NURSING 108 CORRECT ALL QUESTIONS AND
ANSWERS SURE A+
✔✔A nurse is caring for a patient with a UTI. The nurse's selection of two nursing
diagnoses includes acute pain and impaired urinary function. What evidence would lead
the nurse to diagnose acute pain?
1. Low back aching
2. Burning upon urination
3. Frequency of urination
4. Urgency of urination
5. Incontinence of urination - ✔✔-Low back aching
-Burning upon urination
✔✔A patient with diabetes reports to the clinic for diabetes education. The nurse learns
that the patient's wife prepares the family meals. Why is it important to include the
patient's wife in the teaching?
1. She can report when he is not adhering to the care plan.
2. The wife can learn how to follow his new diet too.
3. The main person responsible for managing the patient's diabetes may be the wife.
4. Including a second person in teaching is protocol for the facility. - ✔✔-The wife can
learn how to follow his new diet too.
✔✔What word does the nurse use to describe the five steps?
1. Race
2. Process
3. Story
4. Content - ✔✔-Process
✔✔A nurse is caring for a patient at risk for appendicitis. When considering the
assessment, why should the nurse use the five-step nursing process?
,1. To set up the correct surgery time for the health care provider
2. To carefully match what is done in other hospitals
3. To systematically identify actual or potential patient problems
4. To better console families who are anxious about their loved one - ✔✔-To
systematically identify actual or potential patient problems
✔✔A nurse is caring for a patient who is cyanotic and has edema. The nurse is making
a list of the patient's physical, psychological, emotional, environmental, cultural, and
spiritual health. What stage of the nursing process is this?
1. Assessment
2. Diagnosis
3. Planning
4. Evaluation - ✔✔-Assessment
✔✔A nurse is caring for a 10-year-old tracheotomy patient admitted the previous night.
When assessing the patient's pain level, is the nurse assessing subjective or objective
data?
1. Subjective data, because only the patient can experience the pain.
2. Subjective data, because the blood pressure is an accurate measure of the patient's
pain.
3. Objective data, because the pain level can be turned into a number on a one to ten
scale.
4. Objective data, because the patient can point to the "oucher" picture indicating the
experienced pain level. - ✔✔-Subjective data, because only the patient can experience
the pain.
✔✔A nurse is caring for a patient with decubitus ulcers who is dehydrated and suffering
from malnutrition. In the evaluation stage, what evidence about the decubitus ulcers
should initiate the nurse to change the nursing care plan?
1. new decubitus ulcers have formed
2. there is no change in decubitus ulcer size
3. decubitus ulcers are now smaller
4. color of decubitus ulcers has improved - ✔✔-new decubitus ulcers have formed
✔✔The nurse is receiving a report on a patient recovering from a myocardial infarction
with low oxygen saturation. With a nursing diagnosis of low blood oxygen, what other
interdisciplinary professionals may be consulted for collaboration of this patient?
1. Respiratory therapist, cardiologist, and nephrologist
2. Cardiologist, urologist, and pulmonologist
3. Rheumatologist, respiratory therapist, and cardiologist
,4. Respiratory therapist, cardiologist, and pulmonologist - ✔✔-Respiratory therapist,
cardiologist, and pulmonologist
✔✔A nurse is caring for a patient for a UTI. Which of these interventions address the
patient's short-term goals?
1. Teaching hygiene practices to prevent further UTIs.
2. Educating the patient on the signs and symptoms of UTIs.
3. Applying a heating pad to the low back or abdomen.
4. Refraining from sexual intercourse.
5. Discussing the possibility of using a different type of birth control. - ✔✔-Applying a
heating pad to the low back or abdomen.
-Refraining from sexual intercourse.
✔✔A nurse determines the patient's goal of decreased reflux by sleeping on a pillow
wedge was not totally met. How does the plan need to be revised?
1. Add another pillow wedge at night.
2. Add a step to avoid eating after 7 p.m.
3. Increase grapefruit juice taken with meals.
4. Discontinue the plan. - ✔✔-Add a step to avoid eating after 7 p.m.
✔✔A nurse is evaluating the care plan for a pregnant patient. What is the main reason
the nurse would ask the patient about support systems and eating habits?
1. Ensure individualized care.
2. Concern over the baby arriving prematurely.
3. Facilitate setting patient outcomes.
4. Determine if the patient has other children. - ✔✔-Ensure individualized care
✔✔A patient has a painful jaw that clicks during chewing. The nurse developed a care
plan and taught the patient how to use a bite guard. What step of the nursing process
did the nurse exhibit by teaching use of the bite guard?
