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NURS 153 >NURSING PROCESS FINAL EXAM 2025/QUESTIONS WITH CORRECT DETAILED ANSWERS WITH RAT, Exams of Nursing

Napa Valley College Nursing

NURS 153 >NURSING PROCESS FINAL EXAM 2025/QUESTIONS WITH CORRECT DETAILED ANSWERS WITH RATIONALES/LATEST UPDATE 2025/ALREADY GRADED A +/

Typology: Exams

2024/2025

Available from 12/19/2024

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NURS 153 >NURSING PROCESS FINAL EXAM 2025/QUESTIONS

WITH CORRECT DETAILED ANSWERS WITH

RATIONALES/LATEST UPDATE 2025/ALREADY GRADED A +/

1.

The caregiver is using critical thinking skills during the first phase of the nursing

process. Which action indicates the caregiver is in the first phase?

a.

Completes a comprehensive database

b.

Identifies pertinent nursing diagnoses

c.

Intervenes based on priorities of client care

d.

Determines whether outcomes have been achieved

CORRECT ANS:->>>: A

Rationale: The assessment phase of the nursing process involves data collection to complete a

thorough client database and is the first phase. Identifying nursing diagnoses occurs during the

diagnosis phase or second phase. The caregiver carries out interventions during the

implementation phase (fourth phase), and determining whether outcomes have been achieved

takes place during the evaluation phase (fifth phase) of the nursing process.

2.

A caregiver is using the problem-oriented approach to data collection. Which

action will the caregiver take first?

a.

Complete the questions in chronological order.

b.

Focus on the client’s presenting situation.

c.

Make accurate interpretations of the data.

d.

Conduct an observational overview.

CORRECT ANS:->>>: B

Rationale: A problem-oriented approach focuses on the client’s current problem or presenting

situation rather than on an observational overview. The database is not always completed using

a chronological approach if focusing on the current problem. Making interpretations of the data

is not data collection. Data

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NURS 153 >NURSING PROCESS FINAL EXAM 202 5 /QUESTIONS

WITH CORRECT DETAILED ANSWERS WITH

RATIONALES/LATEST UPDATE 2025/ALREADY GRADED A +/

The caregiver is using critical thinking skills during the first phase of the nursing process. Which action indicates the caregiver is in the first phase? a. Completes a comprehensive database b. Identifies pertinent nursing diagnoses c. Intervenes based on priorities of client care d. Determines whether outcomes have been achieved CORRECT ANS:->>>: A Rationale: The assessment phase of the nursing process involves data collection to complete a thorough client database and is the first phase. Identifying nursing diagnoses occurs during the diagnosis phase or second phase. The caregiver carries out interventions during the implementation phase (fourth phase), and determining whether outcomes have been achieved takes place during the evaluation phase (fifth phase) of the nursing process.
A caregiver is using the problem-oriented approach to data collection. Which action will the caregiver take first? a. Complete the questions in chronological order. b. Focus on the client’s presenting situation. c. Make accurate interpretations of the data. d. Conduct an observational overview. CORRECT ANS:->>>: B Rationale: A problem-oriented approach focuses on the client’s current problem or presenting situation rather than on an observational overview. The database is not always completed using a chronological approach if focusing on the current problem. Making interpretations of the data is not data collection. Data

interpretation occurs while appropriate nursing diagnoses are assigned. The question is asking about data collection.

After reviewing the database, the caregiver discovers that the client’s vital signs have not been recorded by the nursing assistive personnel (NAP). Which clinical decision should the caregiver make? Administer scheduled medications assuming that the NAP would have a. reported abnormal vital signs. Have the client trCORRECT ANS:->>>ported to the radiology department for a scheduled x- ray, and b. review vital signs upon return. c. Ask the NAP to record the client’s vital signs before administering medications. d. Omit the vital signs because the client is presently in no distress. CORRECT ANS:->>>: C Rationale: The caregiver should ask the nursing assistive personnel to record the vital signs for review before administering medicines or transporting the client to another department. The caregiver should not make assumptions when providing high-quality client care, and omitting the vital signs is not an appropriate action.
The caregiver is gathering data on a client. Which data will the caregiver report as objective data? a. States “doesn’t feel good” b. Reports a headache c. Respirations 16 d. Nauseated CORRECT ANS:->>>: C Rationale: Objective data are observations or measurements of a client’s health status, like respirations. Inspecting the condition of a surgical incision or wound, describing an observed behavior, and measuring blood pressure are examples of objective data. States “doesn’t feel

physical examination. The caregiver reviews the current literature in the implementation phase of the nursing process to determine evidence-based actions, and the health care provider is responsible for ordering medications. The caregiver uses results from the diagnostic and laboratory tests to establish a client database, not checking orders for tests.

