Question 1

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

Accepted Answer

A)   The patient felt less short of breath after receiving a nebulizer treatment.
B)   The patient's lung sounds are diminished bilaterally with expiratory wheezes.
C)   The patient worries that the insurance company will not pay the hospital bill.
D)   The patient wonders if supplemental oxygen at home would be beneficial. B

Question 2

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?

Accepted Answer

A)   Assessment
B)   Implementation
C)   Evaluation
D)   Diagnosis A

Question 3

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

Accepted Answer

A)   Chronic sorrow related to loss of independence
B)   Disturbed sensory perception related to nerve cell damage
C)   Risk for powerlessness related to impaired fine- and gross-motor skills
D)   Risk for falls related to impaired mobility and sensation D

Question 4

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

Accepted Answer

A)   Monitor blood glucose level before meals and at bedtime.
B)   Administer a soapsuds enema if no bowel movement for 3 days.
C)   Instruct the patient how to self-administer insulin correctly.
D)   Bathe the patient daily with application of moisturizer to all bony prominences.

Question 5

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?

Accepted Answer

A)   Health-seeking behaviors
B)   Risk-prone health behavior
C)   Readiness for enhanced comfort
D)   Situational low self-esteem

Question 6

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?

Accepted Answer

A)   Cultural differences in health-related practices
B)   Delay in the patient's psychosocial development
C)   Impaired ability of the patient to cope with acute illness
D)   Incorrect organization of health assessment findings

Question 7

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?

Accepted Answer

A)   The patient must be closely monitored in an intensive care unit.
B)   The patient has a history of noncompliance with prescribed therapeutic regimens.
C)   Prevention of septic shock is not a measurable patient outcome.
D)   Both nursing and physician-prescribed interventions are required.

Question 8

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

Accepted Answer

A)   "Does your family doctor know that you are here?"
B)   "Did you drive yourself to the hospital?"
C)   "What brings you to the hospital today?"
D)   "Did you give your insurance card to the receptionist?"

Question 9

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?

Accepted Answer

A)   The agency's medical director placed a standing order for patients to receive the flu vaccination yearly unless contraindicated.
B)   The Centers for Disease Control and Prevention highly recommend yearly flu vaccinations for all individuals over the age of 65.
C)   The State Licensing Board for extended care facilities requires annual flu vaccinations for all residents and staff.
D)   The administrator of the agency has the authority to order annual flu vaccinations for all residents and staff.

Question 10

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

Accepted Answer

A)   "I completely understand.Can you tell me more?"
B)   "When did you first seek health care for your symptoms?"
C)   "I am sure the doctor will answer all of your questions shortly."
D)   "Try not to worry.I'm sure that you will be just fine."

Question 11

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?

Accepted Answer

A)   In the clean utility room immediately after removing the package from the shelf
B)   At the patient's bedside after verifying the patient's name and birthdate
C)   At the nurses' station after verifying the physician's order for the procedure
D)   At the patient's bedside after performing careful perineal care for the patient

Question 12

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?

Accepted Answer

A)   Unclear communication techniques
B)   Unrealistic patient expectations
C)   Inappropriate empathic response
D)   Conflicting assessment findings

Question 13

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?

Accepted Answer

A)   Enter the husband's responses into the patient's chart.
B)   Request that the husband leave the room.
C)   Complete the admission assessment after the husband has gone home.
D)   Allow time for the patient to answer each question.

Question 14

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?

Accepted Answer

A)   Establishing priorities for outcomes
B)   Performing a physical examination
C)   Demonstrating diagnostic reasoning
D)   Setting time frames for interventions

Question 15

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?

Accepted Answer

A)   Call the operating room staff to determine if the bracelet can stay on during surgery.
B)   Insist that the patient remove the bracelet and give it to a family member during surgery.
C)   Notify the patient's surgeon of the patient's refusal to remove the bracelet before having surgery.
D)   Remove the bracelet from the patient's wrist after sedating medication has been administered.

Question 16

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?

Accepted Answer

A)   Contact the physician to obtain an order for diuretics to increase urinary output.
B)   Reassess the patient to determine why the urinary output was less than 30 mL/hour.
C)   Change the goal to: patient will maintain urinary output of at least 20 mL/hour.
D)   Inform the patient that the urinary output goal for the shift was not met.

Question 17

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?

Accepted Answer

A)   Setting priorities
B)   Recognizing inconsistencies
C)   Using empathy
D)   Making inferences

Question 18

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?

Accepted Answer

A)   "Did your family doctor tell you to come to the hospital?"
B)   "When did your chest pain begin?"
C)   "Do you have a family history of heart disease?"
D)   "Did someone come to the hospital with you?"

Question 19

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

Accepted Answer

A)   Calculating the patient's fluid intake and output at the end of every shift
B)   Encouraging fluid and fiber intake to prevent constipation from pain medications
C)   Administering a mild stool softener daily to prevent constipation
D)   Assessing the patient's abdomen for distention,bowel sounds,and passage of flatus
E)   Reinserting of the patient's urinary catheter for retention of greater than 500 mL of urine

Question 20

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

Accepted Answer

A)   Activity intolerance related to fatigue and shortness of breath
B)   Knowledge deficit related to pneumonia risk factors
C)   Pruritus related to side effects of prescribed medications
D)   Impaired gas exchange related to alveolar inflammation and infection

Exam 9: Nursing Process