Test Bank for Davis Advantage for Fundamentals of
Nursing Care 2024-2025 exam
A nurse is providing nursing care to patients after completing a care plan from nursing
diagnoses. In which step of the nursing process is the nurse?
a. Assessment
b. Planning
c. Implementation
d. Evaluation - ANSWER-ANS: C
Implementation, the fourth step of the nursing process, formally begins after a nurse
develops
a plan of care. With a care plan based on clear and relevant nursing diagnoses, a nurse
initiates
interventions that are designed to assist the patient in achieving the goals and expected
outcomes needed to support or improve the patient's health status. The nurse gathers
data
during the assessment phase and mutually sets goals and prioritizes care during the
planning
phase. During the evaluation phase, the nurse determines the achievement of goals
and
effectiveness of interventions.
The nurse is teaching a new nurse about protocols. Which information from the new
nurse
indicates a correct understanding of the teaching?
a. Protocols are guidelines to follow that replace the nursing care plan.
b. Protocols assist the clinician in making decisions and choosing interventions for
specific health care problems or conditions.
c. Protocols are policies designating each nurse's duty according to standards of care
and a code of ethics.
d. Protocols are prescriptive order forms that help individualize the plan of care. -
ANSWER-ANS: B
A clinical practice guideline or protocol is a systematically developed set of statements
that
helps nurses, physicians, and other health care providers make decisions about
appropriate
health care for specific clinical situations. This guideline establishes interventions for
specific
health care problems or conditions. The protocol does not replace the nursing care plan.
Evidence-based guidelines from protocols can be incorporated into an individualized
plan of
care. A clinical guideline is not the same as a hospital policy. Standing orders contain
orders
for the care of a specific group of patients. A protocol is not a prescriptive order form like
a
standing order.
,The standing orders for a patient include acetaminophen 650 mg every 4 hours prn for
headache. After assessing the patient, the nurse identifies the need for headache relief
and
determines that the patient has not had acetaminophen in the past 4 hours. Which
action will
the nurse take next?
a. Administer the acetaminophen.
b. Notify the health care provider to obtain a verbal order.
c. Direct the nursing assistive personnel to give the acetaminophen.
d. Perform a pain assessment only after administering the acetaminophen. - ANSWER-
ANS: A
A standing order is a preprinted document containing orders for the conduct of routine
therapies, monitoring guidelines, and/or diagnostic procedures for specific patients with
identified clinical problems. The nurse will administer the medication. Notifying the
health
care provider is not necessary if a standing order exists. The nursing assistive
personnel are
not licensed to administer medications; therefore, medication administration should not
be
delegated to this person. A pain assessment should be performed before and after pain
medication administration to assess the need for and effectiveness of the medication.
Which action indicates a nurse is using critical thinking for implementation of nursing
care to
patients?
a. Determines whether an intervention is correct and appropriate for the given
situation
b. Reads over the steps and performs a procedure despite lack of clinical competency
c. Establishes goals for a particular patient without assessment
d. Evaluates the effectiveness of interventions - ANSWER-ANS: A
As you implement interventions, use critical thinking to confirm whether the
interventions are
correct and still appropriate for a patient's clinical situation. You are responsible for
having
the necessary knowledge and clinical competency to perform interventions for your
patients
safely and effectively. The nurse needs to recognize the safety hazards of performing
an
intervention without clinical competency and seek assistance from another nurse. The
nurse
cannot evaluate interventions until they are implemented. Patients need ongoing
assessment
before establishing goals because patient conditions can change very rapidly.
A nurse is reviewing a patient's care plan. Which information will the nurse identify as a
, nursing intervention?
a. The patient will ambulate in the hallway twice this shift using crutches correctly.
b. Impaired physical mobility related to inability to bear weight on right leg.
c. Provide assistance while the patient walks in the hallway twice this shift with
crutches.
d. The patient is unable to bear weight on right lower extremity. - ANSWER-ANS: C
Providing assistance to a patient who is ambulating is a nursing intervention. The
statement,
"The patient will ambulate in the hallway twice this shift using crutches correctly" is a
patient
outcome. Impaired physical mobility is a nursing diagnosis. The statement that the
patient is
unable to bear weight and ambulate can be included with assessment data and is a
defining
characteristic for the diagnosis of Impaired physical mobility.
A patient recovering from a leg fracture after a fall reports having dull pain in the
affected leg
and rates it as a 7 on a 0 to 10 scale. The patient is not able to walk around in the room
with
crutches because of leg discomfort. Which nursing intervention is priority?
a. Assist the patient to walk in the room with crutches.
b. Obtain a walker for the patient.
c. Consult physical therapy.
d. Administer pain medication. - ANSWER-ANS: D
The patient's pain is a 7, indicating the priority is pain relief (administer pain medication).
Acute pain is the priority because the nurse can address the problem of immobility after
the
patient receives adequate pain relief. Assisting the patient to walk or obtaining a walker
will
not address the pain the patient is experiencing.