A caregiver is gathering information about a client’s habits and lifestyle patterns. Which method of data collection will the caregiver use that will best obtain this information? a. Carefully review lab results. b. Conduct the physical assessment. c. Perform a thorough nursing health history. d. Prolong the termination phase of the interview. CORRECT ANS:->>>: C Rationale: The nursing health history also includes a description of a client’s habits and lifestyle patterns. Lab results and physical assessment will not reveal as much about the client’s habits and lifestyle patterns as the nursing health history. Collecting data is part of the working phase of the interview.
While interviewing an older female client of Asian descent, the caregiver notices that the client looks at the ground when CORRECT ANS:->>>wering questions. What should the caregiver do? a. Consider cultural differences during this assessment. b. Ask the client to make eye contact to determine her affect. c. Continue with the interview and document that the client is depressed. d. Notify the health care provider to recommend a psychological evaluation. CORRECT ANS:->>>: A Rationale: To conduct an accurate and complete assessment, consider a client’s cultural background. This caregiver needs to practice culturally competent care and appreciate the cultural differences. Assuming that the client is depressed or in need of a psychological

evaluation or to force eye contact is inappropriate.

A caregiver has already set the agenda during a client-centered interview. What will the caregiver do next? a. Begin with introductions. b. Ask about the chief concerns or problems. c. Explain that the interview will be over in a few minutes. d. Tell the client “I will be back to administer medications in 1 hour.” CORRECT ANS:->>>: B After setting the agenda, the caregiver should conduct the actual interview and proceed with data collection, such as asking about the client’s current chief concerns or problems. Introductions occur before setting the agenda. Begin an interview by introducing yourself and your position and explaining the purpose of the interview. Your aim is to set an agenda for how you will gather information about a client’s current chief concerns or problems. The termination phase includes telling the client when the interview is nearing an end. Telling the client that medications will be given later when the caregiver returns would typically take place during the termination phase of the interview.
The caregiver is attempting to prompt the client to elaborate on the reports of daytime fatigue. Which question should the caregiver ask? a. “Is there anything that you are stressed about right now that I should know?” b. “What reasons do you think are contributing to your fatigue?” c. “What are your normal work hours?” d. “Are you sleeping 8 hours a night?” CORRECT ANS:->>>: B The question asking the client what factors might be contributing to the fatigue will elicit the best open- ended response. Asking whether the client is stressed and asking if the client is sleeping 8 hours a night are closed-ended questions eliciting simple yes or no responses. Asking about normal work hours will elicit a matter-of-fact response and does not prompt the client to elaborate on the daytime fatigue or ask about the contributing reasons.

The caregiver begins a shift assessment by examining a surgical dressing that is saturated with serosanguineous drainage on a client who had open abdominal surgery yesterday (or 1 day ago). Which type of assessment approach is the caregiver using? a. Gordon’s Functional Health Patterns b. Activity-exercise pattern assessment c. General to specific assessment d. Problem-oriented assessment CORRECT ANS:->>>: D The caregiver is not doing a complete, general assessment and then focusing on specific problem areas. Instead, the caregiver focuses immediately on the problem at hand (dressing and drainage from surgery) and performs a problem-oriented assessment. Utilizing Gordon’s Functional Health Patterns is an example of a structured database-type assessment technique that includes 11 patterns to assess. The caregiver in this question is performing a specific problem-oriented assessment approach, not a general approach. The caregiver is not performing an activity-exercise pattern assessment in this question.
Which statement by a caregiver indicates a good understanding about the differences between data validation and data interpretation? a. “Data interpretation occurs before data validation.” b. “Validation involves looking for patterns in professional standards.” c. “Validation involves comparing data with other sources for accuracy.” d. “Data interpretation involves discovering patterns in professional standards.” CORRECT ANS:->>>: C Validation, by definition, involves comparing data with other sources for accuracy. Data interpretation involves identifying abnormal findings, clarifying information, and identifying

client problems. The caregiver should validate data before interpreting the data and making inferences. The caregiver is interpreting and validating client data, not professional standards.

