Nurs 2001 Midterm Exam with Accurate
Solutions
Which information is most informative when giving a change of shift report?
a. a patient with dementia is confused
b. a patient reports that incisional pain is now tolerable
c. a patient's blood pressure is within the expected range
d. a patient walked down the hall with no activity intolerance - ANSWER-b. knowing the
incisional pain is now tolerable is the evaluation step of the nursing process, ongoing
evaluation of the effectiveness of the management of pain is most important
A nurse communicates the strategies identified to address the patient's needs. Which
documentation format should the nurse to best communicate the information?
a. progress notes
b. plan of care
c. flow sheet
d. kardex - ANSWER-b. this is the purpose of a care plan. it may be a nursing plan of
care or an integrated health team plan
Which nursing action is an example of the assessment of the nursing process?
a. administering pain medication for a headache
b. taking a patient's blood pressure after ambulating
c. communicating information obtained from an interview
d. determining if a patient tolerated the change from a soft diet to a regular diet -
ANSWER-c. doing an interview is part of an assessment
A patient is admitted to the hospital after several days of diarrhea, nausea, and
vomiting. Which clinical indicator should the nurse expect to identify when completing
an admission nursing assessment?
a. adventitious breath sounds
b. nonelastic skin turgor
c. frothy sputum
d. weight gain - ANSWER-b. nonelastic skin turgor occurs with hypovolemia because
fluid has moved from the interstitial spaces into intravascular system: the pinch of skin
does not return to its original position in less than 2-3 seconds
Which action is essential when maintaining standard precautions?
a. putting on a gown when changing linen
b. wearing goggles when changing a dry sterile dressing
c. wearing gloves during contact with a patient's body fluids
, d. donning a mask with an eye shield when entering a patient's room - ANSWER-c. a
caregiver must wear clean gloves when there is a likelihood of coming in contact with a
patient's body fluids
A nurse is providing passive range of motion exercises. Which principle is important?
a. increase the speed of the exercises progressively and according to the patient's
tolerance
b. assist the patient to complete all planes of movement when the patient is unable to
c. support above and below the joint being exercised
d. repeat each movement ten times - ANSWER-c. this is most important because it
prevents undue stress, strain, or injury to the muscles, joints, and ligaments that can
occur when a joint is unsupported
State the purpose of health assessment - ANSWER--to gather information about the
health status of the patient, analyzing and synthesizing those data, making judgements
about nursing interventions based on the findings, and evaluating patient care outcomes
- includes a health history and a physical assessment
Identify the roles of the nursing process - ANSWER-assessment, diagnosis, planning,
implementation, evaluation
Identify the difference between primary, secondary, and tertiary prevention - ANSWER-
primary- activities to reduce the probability that a disease will develop; strategies aimed
at preventing problems
-Ex: vaccines, health teaching
secondary- early detection and treatments of disease; block progression of disease or
an injury from developing
-Ex: Pap smear, mammogram
tertiary- focus on preventing complications of an existing disease and promoting health
to the highest level
-Ex: infection control practices, long term care
Differentiate between the different types of assessments - ANSWER-emergency-
involves a life threatening or unstable situation; nurses collect the most important
information first until patients are stable
- look at ABCDE (airway, breathing, circulation, disability, exposure)
focused- based on the patient's health issues; can involve one or two body systems and
is smaller in scope than comprehensive, but more in depth on specific issues
comprehensive- includes complete health history and physical assessment; takes place
during an annual physical
Solutions
Which information is most informative when giving a change of shift report?
a. a patient with dementia is confused
b. a patient reports that incisional pain is now tolerable
c. a patient's blood pressure is within the expected range
d. a patient walked down the hall with no activity intolerance - ANSWER-b. knowing the
incisional pain is now tolerable is the evaluation step of the nursing process, ongoing
evaluation of the effectiveness of the management of pain is most important
A nurse communicates the strategies identified to address the patient's needs. Which
documentation format should the nurse to best communicate the information?
a. progress notes
b. plan of care
c. flow sheet
d. kardex - ANSWER-b. this is the purpose of a care plan. it may be a nursing plan of
care or an integrated health team plan
Which nursing action is an example of the assessment of the nursing process?
a. administering pain medication for a headache
b. taking a patient's blood pressure after ambulating
c. communicating information obtained from an interview
d. determining if a patient tolerated the change from a soft diet to a regular diet -
ANSWER-c. doing an interview is part of an assessment
A patient is admitted to the hospital after several days of diarrhea, nausea, and
vomiting. Which clinical indicator should the nurse expect to identify when completing
an admission nursing assessment?
a. adventitious breath sounds
b. nonelastic skin turgor
c. frothy sputum
d. weight gain - ANSWER-b. nonelastic skin turgor occurs with hypovolemia because
fluid has moved from the interstitial spaces into intravascular system: the pinch of skin
does not return to its original position in less than 2-3 seconds
Which action is essential when maintaining standard precautions?
a. putting on a gown when changing linen
b. wearing goggles when changing a dry sterile dressing
c. wearing gloves during contact with a patient's body fluids
, d. donning a mask with an eye shield when entering a patient's room - ANSWER-c. a
caregiver must wear clean gloves when there is a likelihood of coming in contact with a
patient's body fluids
A nurse is providing passive range of motion exercises. Which principle is important?
a. increase the speed of the exercises progressively and according to the patient's
tolerance
b. assist the patient to complete all planes of movement when the patient is unable to
c. support above and below the joint being exercised
d. repeat each movement ten times - ANSWER-c. this is most important because it
prevents undue stress, strain, or injury to the muscles, joints, and ligaments that can
occur when a joint is unsupported
State the purpose of health assessment - ANSWER--to gather information about the
health status of the patient, analyzing and synthesizing those data, making judgements
about nursing interventions based on the findings, and evaluating patient care outcomes
- includes a health history and a physical assessment
Identify the roles of the nursing process - ANSWER-assessment, diagnosis, planning,
implementation, evaluation
Identify the difference between primary, secondary, and tertiary prevention - ANSWER-
primary- activities to reduce the probability that a disease will develop; strategies aimed
at preventing problems
-Ex: vaccines, health teaching
secondary- early detection and treatments of disease; block progression of disease or
an injury from developing
-Ex: Pap smear, mammogram
tertiary- focus on preventing complications of an existing disease and promoting health
to the highest level
-Ex: infection control practices, long term care
Differentiate between the different types of assessments - ANSWER-emergency-
involves a life threatening or unstable situation; nurses collect the most important
information first until patients are stable
- look at ABCDE (airway, breathing, circulation, disability, exposure)
focused- based on the patient's health issues; can involve one or two body systems and
is smaller in scope than comprehensive, but more in depth on specific issues
comprehensive- includes complete health history and physical assessment; takes place
during an annual physical