The nurse is caring for a patient who requires a complex dressing change. While in the
patient's room, the nurse decides to change the dressing. Which action will the nurse
take just
before changing the dressing?
a. Gathers and organizes needed supplies
b. Decides on goals and outcomes for the patient
c. Assesses the patient's readiness for the procedure
d. Calls for assistance from another nursing staff member - ANSWER-ANS: C
Always be sure a patient is physically and psychologically ready for any interventions or
procedures. After determining the patient's readiness for the dressing change, the nurse
gathers needed supplies. The nurse establishes goals and outcomes before
intervening. The
nurse needs to ask another staff member to help if necessary after determining
readiness of the
Nursing Care 2024-2025 exam
A nurse is providing nursing care to patients after completing a care plan from nursing
diagnoses. In which step of the nursing process is the nurse?
a. Assessment
b. Planning
c. Implementation
d. Evaluation - ANSWER-ANS: C
Implementation, the fourth step of the nursing process, formally begins after a nurse
develops
a plan of care. With a care plan based on clear and relevant nursing diagnoses, a nurse
initiates
interventions that are designed to assist the patient in achieving the goals and expected
outcomes needed to support or improve the patient's health status. The nurse gathers
data
during the assessment phase and mutually sets goals and prioritizes care during the
planning
phase. During the evaluation phase, the nurse determines the achievement of goals
and
effectiveness of interventions.
The nurse is teaching a new nurse about protocols. Which information from the new
nurse
indicates a correct understanding of the teaching?
a. Protocols are guidelines to follow that replace the nursing care plan.
b. Protocols assist the clinician in making decisions and choosing interventions for
specific health care problems or conditions.
c. Protocols are policies designating each nurse's duty according to standards of care
and a code of ethics.
d. Protocols are prescriptive order forms that help individualize the plan of care. -
ANSWER-ANS: B
A clinical practice guideline or protocol is a systematically developed set of statements
that
helps nurses, physicians, and other health care providers make decisions about
appropriate
health care for specific clinical situations. This guideline establishes interventions for
specific
health care problems or conditions. The protocol does not replace the nursing care plan.
Evidence-based guidelines from protocols can be incorporated into an individualized
plan of
care. A clinical guideline is not the same as a hospital policy. Standing orders contain
orders
for the care of a specific group of patients. A protocol is not a prescriptive order form like
a
standing order.
,The standing orders for a patient include acetaminophen 650 mg every 4 hours prn for
headache. After assessing the patient, the nurse identifies the need for headache relief
and
determines that the patient has not had acetaminophen in the past 4 hours. Which
action will
the nurse take next?
a. Administer the acetaminophen.
b. Notify the health care provider to obtain a verbal order.
c. Direct the nursing assistive personnel to give the acetaminophen.
d. Perform a pain assessment only after administering the acetaminophen. - ANSWER-
ANS: A
A standing order is a preprinted document containing orders for the conduct of routine
therapies, monitoring guidelines, and/or diagnostic procedures for specific patients with
identified clinical problems. The nurse will administer the medication. Notifying the
health
care provider is not necessary if a standing order exists. The nursing assistive
personnel are
not licensed to administer medications; therefore, medication administration should not
be
delegated to this person. A pain assessment should be performed before and after pain
medication administration to assess the need for and effectiveness of the medication.
Which action indicates a nurse is using critical thinking for implementation of nursing
care to
patients?
a. Determines whether an intervention is correct and appropriate for the given
situation
b. Reads over the steps and performs a procedure despite lack of clinical competency
c. Establishes goals for a particular patient without assessment
d. Evaluates the effectiveness of interventions - ANSWER-ANS: A
As you implement interventions, use critical thinking to confirm whether the
interventions are
correct and still appropriate for a patient's clinical situation. You are responsible for
having
the necessary knowledge and clinical competency to perform interventions for your
patients
safely and effectively. The nurse needs to recognize the safety hazards of performing
an
intervention without clinical competency and seek assistance from another nurse. The
nurse
cannot evaluate interventions until they are implemented. Patients need ongoing
assessment
before establishing goals because patient conditions can change very rapidly.
A nurse is reviewing a patient's care plan. Which information will the nurse identify as a
, nursing intervention?
a. The patient will ambulate in the hallway twice this shift using crutches correctly.
b. Impaired physical mobility related to inability to bear weight on right leg.
c. Provide assistance while the patient walks in the hallway twice this shift with
crutches.
d. The patient is unable to bear weight on right lower extremity. - ANSWER-ANS: C
Providing assistance to a patient who is ambulating is a nursing intervention. The
statement,
"The patient will ambulate in the hallway twice this shift using crutches correctly" is a
patient
outcome. Impaired physical mobility is a nursing diagnosis. The statement that the
patient is
unable to bear weight and ambulate can be included with assessment data and is a
defining
characteristic for the diagnosis of Impaired physical mobility.
A patient recovering from a leg fracture after a fall reports having dull pain in the
affected leg
and rates it as a 7 on a 0 to 10 scale. The patient is not able to walk around in the room
with
crutches because of leg discomfort. Which nursing intervention is priority?
a. Assist the patient to walk in the room with crutches.
b. Obtain a walker for the patient.
c. Consult physical therapy.
d. Administer pain medication. - ANSWER-ANS: D
The patient's pain is a 7, indicating the priority is pain relief (administer pain medication).
Acute pain is the priority because the nurse can address the problem of immobility after
the
patient receives adequate pain relief. Assisting the patient to walk or obtaining a walker
will
not address the pain the patient is experiencing.
The nurse is caring for a patient who requires a complex dressing change. While in the
patient's room, the nurse decides to change the dressing. Which action will the nurse
take just
before changing the dressing?
a. Gathers and organizes needed supplies
b. Decides on goals and outcomes for the patient
c. Assesses the patient's readiness for the procedure
d. Calls for assistance from another nursing staff member - ANSWER-ANS: C
Always be sure a patient is physically and psychologically ready for any interventions or
procedures. After determining the patient's readiness for the dressing change, the nurse
gathers needed supplies. The nurse establishes goals and outcomes before
intervening. The
nurse needs to ask another staff member to help if necessary after determining
readiness of the
