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. Leave me alone FYY FY Y
3. Not talkative FYY
4. Pale anddiaphoretic FY FY FY Y
Correct Answer: 2 FY Y FY Y
Question 4 FY Y
Family of a client demonstrating confusion state that this is not the clients usual behavior. How
FYY FYY FYY FYY FY Y FYY FYY FYY FYY FYY FYY FYY FYY FYY FYY FY Y
should the nurse document this data? FY Y FY Y FY Y FY Y FY Y
,1. Inference
2. Subjective data FYY
3. Objective data FYY
4. Secondarysubjective data FY FY FY Y
Correct Answer: 3 FY Y FY Y
Question 5 FY Y
The nurse provides a back rub to a client after administering a pain medication with the hope that
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these two actions will help decrease the clients pain. Which phase of the nursing process is this
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nurse implementing?
FY Y
1. Assessment
2. Diagnosis
3. Implementation
4. Evaluation
CorrectAnswer: 3 F
Y FYY
Question 6 FY Y
A new client has been admitted to the care area. How soon should the nurse plan to complete a
FY FYY FYY FYY FYY FYY FYY FYY FYY FYY FYY FYY FYY FYY FYY FYY FYY FYY FY Y
physical assessment on this patient? FY Y FY Y FY Y FY Y
1. 1 hour
FY Y
2. 12 hours FY Y
3. 48 hours FY Y
4. 24 hours FY Y
CorrectAnswer: 4 F
Y FYY
Question 7 FY Y
The nurse is admitting an infant to the care area. The parents and grandmother are present. What
FYY FYY FYY FYY FYY FY Y FYY FYY FYY FYY FYY FY Y FYY FYY FYY FYY FY Y
should the nurse use as the best source of data for this client?
FY Y FY Y FY Y FY Y FY Y FY Y FY Y FY Y FY Y FY Y FY Y FY Y
1. Medical record from the childbirth FYY FY Y FYY FY Y
2. Grandmother
3. Parents
4. Admittingphysician FY
CorrectAnswer: 3 F
Y FYY
,Question 8 FY Y
A newly admitted client is angry because nursing staff continue to ask the same questions. What
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should the nurse respond to this client?
FY Y FY Y FY Y FY Y FY Y FY Y
1. In order to make sure all of your information is complete I need to ask these questions.
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2. Youre right. Let me know if theres anything you need right now.
FYY FYY FYY FYY FYY FYY FYY FYY FYY FYY FYY
3. Ill be done shortly just give me a few more minutes.
FYY FYY FYY FY Y , FYY FY Y FYY FY Y FYY FYY
4. Youshouldnt be upset. Were only doing our jobs.
FY FYY FY F
Y FYY FYY FYY FYY FY Y
Correct Answer: 2 FY Y FY Y
Question 9 FY Y
The nurse documents: Client avoids eye contact and gives only vague nonspecific answers to
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direct questioning by the professional staff. Is quite animated (laughs aloud smiles uses hand
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gestures) in conversation with spouse. Which method of data collection does this documentation
FYY FYY FYY FYY FYY FYY FYY FYY FYY FYY FYY FYY FY Y
demonstrate?
1. Examining
2. Interviewing
3. Listening
4. Observing
CorrectAnswer: 4 F
Y FYY
Question 10 FY Y
A nurse has worked in the trauma critical care area for several years. Which noise may become
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indiscriminate for this particular nurse? FY Y FY Y FY Y FY Y
1. Aclient with audible breathing
FY FYY FYY FYY
2. Moaning of a client in pain FY Y FY Y FYY FYY FY Y
3. Whirring of ventilators FYY FYY
4. Co-orkersdiscussing their clients conditions FY FY FY FYY FY Y
Correct Answer: 3 FY Y FY Y
Question 11 FYY
Aclient has been using the call light routinely throughout the evening. Upon entering the room the
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nurse observes the following details. Organize them according to priority sequencing (1 is first
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priority; 5 is least priority). FY Y FY Y FY Y FY Y
Standard Text: Click and drag the options below to move them up or down.
FYY FY Y FYY FY Y FYY FYY FY Y FYY FYY FYY FY Y FYY FYY
, Choice 1. The family is at the bedside. FY Y FY Y FY Y FY Y FY Y FY Y FY Y FY Y
Choice 2. The IVpump is running on battery.
FYY FY FYY FY FYY FYY FYY FYY
Choice 3.The ECG monitor shows tachycardia. Choice
FYY FY FYY FYY FYY FYY FY Y FY Y
4. The client reports being restless.
FY Y FY Y FY Y FY Y FY Y
Choice 5. O2 tubing is not attached to wall regulator.
FYY FYY FYY FYY FYY FYY FYY FYY FYY FY Y
Correct Answer: 3 4 5 2 1 FY Y FY Y FY Y , FY Y , FY Y , FY Y ,
Question 12 FY Y
During an initial interview the client says I dont understand why I have to have surgery; Im really
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not that sick or in pain right now. How should the nurse respond to the client?
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1. Its OK to be worried. Surgery is a big step.
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2. What kind of questions do you have about your surgery?
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3. I think these are things you should be asking your doctor.
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4. Have you had surgerybefore? FY FY FYY FY FY Y
Correct Answer: 2 FY Y FY Y
Question 13 FY Y
The nurse is completing a health history with a client who has complications from chronic
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asthma. Which open-ended question should the nurse use?
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1. How would you describe your sleep pattern? FYY FY Y FY Y FY Y FYY FY Y
2. Can you describe your coughing pattern?
FY Y FYY FYY FYY FY Y
3. Is there anything that makes your breathing worse?
FYY FYY FY Y FY Y FYY FYY FY Y
4. What medications are you on? FYY FYY FYY FYY FY Y
Correct Answer: 1 FY Y FY Y
Question 14 FY Y
The nurse is assessing a client level of pain. Which open-ended question should the nurse use for
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this situation?
FY Y
1. Is your pain worse at night?
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2. What brought you to the clinic? FY Y FYY FY Y FY Y FYY
3. How has the pain impacted your life? FYY FY Y FYY FY Y FYY FY Y
4. Youre feeling down about having pain arent you? FYY FYY FYY FYY FYY FY Y , FYY