1. Evaluation
2. Implementation
3. Assessment
4. Planning - ✔✔-Implementation
✔✔The student nurse is learning about vital signs. Which measurements are included in
vital sign assessment?
1. BP
2. RR
3. Pupil dilation
, 4. Pulse
5. Pulse oximetry - ✔✔-BP
-RR
-Pulse
-Pulse oximetry
✔✔In which patients would pulse oximetry most likely be assessed?
1. An older adult with hypoxemia
2. A male with community-acquired pneumonia
3. A female developing respiratory failure due to carbon monoxide retention
4. A teenager having an asthma attack with oxygen saturations of less than 92% in air
5. An infant displaying symptoms of asymptomatic congenital heart disease - ✔✔-An
older adult with hypoxemia
-A male with community-acquired pneumonia
- A teenager having an asthma attack with oxygen saturations of less than 92% in air
- An infant displaying symptoms of asymptomatic congenital heart disease
✔✔The nurse receives a 50-year-old patient back from the endoscopic department. She
had conscious sedation for an esophageal biopsy. When should the nurse take vital
signs?
1. Monitor vital signs every hour.
2. Monitor vital signs every 15 minutes for one hour than if stable, every hour for 2
hours.
3. Begin vital signs monitor every 4 hours once patient is fully awake back on the
regular floor.
4. No need to monitor vital signs because patient is awake. - ✔✔-Monitor vital signs
every 15 minutes for one hour than if stable, every hour for 2 hours.
✔✔The nurse is ready to give a 60-year-old male his daily digitalis medication. The
CNA reports that the patient's vital signs are pulse 42 bpm, blood pressure 148/86
mmHg, respirations 20 bpm. What interpretation will the nurse make?
1. Recheck the patient's vital signs.
2. Compare the current vital signs with this patient's baseline data.
3. Administer the digitalis medication to the patient.
4. Withhold the digitalis medication.
5. Call a CODE for this patient. - ✔✔-Recheck the patient's vital signs.
-Compare the current vital signs with this patient's baseline data.
-Withhold the digitalis medication.
✔✔A 6-year-old girl is carried into the emergency department (ED) by her mother. The
child is gasping for breath and wheezing. The child's vital signs are respirations 30 bpm,
pulse 120 bpm, SpO2 92%, BP 90/50 mmHg. The nurse takes which actions?
ANSWERS SURE A+
✔✔A nurse is caring for a patient with a UTI. The nurse's selection of two nursing
diagnoses includes acute pain and impaired urinary function. What evidence would lead
the nurse to diagnose acute pain?
1. Low back aching
2. Burning upon urination
3. Frequency of urination
4. Urgency of urination
5. Incontinence of urination - ✔✔-Low back aching
-Burning upon urination
✔✔A patient with diabetes reports to the clinic for diabetes education. The nurse learns
that the patient's wife prepares the family meals. Why is it important to include the
patient's wife in the teaching?
1. She can report when he is not adhering to the care plan.
2. The wife can learn how to follow his new diet too.
3. The main person responsible for managing the patient's diabetes may be the wife.
4. Including a second person in teaching is protocol for the facility. - ✔✔-The wife can
learn how to follow his new diet too.
✔✔What word does the nurse use to describe the five steps?
1. Race
2. Process
3. Story
4. Content - ✔✔-Process
✔✔A nurse is caring for a patient at risk for appendicitis. When considering the
assessment, why should the nurse use the five-step nursing process?
,1. To set up the correct surgery time for the health care provider
2. To carefully match what is done in other hospitals
3. To systematically identify actual or potential patient problems
4. To better console families who are anxious about their loved one - ✔✔-To
systematically identify actual or potential patient problems
✔✔A nurse is caring for a patient who is cyanotic and has edema. The nurse is making
a list of the patient's physical, psychological, emotional, environmental, cultural, and
spiritual health. What stage of the nursing process is this?
1. Assessment
2. Diagnosis
3. Planning
4. Evaluation - ✔✔-Assessment
✔✔A nurse is caring for a 10-year-old tracheotomy patient admitted the previous night.
When assessing the patient's pain level, is the nurse assessing subjective or objective
data?
1. Subjective data, because only the patient can experience the pain.
2. Subjective data, because the blood pressure is an accurate measure of the patient's
pain.
3. Objective data, because the pain level can be turned into a number on a one to ten
scale.
4. Objective data, because the patient can point to the "oucher" picture indicating the
experienced pain level. - ✔✔-Subjective data, because only the patient can experience
the pain.
