Chap11 ,
Question 1 ,,,,,,,,,,
Thestudent islearning thesteps ofthe nursing process.What isthe firstthing that thestudent should reali
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ze about the purpose of this process?
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1. Delivercaretoaclient in anorganized way. , , , , ,,,, ,,,,,, ,,, ,,,
2. Implement aplan that is close to the medical model. ,,,, , ,,,,,,,,,, ,,,,,,,,,, ,,,,,,,,,, ,,,,,, ,,,,,,,,,, ,,,,, ,,,,,,
3. Identifyclient needs and deliver careto meet thoseneeds. , ,,,,,,,,,, ,,,,, ,, ,,,, ,,,, ,,,,,,,,,, , ,,,,,,,,,, ,,,,,,,,,, ,,
4. Makesurethatstandardizedcareisavailabletoclients. Cor , , , , , , , , ,,,,,,,,,,
rect Answer: 3 ,,,,,,,,,, ,,,,,,,,,,
Question 2 ,,,,,,,,,,
While conducting a dressing change, the nurse notes a new area of skin breakdown that was cause
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d from the tapeused to securethe dressing. In which phase o f the nursing process is the nurse working?
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1. Assessment
2. Diagnosis
3. Implementation
4. Evaluation
CorrectAnswer:1 , ,
Question 3 ,,,,,,,,,,
Duringan assessment, aclient who isnotverytalkative appears pale, diaphoretic, andrestlessin the bed,
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and says leave me alone. Which subjective data should the nurse document?
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1. Restlessness
2. Leaveme alone , ,,,,,,, ,,,
3. Not talkative ,,,,
4. Paleanddiaphoretic , , ,,,,,,,,, ,
Correct Answer: 2 ,,,,,,,,,, ,,,,,,,,,,
Question 4 ,,,,,,,,,,
Familyofaclientdemonstrating confusionstatethatthisis nottheclientsusualbehavior.How should the
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nurse document this data? ,,,,, ,,,,, ,,,,,,,,,, ,,,,,,,,,,
,1. Inference
2. Subjectivedata ,
3. Objectivedata ,
4. Secondarysubjectivedata , , ,,,,,,,,,,
Correct Answer: 3 ,,,,,,,,,, ,,,,,,,,,,
Question 5 ,,,,,,,,,,
The nurse provides a back rub to a client after administering apain medication with the hope that these
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two actions will help decrease the clients pain. Which phase of the nursing process is this nurse im
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plementing?
1. Assessment
2. Diagnosis
3. Implementation
4. Evaluation
CorrectAnswer:3 , ,
Question 6 ,,,,,,,,,,
Anewclient has beenadmittedtothecarearea. How soonshould thenurse plantocomplete a physical as
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sessment on this patient? ,,,,,,,,,, ,,,,,,,,,, ,,,,,,,,,,
1. 1 hour ,,,,,,,,,,
2. 12 hours ,,,,,,,,,,
3. 48 hours ,,,,,,,,,,
4. 24 hours ,,,,,,,,,,
CorrectAnswer:4 , ,
Question 7 ,,,,,,,,,,
Thenurseisadmitting aninfant to the carearea.The parents andgrandmother arepresent.What should t
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he nurse use as the best source of data for this client?
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1. Medicalrecord fromthe childbirth ,,, ,,,,,,,,,, ,,, ,,,,,,,,, ,
2. Grandmother
3. Parents
4. Admittingphysician ,
CorrectAnswer:3 , ,
,Question 8 ,,,,,,,,,,
Anewlyadmittedclient isangrybecausenursingstaffcontinuetoaskthesamequestions. What should th
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e nurse respond to this client?
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1. Inorder to make sure all of your information is complete, Ineed to ask these questions.
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2. Youreright.Letmeknowiftheres anythingyou need rightnow. , , , , , , ,,, , ,,, ,,, ,
3. Ill be doneshortly, just give mea few more minutes. ,,,,, ,,, , ,,,,,,,,,, ,, ,,,,,,,, ,, , ,,,,,,,,,, ,,,,,, ,,,
4. Youshouldntbeupset.Wereonlydoingourjobs. Cor , , , , , , , , ,,,,,,,,,,
rect Answer: 2 ,,,,,,,,,, ,,,,,,,,,,
Question 9 ,,,,,,,,,,
The nurse documents: Client avoids eye contact and gives only vague, nonspecific answers to dire
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ct questioning by the professional staff. Is quite animated (laughs aloud, smiles, uses hand gestures
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)inconversationwithspouse. Whichmethodofdatacollectiondoes this documentation demonstrate?
