NUR 200 Exam #1 Solved 100% Correct!!
During which of the five steps in the nursing process does the nurse determine whether outcomes of
care are achieved?
a. Implementation
b. Evaluation
c. Planning
d. Analysis - -b. Evaluation
--Which statement is related to the concept that is central to the nursing process?
a. It is dynamic rather than static
b. It focuses on the role of the nurse
c. It moves from the simple to the complex
d. It is based on the patient's medical problem - -a. It is dynamic rather than static
--A nurse teaches a patient to use visualization to cope with chronic pain. Which step of the nursing
diagnosis is directly related to this concept?
a. Planning
b. Analysis
c. Evaluation
d. Implementation - -d. Implementation
--Which action reflects the assessment step of the nursing process?
a. Taking a patient's apical pulse every 2 hours after being admitted for an episode of chest pain
b. Scheduling a patient's fluid intake over 12 hours when the patient has a fluid restriction
c. Examining a patient for injury after a patient falls in the bathroom
d. Obtaining a patient's respiratory rate after a nebulizer treatment - -c. Examining a patient for
injury after a patient falls in the bathroom
--A nurse is caring for a patient with a fever. Which is a well-designed goal for this patient?
a. The patient will have a lower temperature
b. The patient will be taught how to take an accurate temperature
c. The patient will maintain fluid intake adequate to prevent dehydration
d. The patient will be given aspirin every eight hours whenever necessary - -c. The patient will
maintain fluid intake adequate to prevent dehydration
--During which step of the nursing process does determining which actions will be employed to meet
the needs of a patient occur?
a. Implementation
b. Assessment
c. Planning
d. Analysis - -c. Planning
--Which is the primary goal of the assessment phase of the nursing process?
a. Build trust
,b. Collect data
c. Establish goals
d. Validate the medical diagnosis - -b. Collect data
--When two nursing diagnoses appear closely related, which should the nurse do first to determine
which diagnosis most accurately reflects the needs of the patient?
a. Reassess the patient
b. Examine the related to factors
c. Analyze the secondary to factors
d. Review the defining characteristics - -d. Review the defining characteristics
--Which is the primary reason why a nurse performs a physical assessment of a newly admitted
patient?
a. Identify if the patient is at risk for falls
b. Ensure that the patient's skin is totally intact
c. Identify important information about the patient
d. Establish a therapeutic relationship with the patient - -c. Identify important information about the
patient
--A nurse evaluates a patient's response to a nursing intervention. To which aspect of the nursing
process is this evaluation most directly related?
a. Goal
b. Problem
c. Etiology
d. Implementation - -a. Goal
--A nurse is caring for a patient with a urinary elimination problem. Which are the accurately stated
goals?
SELECT ALL THAT APPLY
a. The patient will be taught how to use a bedpan while on bedrest
b. The patient will experience fewer incontinence episodes at night
c. The patient will transfer independently and safely to a toilet before discharge
d. The patient will be assisted to the commode every 2 hours and whenever necessary
e. The patient will experience one or less events of urinary incontinence daily within 6 weeks - -c.
The patient will transfer independently and safely to a toilet before discharge
e. The patient will experience one or less events of urinary incontinence daily within 6 weeks
--Which human responses identified by the nurse are examples of objective data?
SELECT ALL THAT APPLY
a. Irregular radial pulse of 50
b. Wheezing on expiration
c. Temp of 99F
d. Shortness of breath
e. Dizziness - -a. Irregular radial pulse of 50
b. Wheezing on expiration
c. Temp of 99F
, --A nurse is interviewing a patient. Which patient statements are examples of objective data?
SELECT ALL THAT APPLY
a. I am hungry
b. I feel very warm
c. I ate half my lunch
d. I have a rash on my arm
e. I have the urge to urinate
f. I vomit every time I eat something - -c. I ate half my lunch
d. I have a rash on my arm
f. I vomit every time I eat something
--A nurse is interviewing a patient at the change of shift. Which patient statements reflect subjective
data?
SELECT ALL THAT APPLY
a. When I lift my head up off the bed I feel like vomiting
b. I just went in the urinal and it needs to be emptied
c. My pain feels like a 5 on a scale of 0-5
d. The physician said I can go home today
e. I ate only 50% of my breakfast - -a. When I lift my head up off the bed I feel like vomiting
c. My pain feels like a 5 on a scale of 0-5
--The nurse assesses a patient and collects a variety of data. Identify the human responses that are
subjective data.
SELECT ALL THAT APPLY
a. Nausea
b. Jaundice
c. Dizziness
d. Diaphoresis
e. Hypotension - -a. Nausea
c. Dizziness
--Which early responses indicated to the nurse that the patient is experiencing hypoxia?
