NR 224 EXAM 1 LATEST 2 VERSIONS (VERSION A & B) ACTUAL
EXAM 200 QUESTIONS AND CORRECT DETAILED ANSWERS
WITH RATIONALES|ALREADY GRADED A+||CHAMBERLAINE
COLLEGE
While assessing a patient, the nurse observes the patient's IV line is not infusing at
the ordered rate. The nurse assesses the patient for pain at the IV site, checks the
flow regulator on the tubing, looks to see if the patient is lying on the tubing, checks
the point of connection between the tubing and the IV catheter, and then checks the
condition of the site where the IV catheter enters the patient's skin. After the nurse
readjusts the flow rate, the infusion begins at the correct rate. This is an example of:
A. inference
B. Diagnostic reasoning
C. Competency
D. Problem solving - ANSWER: D. Problem Solving
The nurse sits down to talk with a patient who lost her sister 2 weeks ago. The
patient reports she is unable to sleep, feels very fatigued during the day, and is
having trouble at work. The nurse asks her to clarify the type of trouble. The patient
explains she can't concentrate or even solve simple problems. The nurse records the
results of the assessment, describing the patient as having ineffective coping. This is
an example of :
A. diagnostic reasoning
B. Competency
C. Inference
D. Problem Solving - ANSWER: A. Diagnostic reasoning
A patient on a surgical unit develops sudden shortness of breath and a drop in BP.
The staff respond, but the patient dies 30 minutes later. the manager on the nursing
unit calls the staff involved in the emergency response together, The staff discusses
what occurred over the 30 minute time frame, the actions taken, and whether other
steps should have been implemented. The nurses in this situation are:
A. problem solving
B. showing humility
C. conducting reflective practice
D. Exercising responsibility - ANSWER: C. Conducting reflective practice
A nurse has worked on an oncology unit for 3 years. One patient has become visibly
weaker and states, "I feel funny". The nurse knows how patients often have behavior
changes before developing sepsis when they have cancer. The nurse asks the patient
questions to assess thinking skills and notices the patient shivering. The nurse goes
to the phone, calls the physician, and begins the conversation by saying, "I believe
that your patient is developing sepsis. I want to report symptoms I'm seeing." What
examples of critical thinking concepts does the nurse show? (Select all that apply)
A. Experience
,B. Ethical
C. Analyticity
D. Self-confidence
E. Risk taking - ANSWER: C. Analyticity
D. Self confidence
A nurse who is working on a surgical unit is caring for four different patients. Patient
A will be discharged home and is in need of instruction about wound care. Patients B
and C have returned from the operating room within an hour of each other, and
both require vital signs and monitoring of their intravenous (IV) lines.
Patient D is resting following a visit by physical therapy. Which of the following
activities by the nurse represent(s) use of clinical decision making for groups of
patients? (Select all that apply.)
A. consider how to involve patient A in deciding whether to involve the family
caregiver in wound care instruction
B. Think about past experience with patients who develop postoperative
complications
C. Decide which activities can be combined for patients B and C
D. Carefully gather any assessment info and identify patient problems - ANSWER: A
&C
The surgical unit has initiated the use of a pain-rating scale to assess patients' pain
severity during their postoperative recovery. The registered nurse (RN) looks at the
pain flow sheet to see the pain scores recorded for a patient over the last 24 hours.
Use of the pain scale is an example of which intellectual standard?
A. deep
B. Relevant
C. Consistent
D. Significant - ANSWER: C
During a home health visit the nurse prepares to instruct a patient in how to perform
range-of-motion (ROM) exercises for an injured shoulder. The nurse verifies that the
patient took an analgesic 30 minutes before arrival at the patient's home. After
discussing the purpose for the exercises and demonstrating each one, the nurse has
the patient perform them. After two attempts with only the second of three
exercises, the patient stops and says, "This hurts too much. I don't see why I have to
do this so many times." The nurse applies the critical thinking attitude of integrity in
which of the following actions?"