Which scenario best illustrates the caregiver using data validation when making a nursing clinical decision for a client? The caregiver determines to remove a wound dressing when the client reveals the time a. of the last dressing change and notices old and new drainage. The caregiver administers pain medicine due at 1700 at 1600 because the client reports b. increased pain and the family wants something done. The caregiver immediately asks the health care provider for an order of potassium when a c. client reports leg cramps. d. The caregiver elevates a leg cast when the client reports decreased mobility. CORRECT ANS:->>>: A The only scenario that validates a client’s report with a caregiver’s observation is changing the wound dressing. The caregiver validates what the client says by observing the dressing. The rest of the examples have the caregiver acting only from a client and/or family reports, not the caregiver’s assessment.
While completing an admission database, the caregiver is interviewing a client who states “I am allergic to latex.” Which action will the caregiver take first? a. Immediately place the client in isolation. b. Ask the client to describe the type of reaction. c. Proceed to the termination phase of the interview. d. Document the latex allergy on the medication administration record. CORRECT ANS:->>>: B The caregiver should further assess and ask the client to describe the type of reaction. The client will not need to be placed in isolation; before terminating the interview or documenting the allergy, health care personnel need to be aware of what type of response the client

the client to be as comfortable as possible when conducting an interview. Assessing a client while another member of the health care team is working would be distracting and is not the best time for an interview to take place.

A new caregiver is completing an assessment on an 80 - year-old client who is alert and oriented. The client’s daughter is present in the room. Which action by the caregiver will require follow-up by the charge caregiver? a. The caregiver makes eye contact with the client. b. The caregiver speaks only to the client’s daughter. c. The caregiver leCORRECT ANS:->>> forward while talking with the client. d. The caregiver nods periodically while the client is speaking. CORRECT ANS:->>>: B Gathering data from family members is acceptable, but when a client is able to interact, caregivers need to include information from the older adult to complete the assessment. Therefore, the charge caregiver must correct this misconception. When assessing an older adult, caregivers need to listen carefully and allow the client to speak. Positive nonverbal communication, such as making eye contact, nodding, and leaning forward, shows interest in the client. Thus, the charge caregiver does not need to intervene or follow up. MULTIPLE RESPONSE
A caregiver is completing an assessment. Which findings will the caregiver report as subjective data? (Select all that apply.) a. Client’s temperature b. Client’s wound appearance c. Client describing excitement about discharge d. Client pacing the floor while awaiting test results e. Client’s expression of fear regarding upcoming surgery

CORRECT ANS:->>>: C, E

Subjective data include client’s feelings, perceptions, and reported symptoms. Expressing feelings such as excitement or fear is an example of subjective data. Objective data are observations or measurements of a client’s health status. In this question, the appearance of the wound and the client’s temperature are objective data. Pacing is an observable client behavior and is also considered objective data. MATCHING A caregiver is completing an assessment using the PQRST to obtain data about the client’s chest pain. Match the questions to the components of the PQRST that the caregiver will be using. a. Where is the pain located? b. What causes the pain? c. Does it come and go? d. What does the pain feel like? e. What is the rating on a scale of 0 to 10?

Provokes
Quality
Radiate
Severit y 5.Time 1.CORR ECT ANS:-

:B

a. To form a language that can be encoded only by caregivers b. To distinguish the caregiver’s role from the physician’s role c. To develop clinical judgment based on other’s intuition d. To help caregivers focus on the scope of medical practice CORRECT ANS:->>>: B The standard formal nursing diagnosis serves several purposes. Nursing diagnoses distinguish the caregiver’s role from that of the physician/health care provider and help caregivers focus on the scope of nursing practice (not medical) while fostering the development of nursing knowledge. A nursing diagnosis provides the precise definition that gives all members of the health care team a common language for understanding the client’s needs. A diagnosis is a clinical judgment based on information.