SELECT ALL THAT APPLY
a. Increased heart rate
b. Difficulty breathing
c. Restlessness
d. Bradypnea
e. Irritability - -a. Increased heart rate
c. Restlessness
e. Irritability
--A nurse is assessing several patients who had surgery the previous day. Which sudden patient
response should the nurse identify as a potential life-threatening event?
a. Slightly elevated temp
b. Separation of wound edges
During which of the five steps in the nursing process does the nurse determine whether outcomes of
care are achieved?
a. Implementation
b. Evaluation
c. Planning
d. Analysis - -b. Evaluation
--Which statement is related to the concept that is central to the nursing process?
a. It is dynamic rather than static
b. It focuses on the role of the nurse
c. It moves from the simple to the complex
d. It is based on the patient's medical problem - -a. It is dynamic rather than static
--A nurse teaches a patient to use visualization to cope with chronic pain. Which step of the nursing
diagnosis is directly related to this concept?
a. Planning
b. Analysis
c. Evaluation
d. Implementation - -d. Implementation
--Which action reflects the assessment step of the nursing process?
a. Taking a patient's apical pulse every 2 hours after being admitted for an episode of chest pain
b. Scheduling a patient's fluid intake over 12 hours when the patient has a fluid restriction
c. Examining a patient for injury after a patient falls in the bathroom
d. Obtaining a patient's respiratory rate after a nebulizer treatment - -c. Examining a patient for
injury after a patient falls in the bathroom
--A nurse is caring for a patient with a fever. Which is a well-designed goal for this patient?
a. The patient will have a lower temperature
b. The patient will be taught how to take an accurate temperature
c. The patient will maintain fluid intake adequate to prevent dehydration
d. The patient will be given aspirin every eight hours whenever necessary - -c. The patient will
maintain fluid intake adequate to prevent dehydration
--During which step of the nursing process does determining which actions will be employed to meet
the needs of a patient occur?
a. Implementation
b. Assessment
c. Planning
d. Analysis - -c. Planning
--Which is the primary goal of the assessment phase of the nursing process?
a. Build trust
,b. Collect data
c. Establish goals
d. Validate the medical diagnosis - -b. Collect data
--When two nursing diagnoses appear closely related, which should the nurse do first to determine
which diagnosis most accurately reflects the needs of the patient?
a. Reassess the patient
b. Examine the related to factors
c. Analyze the secondary to factors
d. Review the defining characteristics - -d. Review the defining characteristics
--Which is the primary reason why a nurse performs a physical assessment of a newly admitted
patient?
a. Identify if the patient is at risk for falls
b. Ensure that the patient's skin is totally intact
c. Identify important information about the patient
d. Establish a therapeutic relationship with the patient - -c. Identify important information about the
patient
--A nurse evaluates a patient's response to a nursing intervention. To which aspect of the nursing
process is this evaluation most directly related?
a. Goal
b. Problem
c. Etiology
d. Implementation - -a. Goal
--A nurse is caring for a patient with a urinary elimination problem. Which are the accurately stated
goals?
SELECT ALL THAT APPLY
a. The patient will be taught how to use a bedpan while on bedrest
b. The patient will experience fewer incontinence episodes at night
c. The patient will transfer independently and safely to a toilet before discharge
d. The patient will be assisted to the commode every 2 hours and whenever necessary
e. The patient will experience one or less events of urinary incontinence daily within 6 weeks - -c.
The patient will transfer independently and safely to a toilet before discharge
e. The patient will experience one or less events of urinary incontinence daily within 6 weeks
--Which human responses identified by the nurse are examples of objective data?
SELECT ALL THAT APPLY
a. Irregular radial pulse of 50
b. Wheezing on expiration
c. Temp of 99F
d. Shortness of breath
e. Dizziness - -a. Irregular radial pulse of 50
b. Wheezing on expiration
c. Temp of 99F
, --A nurse is interviewing a patient. Which patient statements are examples of objective data?
SELECT ALL THAT APPLY
a. I am hungry
b. I feel very warm
c. I ate half my lunch
d. I have a rash on my arm
e. I have the urge to urinate
f. I vomit every time I eat something - -c. I ate half my lunch
d. I have a rash on my arm
f. I vomit every time I eat something
--A nurse is interviewing a patient at the change of shift. Which patient statements reflect subjective
data?
SELECT ALL THAT APPLY
a. When I lift my head up off the bed I feel like vomiting
b. I just went in the urinal and it needs to be emptied
c. My pain feels like a 5 on a scale of 0-5
d. The physician said I can go home today
e. I ate only 50% of my breakfast - -a. When I lift my head up off the bed I feel like vomiting
c. My pain feels like a 5 on a scale of 0-5
--The nurse assesses a patient and collects a variety of data. Identify the human responses that are
subjective data.
SELECT ALL THAT APPLY
a. Nausea
b. Jaundice
c. Dizziness
d. Diaphoresis
e. Hypotension - -a. Nausea
c. Dizziness
--Which early responses indicated to the nurse that the patient is experiencing hypoxia?
SELECT ALL THAT APPLY
a. Increased heart rate
b. Difficulty breathing
c. Restlessness
d. Bradypnea
e. Irritability - -a. Increased heart rate
c. Restlessness
e. Irritability
--A nurse is assessing several patients who had surgery the previous day. Which sudden patient
response should the nurse identify as a potential life-threatening event?
a. Slightly elevated temp
b. Separation of wound edges
