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Adult I Exam with question and answer
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When the nurse encourages a patient with heart failure to alternate rest and activity periods to
reduce cardiac workload, what phase of the nursing process is being used?

A. Planning

B. Diagnosis

C. Evaluation

D. Implementation - D. Implementation

*Carrying out a specific, individualized plan constitutes the implementation phase of the
nursing process. The nurse's action of encouragement and instruction to the patient is part of
carrying out a plan of action.



When planning care for a patient, the nurse may use a visual diagram of patient problems and
interventions to illustrate the relationships among pertinent clinical data. What is this format
called?

A. Concept Map

B. Critical Pathway

C. Clinical Pathway

D. Nursing Care Plan - A. Concept Map

*A concept map is another method of recording a nursing care plan. In a concept map, the
nursing process is recorded in a visual diagram of patient problems and interventions. A clinical
(critical) pathway is a prewritten plan that directs the entire health care team in the daily care
goals for select health care problems.

, A nurse is providing care for a patient who had transurethral resection of his prostate this
morning. The patient is receiving continuous bladder irrigation, but his urinary catheter is now
occluded. The nurse is now planning to phone the patient's health care provider and
communicate using the SBAR (Situation-Background-Assessment-Recommendation) format.
Which statement is a component of communication using SBAR?

A. "What do you think could be causing this occlusion?"

B. "I think that we should manually irrigate his catheter."

C. "What do you know about this patient and his history?"

D. "Could you please provide some direction for his care?" - B. "I think that we should
manually irrigate his catheter

*Proposing a recommendation is a component of the "R" component of SBAR communication.
Asking the health care provider for possible contributing factors to the problem or for general
direction may be appropriate in some circumstances, but these are not explicit components of
SBAR. The nurse should briefly identify the patient and his circumstances, not ask an open-
ended question regarding the physician's familiarity.



What factor has been most clearly identified as an influence on the future of nursing practice?

A. Aging of the American population and increases in chronic illnesses

B. Increasing birth rates coupled with decreased average life expectancy

C. Increased awareness of determinants of health and improved self-care

D. Apathy around health behaviors and the relationship of lifestyle to health - A. Aging of the
American population and increases in chronic illnesses

*The American population is aging at the same time that the incidence of chronic health
conditions is increasing. There is no noted increase in the overall awareness of the determinants
of health, but at the same time, observers have not identified apathy as a predominant attitude.
Life expectancy is increasing, not decreasing.



A group of nurses have a plan to implement evidence-based practice (EBP) for care of patients
with pressure ulcers. What will this change in practice encompass (select all that apply)?

A. Consulting with the wound care and ostomy nurse
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