Which diagnosis will the caregiver document in a client’s care plan that is NANDA-I approved? a. Sore throat b. Acute pain c. Sleep apnea d. Heart failure CORRECT ANS:->>>: B Acute pain is the only NANDA-I approved diagnosis listed. Sleep apnea and heart failure are medical diagnoses, and sore throat is subjective data.
A caregiver develops a nursing diagnostic statement for a client with a medical diagnosis of pneumonia with chest x-ray results of lower lobe infiltrates. Which nursing diagnosis did the caregiver write? a. Ineffective breathing pattern related to pneumonia

b. Risk for infection related to chest x-ray procedure c. Risk for deficient fluid volume related to dehydration d. Impaired gas exchange related to alveolar-capillary membrane changes CORRECT ANS:->>>: D The related to factor of alveolar-capillary membrane changes is accurately written because it is a client response to the disease process of pneumonia that the caregiver can treat. The related to factor should be the cause of the problem (nursing diagnosis) that a caregiver can address. The related to factors of dehydration and pneumonia are all medical diagnoses that the caregiver cannot change. A diagnostic test or a chronic dysfunction is not an etiology or a condition that a nursing intervention is able to treat.

The caregiver is reviewing a client’s plan of care, which includes the nursing diagnostic statement, Impaired physical mobility related to tibial fracture as evidenced by client’s inability to ambulate. Which part of the diagnostic statement does the caregiver need to revise? a. Etiology b. Nursing diagnosis c. Collaborative problem d. Defining characteristic CORRECT ANS:->>>: A The etiology, or related to factor, of tibial fracture is a medical diagnosis and needs to be revised. The nursing diagnosis is appropriate because the client is unable to ambulate. A collaborative problem is an actual or potential physiological complication that caregivers monitor to detect the onset of changes in a client’s health status; there is no collaborative problem listed. The defining characteristic (subjective and objective data that support the diagnosis) is appropriate for Impaired physical mobility.
A caregiver is using assessment data gathered about a client and combining critical thinking to develop a nursing diagnosis. What is the caregiver doing?

and the client’s oral intake has significantly decreased since previous shifts. Which step of the nursing process should the caregiver proceed to after this review? a. Diagnosis b. Planning c. Implementation d. Evaluation CORRECT ANS:->>>: A After a thorough assessment, the caregiver should proceed to analyzing the data and formulating a nursing diagnosis before proceeding with developing the plan of care and determining appropriate interventions; this is the diagnosis phase. The evaluation phase involves determining whether the goals were met and interventions were effective.

A client with a spinal cord injury is seeking to enhance urinary elimination abilities by learning self- catheterization versus assisted catheterization by home health caregivers and family members. The caregiver adds Readiness for enhanced urinary elimination in the care plan. Which type of diagnosis did the caregiver write? a. Risk b. Problem focused c. Health promotion d. Collaborative problem CORRECT ANS:->>>: C A health promotion nursing diagnosis is a clinical judgment concerning motivation and desire to increase well-being and actualize human health potential. A problem-focused nursing diagnosis describes a clinical judgment concerning an undesirable human response to a health condition/life process that exists in an individual, family, or community. A risk nursing diagnosis is a clinical judgment concerning the vulnerability of an individual, family, group or community for developing an undesirable human response to health conditions/life processes. A collaborative problem is an actual or potential physiological complication that caregivers monitor to detect the onset of changes in a client’s health status.