✔✔A nurse is caring for a patient with decubitus ulcers who is dehydrated and suffering
from malnutrition. In the evaluation stage, what evidence about the decubitus ulcers
should initiate the nurse to change the nursing care plan?
1. new decubitus ulcers have formed
2. there is no change in decubitus ulcer size
3. decubitus ulcers are now smaller
4. color of decubitus ulcers has improved - ✔✔-new decubitus ulcers have formed
✔✔The nurse is receiving a report on a patient recovering from a myocardial infarction
with low oxygen saturation. With a nursing diagnosis of low blood oxygen, what other
interdisciplinary professionals may be consulted for collaboration of this patient?
1. Respiratory therapist, cardiologist, and nephrologist
2. Cardiologist, urologist, and pulmonologist
3. Rheumatologist, respiratory therapist, and cardiologist
,4. Respiratory therapist, cardiologist, and pulmonologist - ✔✔-Respiratory therapist,
cardiologist, and pulmonologist
✔✔A nurse is caring for a patient for a UTI. Which of these interventions address the
patient's short-term goals?
1. Teaching hygiene practices to prevent further UTIs.
2. Educating the patient on the signs and symptoms of UTIs.
3. Applying a heating pad to the low back or abdomen.
4. Refraining from sexual intercourse.
5. Discussing the possibility of using a different type of birth control. - ✔✔-Applying a
heating pad to the low back or abdomen.
-Refraining from sexual intercourse.
✔✔A nurse determines the patient's goal of decreased reflux by sleeping on a pillow
wedge was not totally met. How does the plan need to be revised?
1. Add another pillow wedge at night.
2. Add a step to avoid eating after 7 p.m.
3. Increase grapefruit juice taken with meals.
4. Discontinue the plan. - ✔✔-Add a step to avoid eating after 7 p.m.
✔✔A nurse is evaluating the care plan for a pregnant patient. What is the main reason
the nurse would ask the patient about support systems and eating habits?
1. Ensure individualized care.
2. Concern over the baby arriving prematurely.
3. Facilitate setting patient outcomes.
4. Determine if the patient has other children. - ✔✔-Ensure individualized care
✔✔A patient has a painful jaw that clicks during chewing. The nurse developed a care
plan and taught the patient how to use a bite guard. What step of the nursing process
did the nurse exhibit by teaching use of the bite guard?
1. Evaluation
2. Implementation
3. Assessment
4. Planning - ✔✔-Implementation
✔✔The student nurse is learning about vital signs. Which measurements are included in
vital sign assessment?
1. BP
2. RR
3. Pupil dilation
, 4. Pulse
5. Pulse oximetry - ✔✔-BP
-RR
-Pulse
-Pulse oximetry
✔✔In which patients would pulse oximetry most likely be assessed?
1. An older adult with hypoxemia
2. A male with community-acquired pneumonia
3. A female developing respiratory failure due to carbon monoxide retention
4. A teenager having an asthma attack with oxygen saturations of less than 92% in air
5. An infant displaying symptoms of asymptomatic congenital heart disease - ✔✔-An
older adult with hypoxemia
-A male with community-acquired pneumonia
- A teenager having an asthma attack with oxygen saturations of less than 92% in air
- An infant displaying symptoms of asymptomatic congenital heart disease
✔✔The nurse receives a 50-year-old patient back from the endoscopic department. She
had conscious sedation for an esophageal biopsy. When should the nurse take vital
signs?
1. Monitor vital signs every hour.
2. Monitor vital signs every 15 minutes for one hour than if stable, every hour for 2
hours.
3. Begin vital signs monitor every 4 hours once patient is fully awake back on the
regular floor.
4. No need to monitor vital signs because patient is awake. - ✔✔-Monitor vital signs
every 15 minutes for one hour than if stable, every hour for 2 hours.
✔✔The nurse is ready to give a 60-year-old male his daily digitalis medication. The
CNA reports that the patient's vital signs are pulse 42 bpm, blood pressure 148/86
mmHg, respirations 20 bpm. What interpretation will the nurse make?
1. Recheck the patient's vital signs.
2. Compare the current vital signs with this patient's baseline data.
3. Administer the digitalis medication to the patient.
4. Withhold the digitalis medication.
5. Call a CODE for this patient. - ✔✔-Recheck the patient's vital signs.
-Compare the current vital signs with this patient's baseline data.
-Withhold the digitalis medication.
✔✔A 6-year-old girl is carried into the emergency department (ED) by her mother. The
child is gasping for breath and wheezing. The child's vital signs are respirations 30 bpm,
pulse 120 bpm, SpO2 92%, BP 90/50 mmHg. The nurse takes which actions?
