NUR 209 NEW EXAM QUESTIONS AND ANSWERS
100% VERIFIED (A+)
A nurse develops a plan of care to enhance walking mobility in an older adult client.
When encouraged to implement the new strategies for ambulation the client refuses to
try and tells the nurse, "I find it easier to use a wheelchair." Which following action by
the nurse may have led to failure to meet the outcome? - ANSWER developing the plan
without client input
The nurse visits the residence of a older adult client. The agency received a call
because a neighbour reported that the client was at home alone. The nurse discovers
the client sitting alone in the living room. When asked about the client's daughter who
lives there and has been caring for her, the client states, "She went on vacation for
about a month. She'll be back soon." Further assessment reveals there are no other
family members or services currently involved. The nurse would identify this situation
as: ANSWER abandonment
A nurse is in a process of diagnostic reasoning to propose proper nursing diagnosis for
a client. Put the steps in order that they would happen first to last in this process. -
ANSWER Correct answer: Organizing the existence of cues, Generating possible
diagnoses, Comparing cues to possible diagnoses, Conducting a focused data
collection, Validating diagnoses
Which is the best example of the evaluation stage of the nursing process? - ANSWER
Correct answer: assessing the client's blood pressure 30 minutes after giving captopril.
During a home health care visit, the nurse determines a nursing diagnosis of Caregiver
Role Strain for the parent caring for a child dependent on a ventilator. What subjective
assessment data would support the nurse's diagnosis? ANSWER The parent says, "I
cannot allow anyone else to help because they won't do it right."
During morning report, the night nurse informs the day nurse that the client refused to
allow the technician to draw blood for laboratory testing. Which of the following steps is
most important for the day nurse to complete before choosing a nursing diagnosis
,related to this problem? - ANSWER The nurse must identify why the client refused to
have the blood drawn.
The night shift RN is caring for a hospitalized adult client who reports the inability to
sleep. The client states, "I just can't sleep here. I miss my home. There are too many
lights and it is too hot." Which would be the best nursing diagnosis for this client? -
ANSWER Disturbed sleep pattern
The nurse is admitting a young client to the unit. Which of the following are objective
data? Select all that apply. - ANSWER 38-year-old man
height 6' (1.82m)
weight 195 lb (89kg)
A client has had major abdominal surgery and just returned to the unit from the
operating room. The nursing priority is to: - ANSWER complete postoperative
assessment.
When the nurse is examining a postoperative incision site for infection, which of the
following types of assessments is being done? ANSWER Focused
Which statement appropriately identifies a risk nursing diagnosis for a female client 78
years of age who is bedridden? - ANSWER Risk for impaired skin integrity related to bed
rest
A student takes an adult client's pulse and counts 20 beats/min. Knowing this is not the
normal range for an adult pulse, what should the student do next? - ANSWER Ask the
instructor or a staff nurse to take the pulse.
A nurse is obtaining the vital signs of a new hospital client admitted with severe
abdominal pain. Which initial step of the nursing process is this nurse performing? -
ANSWER Assessment
The RN is admitting a client to a medical unit. The nurse delegates the measurement of
,the vital signs to unlicensed assistive personnel (UAP) while she collects data. After
completing the admission process the client reports a severe headache, so the nurse
reassesses the vital signs to find the client's blood pressure extremely elevated. Whose
responsibility is the accuracy of the blood pressure measurement? - ANSWER the nurse
Nurses gather objective and subjective data while completing client assessments.
Which is an example of objective data? - ANSWER A client who has liver failure has a
yellowish tint to his skin.
The nurse completes the following on the client's chart: The client will have complete
healing of the surgical incision to the right lower quadrant of the abdomen is 3 weeks.
This is a(an): - ANSWER outcome identification
The nurse is caring for a client who is suspected of having an infection of the kidney.
Which scenario reflects the collection of subjective data from the primary source? -
ANSWER The client reports to the nurse that it hurts when urinating.
A nurse is documenting findings from an assessment. Which finding would the nurse
record as objective data? Choose all that apply. - ANSWER Blood pressure 128/68 mm
Hg
Weight 175 lb (80 kg)
Bowel sounds active in all 4 quadrants
The nurse is reading a client's health history and physical assessment data, while the
client is experiencing a respiratory problem. Which of the following data is collected
from the health history would be a cue for the client to formulate a nursing diagnosis for
this problem? - ANSWER "I get out of breath when I walk a few steps."
After conducting an assessment on a client, which information would the nurse identify
as priority for intervention? - ANSWER
Severe hemorrhage from wound - ANSWER
, The nurse is analyzing data related to a client and identifies the following assessment
data. Which cue does the nurse identify as subjective data? - ANSWER
Pain scale is 7 - ANSWER
The nurse is performing rounds and finds the client slumped down in the bed. The nurse
positions the client to a more comfortable position, and the client grimaces and tenses
the body. The nurse performs a complete pain assessment, notes the time of last
analgesic, and prepares the medication. Administering the medication is which step of
the nursing process? - ANSWER
Implementation - ANSWER
A nurse is administering medications to a client. Which step of the nursing process
would the nurse carry out next? - ANSWER
Evaluating - ANSWER
A nurse is explaining the purpose of nursing diagnoses to a client. Which of the following
statements would be most appropriate for the nurse to make? - ANSWER
"Nursing diagnoses are used to guide the nurse in selecting appropriate nursing
interventions." - ANSWER
Which of the following is licensed to make a nursing diagnosis?
Registered nurse
The hospice nurse is making a visit to the older adult wife of a client 4 weeks after the
client died. Of the following, which statement the wife makes is of most concern to the
hospice nurse?
