NURS 3000- Exam 2 UPDATED ACTUAL Questions and
CORRECT Answers
Setting priorities (Maslow's Hierarchy of Needs) -life-threatening, physiological needs take priority (water, food, air, sleep)
What takes priority? -the need for safety and security is the next tier above physiological needs
Essential focus for at least one goal in plan of nursing
care
How could this goal be revised? Needs a time frame
Pt will list 2 low-fat foods. Pt will list 2 low-fat foods before discharge.
How could this goal be revised? Needs to be measurable
Pt will consume more calories every day beginning on Pt will consume at least 2,000 calories every day beginning on 10/02/25.
10/02/25.
How can this goal be revised? Needs to be specific
Pt will report less pain. Pt's pain rating will decrease by 2 within the next 4 hours.
How could this goal be revised? This goal may not be attainable.
Pt will walk 1 mile independently. Pt will walk to the bathroom without assistance.
SMART goal specific, measurable, attainable, realistic, time frame
How could this goal be revised? Needs to be realistic
Pt will lose 5 pounds by 10/05/25. Pt will verbalize understanding of two strategies to support healthy weight loss
after discharge.
How could this goal be revised? Needs to have time frame
Pt will maintain adequate fluid intake. Pt will consume at least 2,000 mL of fluids daily until D/C.
Is this a long-term or short-term goal? Pt will have daily BM without use of laxatives within two months.
Is this a long-term or short-term goal? Pt will have next BM within 36 hours without aid of PO laxatives.
What is the difference between long-term and short-term Long-term goals center around patient outcomes over one week or more. Short-
goals? term goals have outcomes that can be achieved within a few days or hours.
, How could this nursing order be corrected? This nursing order pertains to a task already covered by physician order.
Give pain meds as needed. Assess pt pain rating on a scale of 1-10 every 2 hours.
How could this nursing order be corrected? Nursing orders should be independent actions of the nurse.
Include at least one fiber-rich food on each meal tray.
Call HCP about implementing fiber-rich foods into the
patient's diet.
How could this nursing intervention be corrected? Too vague
Monitor vital signs every 2 hours. "Monitor vital signs every 4 hours and PRN. Notify HCP if systolic BP < 90 mmHg
or HR > 120 bpm."
How could this nursing intervention be corrected? Needs to be more specific
Assist with ambulation. "Assist patient with ambulation three times daily using a gait belt and walker."
How could this nursing intervention be corrected? Needs to be measurable
Encourage fluid intake. "Encourage oral fluid intake to 2000 mL/day."
Purpose of implementation/taking action phase of clinical decrease or eliminate causal, contributing, or risk factors; relieve symptoms
reasoning/judgment process
Examples of implementation/taking action phase of -Teach coughing and deep breathing exercises.
clinical reasoning/judgment process -Assist to sit up on side of bed when expectorating.
-Auscultate lung sounds every 4 hrs.
Five rights of delegations right task, right circumstance, right person, right direction, right supervision
Right task ones that are repetitively performed; minimal problem solving/innovation
Examples of delegations V/S, I/O, transfer/ambulate, bathing, feeding, weighing, postmortem care, CPR,
feeding, non-invasive tx, attending to safety
Right circumstances appropriate setting with available resources
Right person right person delegating to right person for right patient
Right direction concise description of task
Right supervision appropriate monitoring, evaluation, etc.
RN's ultimate responsibility for client care still responsible for quality of care; needs to clearly communicate to UAP and
verify UAP understands
Purpose of evaluation of outcomes decide whether to continue, modify, or terminate the plan of nursing care
CORRECT Answers
Setting priorities (Maslow's Hierarchy of Needs) -life-threatening, physiological needs take priority (water, food, air, sleep)
What takes priority? -the need for safety and security is the next tier above physiological needs
Essential focus for at least one goal in plan of nursing
care
How could this goal be revised? Needs a time frame
Pt will list 2 low-fat foods. Pt will list 2 low-fat foods before discharge.
How could this goal be revised? Needs to be measurable
Pt will consume more calories every day beginning on Pt will consume at least 2,000 calories every day beginning on 10/02/25.
10/02/25.
How can this goal be revised? Needs to be specific
Pt will report less pain. Pt's pain rating will decrease by 2 within the next 4 hours.
How could this goal be revised? This goal may not be attainable.
Pt will walk 1 mile independently. Pt will walk to the bathroom without assistance.
SMART goal specific, measurable, attainable, realistic, time frame
How could this goal be revised? Needs to be realistic
Pt will lose 5 pounds by 10/05/25. Pt will verbalize understanding of two strategies to support healthy weight loss
after discharge.
How could this goal be revised? Needs to have time frame
Pt will maintain adequate fluid intake. Pt will consume at least 2,000 mL of fluids daily until D/C.
Is this a long-term or short-term goal? Pt will have daily BM without use of laxatives within two months.
Is this a long-term or short-term goal? Pt will have next BM within 36 hours without aid of PO laxatives.
What is the difference between long-term and short-term Long-term goals center around patient outcomes over one week or more. Short-
goals? term goals have outcomes that can be achieved within a few days or hours.
, How could this nursing order be corrected? This nursing order pertains to a task already covered by physician order.
Give pain meds as needed. Assess pt pain rating on a scale of 1-10 every 2 hours.
How could this nursing order be corrected? Nursing orders should be independent actions of the nurse.
Include at least one fiber-rich food on each meal tray.
Call HCP about implementing fiber-rich foods into the
patient's diet.
How could this nursing intervention be corrected? Too vague
Monitor vital signs every 2 hours. "Monitor vital signs every 4 hours and PRN. Notify HCP if systolic BP < 90 mmHg
or HR > 120 bpm."
How could this nursing intervention be corrected? Needs to be more specific
Assist with ambulation. "Assist patient with ambulation three times daily using a gait belt and walker."
How could this nursing intervention be corrected? Needs to be measurable
Encourage fluid intake. "Encourage oral fluid intake to 2000 mL/day."
Purpose of implementation/taking action phase of clinical decrease or eliminate causal, contributing, or risk factors; relieve symptoms
reasoning/judgment process
Examples of implementation/taking action phase of -Teach coughing and deep breathing exercises.
clinical reasoning/judgment process -Assist to sit up on side of bed when expectorating.
-Auscultate lung sounds every 4 hrs.
Five rights of delegations right task, right circumstance, right person, right direction, right supervision
Right task ones that are repetitively performed; minimal problem solving/innovation
Examples of delegations V/S, I/O, transfer/ambulate, bathing, feeding, weighing, postmortem care, CPR,
feeding, non-invasive tx, attending to safety
Right circumstances appropriate setting with available resources
Right person right person delegating to right person for right patient
Right direction concise description of task
Right supervision appropriate monitoring, evaluation, etc.
RN's ultimate responsibility for client care still responsible for quality of care; needs to clearly communicate to UAP and
verify UAP understands
Purpose of evaluation of outcomes decide whether to continue, modify, or terminate the plan of nursing care