A. "I understand your reluctance, but the exercises are necessary for you to regain
function in your shoulder. Let's go a bit more slowly and try to relax"
B. "I see that you're uncomfortable. I'll call your doctor to decide the next step."
C. "Show me exactly where your pain is and rate it for me on a scale - ANSWER: A
The nurse cared for a 14-year-old with renal failure who died near the end of the
work shift. The health care team tried for 45 minutes to resuscitate the child with no
, success. The family was devastated by the loss, and, when the nurse tried to talk
with them, the mother said, "You can't make me feel better; you don't know what
it's like to lose a child." Which of the following examples of journal entries might best
help the nurse reflect and think about this clinical experience? (Select all that apply.)
A. Data entry of the time of day, who was present, and the condition or the child
B. Description of the efforts to restore the child's BP, what was used, and questions
about the child's response
C. The meaning the experience had for the nurse with respect to her understanding
of dealing with the patient's death
D. A description of what the nurse said to the mother, the mother's response, and
how the nurse might app - ANSWER: B, C, & D
A nurse has been working on a surgical unit for 3 weeks. A patient requires a Foley
catheter to be inserted, so the nurse reads the procedure manual for the institution
to review how to insert it. The level of critical thinking the nurse is using is:
A. Commitment
B. Scientific method
C. basic critical thinking
D. Complex critical thinking - ANSWER: C
A patient had hip surgery 16 hours ago. During the previous shift the patient had 40
mL of drainage in the surgical drainage collection device for an 8-hour period. The
nurse refers to the written plan of care, noting that the health care provider is to be
notified when drainage in the device exceeds 100 mL for the day. On entering the
room, the nurse looks at the device and carefully notes the amount of drainage
currently in it. This is an example of:
A. planning
B. evaluation
C. Intervention
D. Diagnosis - ANSWER: B
A 67-year-old patient will be discharged from the hospital in the morning. The health
care provider has ordered three new medications for her. Place the following steps
of the nursing process in the correct order.
A. The nurse returns to the patient's room and asks her to describe the medicines
she will be taking at home
B. The nurse talks with the patient and family about who will be available if the
patient has difficulty taking medicines and considers consulting with the health care
provider about a home health visit
C. The nurse asks the patient if she is in pain, feels tired, and is willing to spend the
next few minutes learning about new medicines
D. The nurse brings the containers of medicines and info leaflets to the bedside and
discusses each medication with her
E. The nurse considers what she learns from the patient and identifies the patient's
nursing diagnosis - ANSWER: C, E, B, D, A
EXAM 200 QUESTIONS AND CORRECT DETAILED ANSWERS
WITH RATIONALES|ALREADY GRADED A+||CHAMBERLAINE
COLLEGE
While assessing a patient, the nurse observes the patient's IV line is not infusing at
the ordered rate. The nurse assesses the patient for pain at the IV site, checks the
flow regulator on the tubing, looks to see if the patient is lying on the tubing, checks
the point of connection between the tubing and the IV catheter, and then checks the
condition of the site where the IV catheter enters the patient's skin. After the nurse
readjusts the flow rate, the infusion begins at the correct rate. This is an example of:
A. inference
B. Diagnostic reasoning
C. Competency
D. Problem solving - ANSWER: D. Problem Solving
The nurse sits down to talk with a patient who lost her sister 2 weeks ago. The
patient reports she is unable to sleep, feels very fatigued during the day, and is
having trouble at work. The nurse asks her to clarify the type of trouble. The patient
explains she can't concentrate or even solve simple problems. The nurse records the
results of the assessment, describing the patient as having ineffective coping. This is
an example of :
A. diagnostic reasoning
B. Competency
C. Inference
D. Problem Solving - ANSWER: A. Diagnostic reasoning
A patient on a surgical unit develops sudden shortness of breath and a drop in BP.
The staff respond, but the patient dies 30 minutes later. the manager on the nursing
unit calls the staff involved in the emergency response together, The staff discusses
what occurred over the 30 minute time frame, the actions taken, and whether other
steps should have been implemented. The nurses in this situation are:
A. problem solving
B. showing humility
C. conducting reflective practice
D. Exercising responsibility - ANSWER: C. Conducting reflective practice
A nurse has worked on an oncology unit for 3 years. One patient has become visibly
weaker and states, "I feel funny". The nurse knows how patients often have behavior
changes before developing sepsis when they have cancer. The nurse asks the patient
questions to assess thinking skills and notices the patient shivering. The nurse goes
to the phone, calls the physician, and begins the conversation by saying, "I believe
that your patient is developing sepsis. I want to report symptoms I'm seeing." What
examples of critical thinking concepts does the nurse show? (Select all that apply)
A. Experience
,B. Ethical
C. Analyticity
D. Self-confidence
E. Risk taking - ANSWER: C. Analyticity
D. Self confidence
A nurse who is working on a surgical unit is caring for four different patients. Patient
A will be discharged home and is in need of instruction about wound care. Patients B
and C have returned from the operating room within an hour of each other, and
both require vital signs and monitoring of their intravenous (IV) lines.
