the illness 3. Nursing care focus 4, Prognosis Correct Answer: 3 Question 21 The nurse is using the Taxonomy IT nursing diagnoses system. What axes should the nurse realize are coded within this system? Standard Text: Select all that apply. 1. Gordons health pattern groupings N Age . Time ow . Health status wn . Gender 6. Location Correct Answer: 2, 3, 4,6 Question 22 The nurse is reviewing assessment data collected for a clients care plan. What criteria should the nurse use when formulating this clients nursing diagnoses? Standard Text: Select all that apply. 1. Nonjudgmental statements 2. Stated in terms of a need w . Must be legally advisable 4. Cause/cffect correctly stated 5. Medical terminology used to describe the cause 6. Diagnosis worded specifically and precisely Correct Answer: 1,3,4,6 Question 23 The nurse wants to propose a new nursing diagnosis. What action should the nurse take first? 1. Using the proposed nursing diagnosis when constructing client care plans 2. Getting permission for the proposed nursing diagnosis to be implemented by a nursing facility 3. Submitting the diagnosis to NANDAs Diagnostic Review Committee 4. Presenting the proposed nursing diagnosis at the local AMA (American Medical Association) meeting. Correct Answer: 3 Question 24 The nurse is providing care to a clicnt. Which nursing diagnoses can the nurse apply when providing client care? Standard Text: Sclcet all that apply. 1. Incffective Breathing Pattern N . Risk of Infection w . Readiness for Enhanced Nutrition 4, Readiness for Enhanced Family Coping Question 3 A client is scheduled for elective hip replacement and will be admitted postoperatively to the orthopedic unit for care. What should the nurses usc to help plan this clients care? 1. Informal nursing care plan 2. Formal nursing care plan 3. Standardized care plan 4. Individualized care plan Correct Answer: 3 The nurse being oriented to a new position is reviewing the hospitals standards of care, standardized care plans, protocols, policies, and procedures. For which reasons should the nurse realize that these documents are being used by the nursing staff? SAP 1. Making sure all clients have the same types of care 2. Ensuring that minimally accepted standards are met 3. Promoting efficient use of the nurses time 4. Eliminating care disparities among clients 5. Ensuring medication errors do not occur Correct Answer: 2, 3 Question 5 The neonatal intensive care nurse implements several actions to prevent further complications in anewly admitted premature infant. Which type of document did the nurse use to find these actions? 1. Standardized care plan i) . Protocol 3. Standards of care 4. Policy and procedure manual Correct Answer: 2 Question 6 A nurse in the intensive care unit consults unit policy and administers a routinely used medication to a client admitted to the unit with severe hypotension. What did the nurse implement in this situation? 1. ASTAT order 2. A one-time order 3. Aprn order 4. A standing order Correct Answer: 4 Question 7 According to the care plan, a clicnt is to reecive chest physiotherapy twice daily. The clicnt lives alone in a rural area, does not drive, and is 40 miles away from a hospital. What should the home care nurse do when setting priorities for this client? 1. Make sure that he or she is able to get to the clients home. 2. Assist the clicnt in finding an alternative plan for the achicving the therapys outcomes. 3. Tell the clicnt that this therapy will be impossible to reecive. 4. Make arrangements to have the client moved to a long-term care facility. Correct Answer: 2 Question 8 A discharge goal for a client is to have improved mobility. Which outcome statement did the nurse write appropriately? 1. Client will ambulate without a walker by 6 weeks. 2. Client will ambulate freely in house. 3. Client will not fall. 4. Client will have freer movement in daily activities. Correct Answer: | Question 9 The nurse identifies for a client the nursing diagnosis Fluid volume deficit, related to active fluid loss, secondary to diarrhea. What would be and appropriate goal statement for this diagnosis? 1. Client will drink more fluids by tomorrow. i) . Client will have good skin turgor. w . Client will have moist mucous membranes. 4. Client will have intake of at least 1000 mL within 24 hours. Correct Answer: 4