TEST BANK: Chapter 1 – Using Nursing Care Plans to Individualize and Improve Care

A new graduate nurse is caring for a patient admitted with heart failure. The electronic care plan lists “fluid volume excess,” “activity intolerance,” and “risk for impaired gas exchange,” but the nurse notices the patient is also anxious and asks repeated questions about discharge. Which statement best describes the purpose of the nursing care plan? A. It replaces the need for bedside assessment once diagnoses are identified B. It organizes individualized nursing actions and expected outcomes for the patient C. It is primarily a documentation form for the provider’s medical plan D. It is used only after discharge to guide patient teaching 2. A patient with pneumonia has a care plan that includes “impaired gas exchange” and “ineffective airway clearance.” Which component of the care plan gives the nurse the clearest target for evaluating whether interventions are working? A. Nursing diagnosis B. Expected outcomes C. Assessment data D. Etiology statement 3. Two patients each have postoperative pain after abdominal surgery. One has a history of opioid intolerance and fears addiction; the other has chronic back pain and requests music during recovery. Which nursing action best reflects individualized care? A. Use the same standardized pain plan for both patients B. Ask the provider to choose the plan without changing nursing care C. Tailor interventions to each patient’s preferences, history, and responses D. Delay care plan changes until discharge teaching begins 4. A patient with COPD is admitted with shortness of breath, wheezing, anxiety, and hypotension (BP 88/54 mm Hg). Which nursing diagnosis is the priority? A. Anxiety B. Ineffective coping C. Impaired gas exchange D. Deficient knowledge 5. An older adult admitted after a fall is alert but unsteady and states they will get up alone. The call light is out of reach. Which nursing diagnosis should be prioritized? A. Risk for falls B. Disturbed body image C. Readiness for enhanced self-care D. Social isolation 6. A patient recovering from a stroke becomes fatigued after a few bites but can swallow safely. Which intervention best supports optimizing care? A. Encourage rapid meal completion B. Offer small, frequent meals with rest periods C. Restrict oral intake D. Keep the patient NPO 7. A patient with diabetes has a foot ulcer and reports stopping glucose monitoring due to cost. Which nursing diagnosis should be addressed first? A. Ineffective health management B. Risk for infection C. Knowledge deficit D. Readiness for enhanced coping 8. A patient with a latex allergy is scheduled for a procedure, and latex products are present in the room. What is the best nursing action? A. Proceed as usual B. Ask the patient to remind staff C. Replace latex items with latex-free supplies D. Wait for the provider 9. A unit identifies increased catheter-associated infections and reviews catheter practices. What quality improvement method is this? A. Incident reporting B. Root cause analysis and process review C. Patient satisfaction scoring D. Individual counseling 10. A nurse is preparing discharge materials for a patient with low health literacy. Which approach is best? A. Use medical terminology B. Provide dense written content C. Use simple language and visuals D. Provide only verbal instructions 11. A patient on a low-sodium diet finds hospital food unpalatable. What is the best nursing action? A. Instruct the patient to ignore preferences B. Consult a dietitian for acceptable alternatives C. Cancel the diet D. Delay intervention 12. A postoperative patient has the outcome: “Maintain oxygen saturation 94% within 24 hours.” Why is this outcome effective? A. It is broad B. It is measurable and time-limited C. It reflects provider goals D. It lists interventions 13. A postoperative patient has fever and purulent wound drainage. Which diagnosis is priority? A. Acute pain B. Risk for ineffective coping C. Risk for infection D. Disturbed sleep pattern 14. A heart failure patient shows decreased weight and improved lung sounds after interventions. What does this indicate? A. Fatigue persists B. Interventions are effective C. More teaching is needed D. Patient dissatisfaction 15. An older adult fears falling but needs to mobilize. What is the best intervention? A. Bed rest B. Unassisted walking C. Assisted ambulation with a gait belt D. Ignore fear 16. A depressed patient neglects health management and follow-ups. Which diagnosis best applies? A. Ineffective health management B. Impaired mobility C. Acute confusion D. Risk for unstable glucose 17. A nurse prepares to administer medication but the patient has no ID band. What is the priority action? A. Use room number B. Ask another nurse C. Verify identity using approved identifiers D. Delay until next shift 18. Falls frequently occur when call lights are out of reach. What is the best QI intervention? A. Instruct patients to be careful B. Standardize keeping call lights accessible C. Discharge early D. Document incidents only 19. What feature best improves discharge teaching materials? A. Dense paragraphs B. Step-by-step visuals and headings C. Small font D. Medical abbreviations 20. A COPD patient reports improved function after care plan implementation. What is the best interpretation? A. Care plan no longer needed B. Continue plan with reassessment C. Diagnosis was incorrect D. Teaching is complete ANSWER KEY B B C C A B B C B C B B C B C A C B B B