Patient D is resting following a visit by physical therapy. Which of the following
activities by the nurse represent(s) use of clinical decision making for groups of
patients? (Select all that apply.)
A. consider how to involve patient A in deciding whether to involve the family
caregiver in wound care instruction
B. Think about past experience with patients who develop postoperative
complications
C. Decide which activities can be combined for patients B and C
D. Carefully gather any assessment info and identify patient problems - ANSWER: A
&C
The surgical unit has initiated the use of a pain-rating scale to assess patients' pain
severity during their postoperative recovery. The registered nurse (RN) looks at the
pain flow sheet to see the pain scores recorded for a patient over the last 24 hours.
Use of the pain scale is an example of which intellectual standard?
A. deep
B. Relevant
C. Consistent
D. Significant - ANSWER: C
During a home health visit the nurse prepares to instruct a patient in how to perform
range-of-motion (ROM) exercises for an injured shoulder. The nurse verifies that the
patient took an analgesic 30 minutes before arrival at the patient's home. After
discussing the purpose for the exercises and demonstrating each one, the nurse has
the patient perform them. After two attempts with only the second of three
exercises, the patient stops and says, "This hurts too much. I don't see why I have to
do this so many times." The nurse applies the critical thinking attitude of integrity in
which of the following actions?"
A. "I understand your reluctance, but the exercises are necessary for you to regain
function in your shoulder. Let's go a bit more slowly and try to relax"
B. "I see that you're uncomfortable. I'll call your doctor to decide the next step."
C. "Show me exactly where your pain is and rate it for me on a scale - ANSWER: A
The nurse cared for a 14-year-old with renal failure who died near the end of the
work shift. The health care team tried for 45 minutes to resuscitate the child with no
, success. The family was devastated by the loss, and, when the nurse tried to talk
with them, the mother said, "You can't make me feel better; you don't know what
it's like to lose a child." Which of the following examples of journal entries might best
help the nurse reflect and think about this clinical experience? (Select all that apply.)
A. Data entry of the time of day, who was present, and the condition or the child
B. Description of the efforts to restore the child's BP, what was used, and questions
about the child's response
C. The meaning the experience had for the nurse with respect to her understanding
of dealing with the patient's death
D. A description of what the nurse said to the mother, the mother's response, and
how the nurse might app - ANSWER: B, C, & D
A nurse has been working on a surgical unit for 3 weeks. A patient requires a Foley
catheter to be inserted, so the nurse reads the procedure manual for the institution
to review how to insert it. The level of critical thinking the nurse is using is:
A. Commitment
B. Scientific method
C. basic critical thinking
D. Complex critical thinking - ANSWER: C
A patient had hip surgery 16 hours ago. During the previous shift the patient had 40
mL of drainage in the surgical drainage collection device for an 8-hour period. The
nurse refers to the written plan of care, noting that the health care provider is to be
notified when drainage in the device exceeds 100 mL for the day. On entering the
room, the nurse looks at the device and carefully notes the amount of drainage
currently in it. This is an example of:
A. planning
B. evaluation
C. Intervention
D. Diagnosis - ANSWER: B
A 67-year-old patient will be discharged from the hospital in the morning. The health
care provider has ordered three new medications for her. Place the following steps
of the nursing process in the correct order.
A. The nurse returns to the patient's room and asks her to describe the medicines
she will be taking at home
B. The nurse talks with the patient and family about who will be available if the
patient has difficulty taking medicines and considers consulting with the health care
provider about a home health visit
C. The nurse asks the patient if she is in pain, feels tired, and is willing to spend the
next few minutes learning about new medicines
D. The nurse brings the containers of medicines and info leaflets to the bedside and
discusses each medication with her
E. The nurse considers what she learns from the patient and identifies the patient's
nursing diagnosis - ANSWER: C, E, B, D, A