A caregiver administers an antihypertensive medication to a client at the scheduled time of
The nursing assistive personnel (NAP) then reports to the caregiver that the client’s blood pressure was low when it was taken at 0830. The NAP states that was busy and had not had a chance to tell the caregiver yet. The client begins to complain of feeling dizzy and light- headed. The blood pressure is rechecked and it has dropped even lower. In which phase of the nursing process did the caregiver first make an error? a. Assessment b. Diagnosis c. Implementation d. Evaluation CORRECT ANS:->>>: A The diagnostic process should flow from the assessment. In this case, the caregiver should have assessed the client’s blood pressure before giving the medication. The caregiver could have prevented the client’s untoward reaction if the low blood pressure was assessed first. Diagnosis follows assessment. Administering the medication occurs in implementation, but this is not the first error. There are no errors in evaluation.
A caregiver adds the following diagnosis to a client’s care plan: Constipation related to decreased gastrointestinal motility secondary to pain medication administration as evidenced by the client reporting no bowel movement in seven days, abdominal distention, and abdominal pain. Which element did the caregiver write as the defining characteristic? a. Decreased gastrointestinal motility b. Pain medication c. Abdominal distention d. Constipation CORRECT ANS:->>>: C

CORRECT ANS:->>>: C

Disruption of tissue integrity is a possible cause or etiology of pain. A report of pain, headache, and discomfort are examples of things a client might say (subjective data or defining characteristics) that may lead a caregiver to select Acute pain as a nursing diagnosis.

A new caregiver writes the following nursing diagnoses on a client’s care plan. Which nursing diagnosis will cause the caregiver manager to intervene? a. Wandering b. Hemorrhage c. Urinary retention d. Impaired swallowing CORRECT ANS:->>>: B Hemorrhage is a collaborative problem, not a nursing diagnosis; the caregiver manager will need to correct this misunderstanding with the new caregiver. Caregivers manage collaborative problems such as hemorrhage, infection, and paralysis using medical, nursing, and allied health (e.g., physical therapy) interventions. Wandering, urinary retention, and impaired swallowing are all examples of nursing diagnoses.
A client has a bacterial infection in left lower leg. Which nursing diagnosis will the caregiver add to the client’s care plan? a. Infection b. Risk for infection c. Impaired skin integrity d. Staphylococcal leg infection CORRECT ANS:->>>: C Impaired skin integrity is the only nursing diagnosis listed that will correlate to the client information. While risk for infection is a nursing diagnosis, the client is not at risk; the client

has an actual infection. Infection can be a medical diagnosis as well as a collaborative problem. Staphylococcal leg infection is a medical diagnosis.

A caregiver adds a nursing diagnosis to a client’s care plan. Which information did the caregiver document? a. Decreased cardiac output related to altered myocardial contractility. b. Client needs a low-fat diet related to inadequate heart perfusion. c. Offer a low-fat diet because of heart problems. d. Acute heart pain related to discomfort. CORRECT ANS:->>>: A Decreased cardiac output related to altered myocardial contractility is a correctly written nursing diagnosis. Client needs a low-fat diet related to inadequate heart perfusion is a goal phrased statement, not a nursing diagnosis. Offer a low-fat diet is an intervention, not a diagnosis. Acute pain related to discomfort is a circular diagnosis and gives no direction to nursing care.
A charge caregiver is evaluating a new caregiver’s plan of care. Which finding will cause the charge caregiver to follow up? Assigning a documented nursing diagnosis of Risk for infection for a client a. on intravenous (IV) antibiotics b. Completing an interview and physical examination before adding a nursing diagnosis c. Developing nursing diagnoses before completing the database d. Including cultural and religious preferences in the database CORRECT ANS:->>>: C Developing nursing diagnoses before completion of the database needs to be corrected by the charge caregiver. Always identify a nursing diagnosis from the data, not the reverse. The data should be clustered and reviewed to see if any patterns are present before a nursing diagnosis is assigned. Risk for infection is an appropriate diagnosis for a client with an intravenous (IV)

NURS 153 >NURSING PROCESS FINAL EXAM 2025/QUESTIONS WITH CORRECT DETAILED ANSWERS WITH RAT, Exams of Nursing

Related documents

Partial preview of the text

Download NURS 153 >NURSING PROCESS FINAL EXAM 2025/QUESTIONS WITH CORRECT DETAILED ANSWERS WITH RAT and more Exams Nursing in PDF only on Docsity!

NURS 153 >NURSING PROCESS FINAL EXAM 202 5 /QUESTIONS

WITH CORRECT DETAILED ANSWERS WITH

RATIONALES/LATEST UPDATE 2025/ALREADY GRADED A +/

CORRECT ANS:->>>: C, E

CORRECT ANS:->>>: C