Which step of the nursing process does a nurse use when finding blood pressure
of 180/75, a heart rate of 90, and a patient complaint of chest pain? - ANSWER
Assessment
Which best describes the diagnosis step of the nursing process? - ANSWER The
nurse analyzes, validates, and clusters patient data to identify patient problems.
Patient data clusters are stated in standardized language, which provides clarity
and universal understanding by all healthcare providers
Which term describes the nurse prioritizing the diagnoses and identifying goals
that are realistic, measurable, and patient-focused with specific outcomes? -
ANSWER Planning
Which actions demonstrate a nurse utilizing critical thinking when her patient
complains of increased pain at the surgical site?
- The nurse verifies that no pain medications were ordered and calls the
provider on call for pain medications
- The nurse verifies that no pain medications were ordered and tells the patient
she has no medications ordered
- The nurse uses the non-pharmaceutical treatment of focused deep breaths to
relieve pain for patient
- The nurse assesses vital signs and checks to see when patient was last
medicated for pain
- The nurse assesses the surgical site to determine the cause of increased pain -
ANSWER - The nurse verifies that no pain medications were ordered and calls
provider on call for pain medications
- The nurse uses non-pharmaceutical treatment of focused deep breaths to
relieve pain for patient
- The nurse assesses vital signs and checks to see when patient was last
medicated for pain
- The nurse assesses the surgical site to determine the cause of increased pain
,A patient reports that his pain level is now a 6 out of 10. The patient's goal for a
pain level of 3-4 out of 10 is not met. Which step of the nursing process does
this statement reflect? - ANSWER Evaluation
A nurse educator is reviewing the steps of the nursing process with the class.
While reviewing a case study, the educator asks the students to determine which
part of the process a nurse uses when establishing short- and long-term goals
with the patient. How should the students respond? - ANSWER Planning
A nurse is preparing a presentation to the unit on ANA, the organization that
defined the five steps of the nursing process. What does ANA stand for? -
ANSWER American Nurses Association
What is the primary purpose of the nursing diagnosis? - ANSWER
Communicating patient needs
A patient comes to the emergency department complaining of fever and
diarrhea. What should the nurse ask the patient first? - ANSWER "What is the
severity and duration of your fever and diarrhea?"
Stella Jones, RN, reassesses a patient one hour after giving morphine for the
patient's pain. The patient states that she is still in horrible pain, eliciting a
response of 8 out of 10. What would be the most appropriate intervention? -
ANSWER Give additional breakthrough pain medication
Who first pioneered the term "nursing process"? - ANSWER Lydia Hall
The five steps that make up the nursing process allow it to be: - ANSWER
Dynamic
What does the term "dynamic nature" of the nursing process refer to? -
ANSWER Change over time in response to the patient's needs
What is a part of the assessment process? - ANSWER Data collection
What analytical questions are asked at each step in the nursing process?
- "Is the data collection thorough and accurate?"
, - "Are outcomes general and hopeful?"
- "Have all underlying factors been addressed in the care plan?"
- "Are the interventions available?"
- "Could interventions impact the patient negatively?" - ANSWER - "Is the data
collection thorough and accurate?"
- "Have all underlying factors been addressed in the care plan?"
- "Could interventions impact the patient negatively?"
Which statement illustrates the collaborative characteristic of the nursing
practice? - ANSWER Nurses may incorporate actions by the patient or family to
address patient goals
Which subcategory of planning is recognized by professionals and educators as
part of the traditional five-step nursing process? - ANSWER Outcome
identification
Which option exemplifies a short-term goal the nurse may identify during the
planning step of the nursing process? - ANSWER Patient verbalizes a pain level
of 4 or 5, out of 10, within 2 hours of receiving prescribed pain medication
How does the medical record function as a communication tool? - ANSWER
Allows staff to access patient information simultaneously
In which section of the EMR would a nurse find laboratory test values? -
ANSWER Diagnostic results
In which way(s) does the decision support component of the electronic medical
record assist health care providers?
- Provides recommendations for treatment
- Allows ordering of a PET scan
- Describes past treatments
- Assists in the diagnostic process
- Provides reminders of preventive health actions such as vaccinations -
ANSWER - Provides recommendations for treatment
- Assists in the diagnostic process
- Provides reminders of preventive health actions such as vaccines
of 180/75, a heart rate of 90, and a patient complaint of chest pain? - ANSWER
Assessment
Which best describes the diagnosis step of the nursing process? - ANSWER The
nurse analyzes, validates, and clusters patient data to identify patient problems.
