NSG 252 - Exam #2 Study Guide Questions With Complete
Solutions
Chapter 20
10. A nurse enters a patient's room and begins a conversation.
During this time the nurse evaluates how a patient is tolerating a
new diet plan. The nurse decides to also evaluate the patient's
expectations of care. Which statement is appropriate for
evaluating a patient's expectations of care?
1. On a scale of 0 to 10 rate your level of nausea.
2. The nurse weighs the patient.
3. The nurse asks, "Did you believe that you received the
information you needed to follow your diet?"
4. The nurse states, "Tell me four different foods included in
your diet." Correct Answers 3
Chapter 20
11. A nurse checks an intravenous (IV) solution container for
clarity of the solution, noting that it is infusing into the patient's
left arm. The IV solution of 9% NS is infusing freely at 100 mL/
hr as ordered. The nurse reviews the nurses' notes from the
previous shift to determine if the dressing over the site was
changed as scheduled per standard of care. While in the room
the nurse inspects the condition of the dressing and notes the
date on the dressing label. In which ways did the nurse evaluate
the condition of the IV site? (Select all that apply.)
1. Checked the IV infusion rate
2. Checked the type of IV solution
3. Confirmed from nurses' notes the time of dressing change
,4. Inspected the condition of the IV dressing at the site
5. Checked clarity of IV solution Correct Answers 1, 4
Chapter 20
12. A patient is being discharged after treatment for colitis
(inflammation of the colon). The patient has had no episodes of
diarrhea or abdominal pain for 24 hours. Following instruction,
the patient identified correctly the need to follow a low-residue
diet and the types of food to include if a bout of diarrhea
develops at home. These behaviors are examples of:
1. Evaluative measures.
2. Expected outcomes.
3. Reassessments.
4. Standards of care. Correct Answers 2
Chapter 17
14. The use of standard formal nursing diagnostic statements
serves several purposes in nursing practice, including which of
the following? (Select all that apply.)
A. Defines a patient's problem, giving members of the health
care team a common language for understanding the patient's
needs
B. Allows physicians and allied health staff to communicate
with nurses how they provide care among themselves
C. Helps nurses focus on the scope of nursing practice
D. Creates practice guidelines for collaborative health care
activities
E. Builds and expands nursing knowledge Correct Answers A,
C, E
,Chapter 17
15. Which of the following nursing diagnoses is stated
correctly? (Select all that apply)
A. Fluid volume excess related to HF
B. Sleep deprivation related to sustained noisy environment
C. Impaired bed mobility related to post cardiac catheterization
D. Ineffective protection related to inadequate nutrition
E. Diarrhea related to frequent small watery stools Correct
Answers B, D
Chapter 18
1. A nurse enters the room of a 32-year-old patient newly
diagnosed with cancer at the beginning of the 0700
evening/night shift. The nurse noted in the patient's nursing
history that this is her first hospitalization. She is scheduled for
surgery in the morning to remove a tumor and has questions
about what to expect after surgery. She is observed talking with
her mother and is crying. The patient says, "This is so unfair."
An order has been written for an enema to be given this evening
in preparation for the surgery. The nurse establishes priorities
for which of the following situations first?
A. Giving the enema on time
B. Talking with the patient about her past experiences with
illness
C. Talking with the patient about her concerns and
acknowledging her sense of unfairness
D. Beginning instruction on postoperative procedures Correct
Answers C
, Chapter 18
2. A 62-year-old patient had a portion of the large colon
removed and a colostomy created for drainage of stool. The
nurse has had repeated problems with the patient's colostomy
bag not adhering to the skin and thus leaking. The nurse wants
to consult with the wound care nurse specialist. Which of the
following should the nurse do? (Select all that apply)
A. Assess condition of skin before making the call
B. Rely on the nurse specialist to know the type of surgery the
patient likely had
C. Explain the patients response emotionally to the repeated
leaking of stool
D. Describe the type of bag being used and how long it lasts
before leaking
E. Order extra colostomy bags currently being used Correct
Answers A, C, D
Chapter 18
3. It is time for a nurse hand-off between the night nurse and
nurse starting the day shift. The night nurse checks the most
recent laboratory results for the patient and then begins to
discuss the patient's plan of care to the day nurse using the
standard checklist for reporting essential information. The
patient has been seriously ill, and his wife is at the bedside. The
nurse asks the wife to leave the room for just a few minutes. The
night nurse completes the summary of care before the day nurse
is able to ask a question. Which of the following activities are
strategies for an effective hand-off? (Select all that Apply)
Solutions
Chapter 20
10. A nurse enters a patient's room and begins a conversation.
During this time the nurse evaluates how a patient is tolerating a
new diet plan. The nurse decides to also evaluate the patient's
expectations of care. Which statement is appropriate for
evaluating a patient's expectations of care?