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1. Examining
2. Interviewing
3. Listening
4. Observing
CorrectAnswer:4 , ,
Question 10 ,,,,,,,,,,
A nursehasworkedinthetraumacriticalcare areaforseveral years. Which noisemay become indiscrimi
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nate for this particular nurse? ,,,,,,,,,, ,,,,,,,,,, ,,,,,,,,,, ,,,,,,,,,,
1. Aclientwith audible breathing , , ,,,,,, ,,,,,
2. Moaning of aclient in pain ,,,,,,,,,, ,,,,,,,,, ,, ,,,, ,,,,,,,,, ,
3. Whirring o fventilators ,,,, ,,,
4. Co-
orkersdiscussingtheirclientsconditions Correct , , , , ,,,,,,,,,, ,,,,,,,,,,
Answer: 3 ,,,,,,,,,,
Question11 ,
Aclienthas beenusingthe call light routinely throughout the evening. Uponentering the room, the nurs
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e observes the following details. Organize them according to priority sequencing (1 is first priority
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; 5 is least priority).
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StandardText: Click and drag the options below to movethem upordown. , ,,,,,,,,,, ,,,,,, ,,,,, ,,,,, ,,,,, ,,, ,,,,,,,,,, ,,, ,, , ,,,,,,,,,, ,, ,,
, Choice 1. The family is at the bedside. Choice ,,,,,,,,,, ,,,,,,,,,, ,,,,,,,,,, ,,,,,,,,,, ,,,, ,,,,,, ,,,,,,,,,, ,,,,,,,,,, ,,,,,,,,,, ,
2.TheIVpumpisrunningonbattery.
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Choice3.TheECGmonitorshowstachycardia. Choice 4 , , , , , , ,,,,,,,,,, ,,,,,,,,,,
. The client reports being restless.
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Choice5.O2tubingisnotattachedtowallregulator. Corre , , , , , , , , , ,,,,,,,,,,
ct Answer: 3, 4, 5, 2, 1
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Question 12 ,,,,,,,,,,
Duringaninitialinterview,theclientsays IdontunderstandwhyIhaveto havesurgery; Im really not th
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at sick or in pain right now. How should the nurse respond to the client?
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1. Its OK to beworried. Surgery is a big step. ,,,, ,,,,,,,,,, ,,,,,,,,,, , ,,,,,,,,,, ,,,,,,,,,, ,,,,,,,,,, ,,,,,,,,, ,,,,,,,,,,
2. What kind ofquestions do you have about your surgery? ,,,,,,,,,, ,,,,,,,,,, ,,, ,,,,,,,,,, ,,,,,,,,, ,,,,,,,,,, ,,, ,,,,,,,,, ,,,,
3. Ithink theseare things you should be asking yourdoctor.
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4. Haveyouhadsurgerybefore? C , , , , , ,,,,,,,,,
orrect Answer: 2 ,,,,,,,,,, ,,,,,,,,,,
Question 13 ,,,,,,,,,,
Thenurseis completing a health history with a client who has complications from chronic asthma. W
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hich open-ended question should the nurse use?
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1. Howwould you describe yoursleep pattern? , ,,,,,,,,,, ,,,,,,,,,, ,,,,,,,,,, , ,,,,,,,,,,
2. Can you describe your coughing pattern? ,,,,,,,,,, ,,,,,, ,,, ,,,,, ,,,,,,,,,,
3. Isthere anything that makes yourbreathing worse?
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4. What medicationsareyouon? C , , , , ,,,,,,,,,,
orrect Answer: 1 ,,,,,,,,,, ,,,,,,,,,,
Question 14 ,,,,,,,,,,
The nurseis assessing a client levelo fpain. Which open-
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ended question should thenurseusefor this situation? ,,,,, ,,,,,, ,,,,, , , , ,,,,,,,,,, ,,,,,,,,,,
1. Is your pain worse at night? ,, ,,,,,,,,, ,,,,,,,,,, ,,,,,,,,, ,,,,,,,,,,
2. What brought you to the clinic? ,,,,,,,,,, ,,, ,,,,, ,,,,, ,,,,,,,,,, ,,,,
3. Howhas the pain impacted your life? , ,,,,,,,,,, ,, ,,,,,,,,,, ,,,, ,,,,,,,,,,
4. Yourefeeling downabouthaving pain,arent you? , ,,, , , ,,, , ,