Nursing 305 Exam 2 questions with correct answers
7. The nurse is reviewing a patient's database for significant changes and
discovers that the patient has not voided in over 8 hours. The patient's
kidney function lab results are abnormal, and the patient's oral intake has
significantly decreased since previous shifts. Which step of the nursing
process should the nurse proceed to after this review?
a. Diagnosis
b. Planning
c. Implementation
d. Evaluation Correct Answer-ANS: A
9. A nurse administers an antihypertensive medication to a patient at the
scheduled time of 0900. The nursing assistive personnel (NAP) then
reports to the nurse that the patient's blood pressure was low when it was
taken at 0830. The NAP states that was busy and had not had a chance to
tell the nurse yet. The patient begins to complain of feeling dizzy and
light-headed. The blood pressure is rechecked and it has dropped even
lower. In which phase of the nursing process did the nurse first make an
error?
a. Assessment
b. Diagnosis
c. Implementation
d. Evaluation Correct Answer-a. Assessment
11. The patient database reveals that a patient has decreased oral intake,
decreased oxygen saturation when ambulating, reports of shortness of
breath when getting out of bed, and a productive cough. Which elements
,will the nurse identify as defining characteristics for the diagnostic label
of Activity intolerance?
a. Decreased oral intake and decreased oxygen saturation when
ambulating
b. Decreased oxygen saturation when ambulating and reports of
shortness of breath when getting out of bed
c. Reports of shortness of breath when getting out of bed and a
productive cough
d. Productive cough and decreased oral intake Correct Answer-b.
Decreased oxygen saturation when ambulating and reports of shortness
of breath when getting out of bed
12. A nurse performs an assessment on a patient. Which assessment data
will the nurse use as an etiology for Acute pain?
a. Discomfort while changing position
b. Reports pain as a 7 on a 0 to 10 scale
c. Disruption of tissue integrity
d. Dull headache Correct Answer-Disruption of tissue integrity
13. A new nurse writes the following nursing diagnoses on a patient's
care plan. Which nursing diagnosis will cause the nurse manager to
intervene?
a. Wandering
b. Hemorrhage
c. Urinary retention
d. Impaired swallowing Correct Answer-ANS: B
, 15. A nurse adds a nursing diagnosis to a patient's care plan. Which
information did the nurse document?
a. Decreased cardiac output related to altered myocardial contractility.
b. Patient needs a low-fat diet related to inadequate heart perfusion.
c. Offer a low-fat diet because of heart problems.
d. Acute heart pain related to discomfort. Correct Answer-ANS: A
16. A charge nurse is evaluating a new nurse's plan of care. Which
finding will cause the charge nurse to follow up?
a. Assigning a documented nursing diagnosis of Risk for infection for a
patient on intravenous (IV) antibiotics
b. Completing an interview and physical examination before adding a
nursing diagnosis
c. Developing nursing diagnoses before completing the database
d. Including cultural and religious preferences in the database Correct
Answer-c. Developing nursing diagnoses before completing the database
19. A nurse assesses that a patient has not voided in 6 hours. Which
question should the nurse ask to assist in establishing a nursing diagnosis
of Urinary retention?
a. "Do you feel like you need to go to the bathroom?"
b. "Are you able to walk to the bathroom by yourself?"
c. "When was the last time you took your medicine?"
7. The nurse is reviewing a patient's database for significant changes and
discovers that the patient has not voided in over 8 hours. The patient's
kidney function lab results are abnormal, and the patient's oral intake has
significantly decreased since previous shifts. Which step of the nursing
process should the nurse proceed to after this review?
a. Diagnosis
b. Planning
c. Implementation
d. Evaluation Correct Answer-ANS: A
9. A nurse administers an antihypertensive medication to a patient at the
scheduled time of 0900. The nursing assistive personnel (NAP) then
reports to the nurse that the patient's blood pressure was low when it was
taken at 0830. The NAP states that was busy and had not had a chance to
tell the nurse yet. The patient begins to complain of feeling dizzy and
light-headed. The blood pressure is rechecked and it has dropped even
lower. In which phase of the nursing process did the nurse first make an
error?
a. Assessment
b. Diagnosis
c. Implementation
d. Evaluation Correct Answer-a. Assessment
11. The patient database reveals that a patient has decreased oral intake,
decreased oxygen saturation when ambulating, reports of shortness of
breath when getting out of bed, and a productive cough. Which elements
,will the nurse identify as defining characteristics for the diagnostic label
of Activity intolerance?
a. Decreased oral intake and decreased oxygen saturation when
ambulating
b. Decreased oxygen saturation when ambulating and reports of
shortness of breath when getting out of bed
c. Reports of shortness of breath when getting out of bed and a
productive cough
d. Productive cough and decreased oral intake Correct Answer-b.
Decreased oxygen saturation when ambulating and reports of shortness
of breath when getting out of bed
12. A nurse performs an assessment on a patient. Which assessment data
will the nurse use as an etiology for Acute pain?
a. Discomfort while changing position
b. Reports pain as a 7 on a 0 to 10 scale
c. Disruption of tissue integrity
d. Dull headache Correct Answer-Disruption of tissue integrity
13. A new nurse writes the following nursing diagnoses on a patient's
care plan. Which nursing diagnosis will cause the nurse manager to
intervene?
a. Wandering
b. Hemorrhage
c. Urinary retention
d. Impaired swallowing Correct Answer-ANS: B
, 15. A nurse adds a nursing diagnosis to a patient's care plan. Which
information did the nurse document?
a. Decreased cardiac output related to altered myocardial contractility.
b. Patient needs a low-fat diet related to inadequate heart perfusion.
c. Offer a low-fat diet because of heart problems.
d. Acute heart pain related to discomfort. Correct Answer-ANS: A
16. A charge nurse is evaluating a new nurse's plan of care. Which
finding will cause the charge nurse to follow up?
a. Assigning a documented nursing diagnosis of Risk for infection for a
patient on intravenous (IV) antibiotics
b. Completing an interview and physical examination before adding a
nursing diagnosis
c. Developing nursing diagnoses before completing the database
d. Including cultural and religious preferences in the database Correct
Answer-c. Developing nursing diagnoses before completing the database
19. A nurse assesses that a patient has not voided in 6 hours. Which
question should the nurse ask to assist in establishing a nursing diagnosis
of Urinary retention?
a. "Do you feel like you need to go to the bathroom?"
b. "Are you able to walk to the bathroom by yourself?"
c. "When was the last time you took your medicine?"