1. On a scale of 0 to 10 rate your level of nausea.
2. The nurse weighs the patient.
3. The nurse asks, "Did you believe that you received the
information you needed to follow your diet?"
4. The nurse states, "Tell me four different foods included in
your diet." Correct Answers 3
Chapter 20
11. A nurse checks an intravenous (IV) solution container for
clarity of the solution, noting that it is infusing into the patient's
left arm. The IV solution of 9% NS is infusing freely at 100 mL/
hr as ordered. The nurse reviews the nurses' notes from the
previous shift to determine if the dressing over the site was
changed as scheduled per standard of care. While in the room
the nurse inspects the condition of the dressing and notes the
date on the dressing label. In which ways did the nurse evaluate
the condition of the IV site? (Select all that apply.)
1. Checked the IV infusion rate
2. Checked the type of IV solution
3. Confirmed from nurses' notes the time of dressing change
,4. Inspected the condition of the IV dressing at the site
5. Checked clarity of IV solution Correct Answers 1, 4
Chapter 20
12. A patient is being discharged after treatment for colitis
(inflammation of the colon). The patient has had no episodes of
diarrhea or abdominal pain for 24 hours. Following instruction,
the patient identified correctly the need to follow a low-residue
diet and the types of food to include if a bout of diarrhea
develops at home. These behaviors are examples of:
1. Evaluative measures.
2. Expected outcomes.
3. Reassessments.
4. Standards of care. Correct Answers 2
Chapter 17
14. The use of standard formal nursing diagnostic statements
serves several purposes in nursing practice, including which of
the following? (Select all that apply.)
A. Defines a patient's problem, giving members of the health
care team a common language for understanding the patient's
needs
B. Allows physicians and allied health staff to communicate
with nurses how they provide care among themselves
C. Helps nurses focus on the scope of nursing practice
D. Creates practice guidelines for collaborative health care
activities
E. Builds and expands nursing knowledge Correct Answers A,
C, E
,Chapter 17
15. Which of the following nursing diagnoses is stated
correctly? (Select all that apply)
A. Fluid volume excess related to HF
B. Sleep deprivation related to sustained noisy environment
C. Impaired bed mobility related to post cardiac catheterization
D. Ineffective protection related to inadequate nutrition
E. Diarrhea related to frequent small watery stools Correct
Answers B, D
Chapter 18
1. A nurse enters the room of a 32-year-old patient newly
diagnosed with cancer at the beginning of the 0700
evening/night shift. The nurse noted in the patient's nursing
history that this is her first hospitalization. She is scheduled for
surgery in the morning to remove a tumor and has questions
about what to expect after surgery. She is observed talking with
her mother and is crying. The patient says, "This is so unfair."
An order has been written for an enema to be given this evening
in preparation for the surgery. The nurse establishes priorities
for which of the following situations first?
A. Giving the enema on time
B. Talking with the patient about her past experiences with
illness
C. Talking with the patient about her concerns and
acknowledging her sense of unfairness
D. Beginning instruction on postoperative procedures Correct
Answers C
, Chapter 18
2. A 62-year-old patient had a portion of the large colon
removed and a colostomy created for drainage of stool. The
nurse has had repeated problems with the patient's colostomy
bag not adhering to the skin and thus leaking. The nurse wants
to consult with the wound care nurse specialist. Which of the
following should the nurse do? (Select all that apply)
A. Assess condition of skin before making the call
B. Rely on the nurse specialist to know the type of surgery the
patient likely had
C. Explain the patients response emotionally to the repeated
leaking of stool
D. Describe the type of bag being used and how long it lasts
before leaking
E. Order extra colostomy bags currently being used Correct
Answers A, C, D
Chapter 18
3. It is time for a nurse hand-off between the night nurse and
nurse starting the day shift. The night nurse checks the most
recent laboratory results for the patient and then begins to
discuss the patient's plan of care to the day nurse using the
standard checklist for reporting essential information. The
patient has been seriously ill, and his wife is at the bedside. The
nurse asks the wife to leave the room for just a few minutes. The
night nurse completes the summary of care before the day nurse
is able to ask a question. Which of the following activities are
strategies for an effective hand-off? (Select all that Apply)
