Exam 9: Nursing Process

The nurse has just completed an assessment for a patient.Which data will the nurse categorize as objective?

The nurse carefully enters a new patient's medical history and current medication list into the agency's electronic health record (EHR).Which step of the nursing process is being performed by the nurse?

Which nursing diagnosis is the highest priority for a patient with multiple sclerosis?

Which nursing care order is an example of a standing order?

The nurse observed a postoperative patient trying to take her friend's narcotic pain pills in addition to the pain medication administered by the nurse.Which nursing diagnosis is the highest priority for this patient?

The nurse becomes frustrated when a patient insists on taking herbal remedies rather than prescribed medications and spends certain hours of each day in prayer.The patient also prefers the care of the spiritualist healer over the attending physician.Which factor may be responsible for the nurse's frustration?

The nurse is caring for a patient with sepsis.The nurse includes potential complications: septic shock in the plan of care.Why is this nursing diagnosis considered a collaborative problem?

Which question is the most appropriate for the nurse to use to start the health history assessment?

The extended care agency administers the flu vaccination to all of the patients who do not have contraindications to the injection.What is the reason that the nurses do not have to obtain orders from each patient's physician for vaccination each year?

Which statement by the nurse is an example of back-channeling?

The nurse is preparing to insert an indwelling urinary catheter into the patient.Where will the nurse check to ensure that the packaging is sterile,intact,and not past the expiration date?

The nurse is caring for a patient who denies having any pain.The nurse notes that the patient is restless and the patient's hands are tightly clenched.The nurse also heard the patient moaning before walking into the room.What will the nurse take into consideration as the patient assessment is completed?

Every time the nurse asks the patient a question for the admission assessment,the patient's husband interrupts and answers the question for her.What is the best action of the nurse?

The nurse is caring for a trauma patient who has just arrived to the emergency room.The nurse listens to the patient's lung sounds,palpates the patient's peripheral pulses,and obtains vital signs.What is the best description of the nurse's actions?

The nurse is caring for a patient who will be having surgery shortly.The patient requests that a religious bracelet be worn in the operating room to help ensure a good surgical outcome.Which is the most appropriate action of the nurse?

The patient has a goal of maintaining urinary output of at least 30 mL/hour as part of the nursing care plan.However the patient's urinary output for the shift was only 20 mL/hour.What is the appropriate action of the nurse?

The nurse is caring for a nonverbal patient who just had surgery.The nurse notes that the patient moans with position changes,the hands are clenched,and the skin is very sweaty.The nurse decides that the patient is in pain and decides to administer an analgesic.What is the correct term for this nursing action?

The nurse is caring for a patient who has just arrived at the hospital with chest pain.Which is the most important question for the nurse to ask the patient?

Which actions by the nurse are examples of dependent nursing interventions for a postoperative patient?

Which nursing diagnosis is the highest priority for a patient with pneumonia?