100% VERIFIED (A+)
A nurse develops a plan of care to enhance walking mobility in an older adult client.
When encouraged to implement the new strategies for ambulation the client refuses to
try and tells the nurse, "I find it easier to use a wheelchair." Which following action by
the nurse may have led to failure to meet the outcome? - ANSWER developing the plan
without client input
The nurse visits the residence of a older adult client. The agency received a call
because a neighbour reported that the client was at home alone. The nurse discovers
the client sitting alone in the living room. When asked about the client's daughter who
lives there and has been caring for her, the client states, "She went on vacation for
about a month. She'll be back soon." Further assessment reveals there are no other
family members or services currently involved. The nurse would identify this situation
as: ANSWER abandonment
A nurse is in a process of diagnostic reasoning to propose proper nursing diagnosis for
a client. Put the steps in order that they would happen first to last in this process. -
ANSWER Correct answer: Organizing the existence of cues, Generating possible
diagnoses, Comparing cues to possible diagnoses, Conducting a focused data
collection, Validating diagnoses
Which is the best example of the evaluation stage of the nursing process? - ANSWER
Correct answer: assessing the client's blood pressure 30 minutes after giving captopril.
During a home health care visit, the nurse determines a nursing diagnosis of Caregiver
Role Strain for the parent caring for a child dependent on a ventilator. What subjective
assessment data would support the nurse's diagnosis? ANSWER The parent says, "I
cannot allow anyone else to help because they won't do it right."
During morning report, the night nurse informs the day nurse that the client refused to
allow the technician to draw blood for laboratory testing. Which of the following steps is
most important for the day nurse to complete before choosing a nursing diagnosis
,related to this problem? - ANSWER The nurse must identify why the client refused to
have the blood drawn.
The night shift RN is caring for a hospitalized adult client who reports the inability to
sleep. The client states, "I just can't sleep here. I miss my home. There are too many
lights and it is too hot." Which would be the best nursing diagnosis for this client? -
ANSWER Disturbed sleep pattern
The nurse is admitting a young client to the unit. Which of the following are objective
data? Select all that apply. - ANSWER 38-year-old man
height 6' (1.82m)
weight 195 lb (89kg)
A client has had major abdominal surgery and just returned to the unit from the
operating room. The nursing priority is to: - ANSWER complete postoperative
assessment.
When the nurse is examining a postoperative incision site for infection, which of the
following types of assessments is being done? ANSWER Focused
Which statement appropriately identifies a risk nursing diagnosis for a female client 78
years of age who is bedridden? - ANSWER Risk for impaired skin integrity related to bed
rest
A student takes an adult client's pulse and counts 20 beats/min. Knowing this is not the
normal range for an adult pulse, what should the student do next? - ANSWER Ask the
instructor or a staff nurse to take the pulse.
A nurse is obtaining the vital signs of a new hospital client admitted with severe
abdominal pain. Which initial step of the nursing process is this nurse performing? -
ANSWER Assessment
The RN is admitting a client to a medical unit. The nurse delegates the measurement of
,the vital signs to unlicensed assistive personnel (UAP) while she collects data. After
completing the admission process the client reports a severe headache, so the nurse
reassesses the vital signs to find the client's blood pressure extremely elevated. Whose
responsibility is the accuracy of the blood pressure measurement? - ANSWER the nurse
Nurses gather objective and subjective data while completing client assessments.
Which is an example of objective data? - ANSWER A client who has liver failure has a
yellowish tint to his skin.
The nurse completes the following on the client's chart: The client will have complete
healing of the surgical incision to the right lower quadrant of the abdomen is 3 weeks.
This is a(an): - ANSWER outcome identification
The nurse is caring for a client who is suspected of having an infection of the kidney.
Which scenario reflects the collection of subjective data from the primary source? -
ANSWER The client reports to the nurse that it hurts when urinating.
A nurse is documenting findings from an assessment. Which finding would the nurse
record as objective data? Choose all that apply. - ANSWER Blood pressure 128/68 mm
Hg
Weight 175 lb (80 kg)
Bowel sounds active in all 4 quadrants
The nurse is reading a client's health history and physical assessment data, while the
client is experiencing a respiratory problem. Which of the following data is collected
from the health history would be a cue for the client to formulate a nursing diagnosis for
this problem? - ANSWER "I get out of breath when I walk a few steps."
After conducting an assessment on a client, which information would the nurse identify
as priority for intervention? - ANSWER
Severe hemorrhage from wound - ANSWER
, The nurse is analyzing data related to a client and identifies the following assessment
data. Which cue does the nurse identify as subjective data? - ANSWER
Pain scale is 7 - ANSWER
The nurse is performing rounds and finds the client slumped down in the bed. The nurse
positions the client to a more comfortable position, and the client grimaces and tenses
the body. The nurse performs a complete pain assessment, notes the time of last
analgesic, and prepares the medication. Administering the medication is which step of
the nursing process? - ANSWER
Implementation - ANSWER
A nurse is administering medications to a client. Which step of the nursing process
would the nurse carry out next? - ANSWER
Evaluating - ANSWER
A nurse is explaining the purpose of nursing diagnoses to a client. Which of the following
statements would be most appropriate for the nurse to make? - ANSWER
"Nursing diagnoses are used to guide the nurse in selecting appropriate nursing
interventions." - ANSWER
Which of the following is licensed to make a nursing diagnosis?
Registered nurse
The hospice nurse is making a visit to the older adult wife of a client 4 weeks after the
client died. Of the following, which statement the wife makes is of most concern to the
hospice nurse?