Patient data clusters are stated in standardized language, which provides clarity
and universal understanding by all healthcare providers
Which term describes the nurse prioritizing the diagnoses and identifying goals
that are realistic, measurable, and patient-focused with specific outcomes? -
ANSWER Planning
Which actions demonstrate a nurse utilizing critical thinking when her patient
complains of increased pain at the surgical site?
- The nurse verifies that no pain medications were ordered and calls the
provider on call for pain medications
- The nurse verifies that no pain medications were ordered and tells the patient
she has no medications ordered
- The nurse uses the non-pharmaceutical treatment of focused deep breaths to
relieve pain for patient
- The nurse assesses vital signs and checks to see when patient was last
medicated for pain
- The nurse assesses the surgical site to determine the cause of increased pain -
ANSWER - The nurse verifies that no pain medications were ordered and calls
provider on call for pain medications
- The nurse uses non-pharmaceutical treatment of focused deep breaths to
relieve pain for patient
- The nurse assesses vital signs and checks to see when patient was last
medicated for pain
- The nurse assesses the surgical site to determine the cause of increased pain
,A patient reports that his pain level is now a 6 out of 10. The patient's goal for a
pain level of 3-4 out of 10 is not met. Which step of the nursing process does
this statement reflect? - ANSWER Evaluation
A nurse educator is reviewing the steps of the nursing process with the class.
While reviewing a case study, the educator asks the students to determine which
part of the process a nurse uses when establishing short- and long-term goals
with the patient. How should the students respond? - ANSWER Planning
A nurse is preparing a presentation to the unit on ANA, the organization that
defined the five steps of the nursing process. What does ANA stand for? -
ANSWER American Nurses Association
What is the primary purpose of the nursing diagnosis? - ANSWER
Communicating patient needs
A patient comes to the emergency department complaining of fever and
diarrhea. What should the nurse ask the patient first? - ANSWER "What is the
severity and duration of your fever and diarrhea?"
Stella Jones, RN, reassesses a patient one hour after giving morphine for the
patient's pain. The patient states that she is still in horrible pain, eliciting a
response of 8 out of 10. What would be the most appropriate intervention? -
ANSWER Give additional breakthrough pain medication
Who first pioneered the term "nursing process"? - ANSWER Lydia Hall
The five steps that make up the nursing process allow it to be: - ANSWER
Dynamic
What does the term "dynamic nature" of the nursing process refer to? -
ANSWER Change over time in response to the patient's needs
What is a part of the assessment process? - ANSWER Data collection
What analytical questions are asked at each step in the nursing process?
- "Is the data collection thorough and accurate?"
, - "Are outcomes general and hopeful?"
- "Have all underlying factors been addressed in the care plan?"
- "Are the interventions available?"
- "Could interventions impact the patient negatively?" - ANSWER - "Is the data
collection thorough and accurate?"
- "Have all underlying factors been addressed in the care plan?"
- "Could interventions impact the patient negatively?"
Which statement illustrates the collaborative characteristic of the nursing
practice? - ANSWER Nurses may incorporate actions by the patient or family to
address patient goals
Which subcategory of planning is recognized by professionals and educators as
part of the traditional five-step nursing process? - ANSWER Outcome
identification
Which option exemplifies a short-term goal the nurse may identify during the
planning step of the nursing process? - ANSWER Patient verbalizes a pain level
of 4 or 5, out of 10, within 2 hours of receiving prescribed pain medication
How does the medical record function as a communication tool? - ANSWER
Allows staff to access patient information simultaneously
In which section of the EMR would a nurse find laboratory test values? -
ANSWER Diagnostic results
In which way(s) does the decision support component of the electronic medical
record assist health care providers?
- Provides recommendations for treatment
- Allows ordering of a PET scan
- Describes past treatments
- Assists in the diagnostic process
- Provides reminders of preventive health actions such as vaccinations -
ANSWER - Provides recommendations for treatment
- Assists in the diagnostic process
- Provides reminders of preventive health actions such as vaccines
