NR 226 Exam 1 - Review Questions with
correct Answers (Chamberlain
University-Illinois)
.A goal specifies the expected behavior or response that indicates:
A. The specific nursing action was completed.
B. The validation of the nurse's physical assessment.
C. The nurse has made the correct nursing diagnoses.
D. Resolution of a nursing diagnosis or maintenance of a healthy state. -
------------ANS: D. Resolution of a nursing diagnosis or maintenance of a
healthy state
-The success in meeting a goal is reflected in achieving expected
outcomes—the physiological responses or behaviors that indicate that a
nursing diagnosis has been resolved and the patient's health is improving.
.A nurse who is working on a surgical unit is caring for four different patients.
Patient A will be discharged home and is in need of instruction about wound
care. Patients B and C have returned from the operating room within an hour
of each other, and both require vital signs and monitoring of their intravenous
(IV) lines. Patient D is resting following a visit by physical therapy. Which of
the following activities by the nurse represent(s) use of clinical decision
making for groups of patients? (Select all that apply.)
A. Consider how to involve patient A in deciding whether to involve the family
caregiver in wound care instruction.
B. Think about past experience with patients who develop postoperative
complications.
C. Decide which activities can be combined for patients B and C.
D. Carefully gather any assessment information and identify patient problems.
- ------------ANS: A & C
-Considering how to involve patients in decisions and how to combine nursing
activities to be more organized and allow for resolving more than one problem
at a time are examples of clinical decision making for groups of patients.
Thinking about past experience with patients is an example of reflection, an
approach to strengthen critical thinking skills. Gathering assessment
information is part of the process of diagnostic reasoning, which should be
applied to each patient.
,.The nurse reviews a patient's medical record and sees that tube feedings are
to begin after a feeding tube is inserted. In recent past experiences the nurse
has seen patients on the unit develop diarrhea from tube feedings. The nurse
consults with the dietitian and physician to determine the initial rate that will be
ordered for the feeding to lessen the chance of diarrhea. This is an example of
what type of direct care measure?
A. Preventive
B. Controlling for an adverse reaction
C. Consulting
D. Counseling - ------------ANS: B. Controlling for an adverse reaction
-Anticipating the need to start the feeding at a slower rate is an example of
controlling for an adverse reaction, which in this case would be a harmful or
unintended effect (diarrhea) of therapeutic intervention.
A 58-year-old patient with nerve deafness has come to his doctor's office for a
routine examination. The patient wears two hearing aids. The advanced
practice nurse who is conducting the assessment uses which of the following
approaches while conducting the interview with this patient? (Select all that
apply.)
A. Maintain a neutral facial expression
B. Lean forward when interacting with the patient
C. Acknowledge the patient's answers through head nodding
D. Limit direct eye contact - ------------ANS: B & C
-Leaning forward shows that the nurse is aware and attending to what the
patient is saying. The use of head nodding regulates the interaction and
makes it easier for the patient to know the nurse's responses to his comments.
A neutral expression does not express warmth or immediacy, which is needed
to establish a positive relationship. Good eye contact communicates the
nurse's interest in what the patient has to say.
A child's immunization may cause discomfort during administration, but the
benefits of protection from disease, both for the individual and society,
outweigh the temporary discomforts. Which principle is involved in this
situation?
A. Fidelity
B. Beneficence
C. Nonmaleficence
D. Respect for autonomy - ------------ANS: B. Beneficence
-The immunization is a clear effort to provide benefit. Beneficence refers to
"doing good." Fidelity refers more to keeping promises. Nonmaleficence refers
,to the commitment to avoid harm. Respect for autonomy refers to the
commitment to include patients in the decision-making process regarding
health care plans.
A clinic nurse assesses a patient who reports a loss of appetite and a
15-pound weight loss since 2 months ago. The patient is 5 feet 10 inches tall
and weighs 135 pounds (61.2 kg). She shows signs of depression and does
not have a good understanding of foods to eat for proper nutrition. The nurse
makes the nursing diagnosis of imbalanced nutrition: less than body
requirements related to reduced intake of food. For the goal of, "Patient will
return to baseline weight in 3 months," which of the following outcomes would
be appropriate? (Select all that apply.)
A. Patient will discuss source of depression by next clinic visit.
B. Patient will achieve a calorie intake of 2400 daily in 2 weeks.
C. Patient will report improvement in appetite in 1 week.
D. Patient will identify food protein sources. - ------------ANS: B & C
-With the related factor of reduced intake of food, the outcomes should focus
on behaviors that reflect an increase in intake. Thus achieving an increase in
calories and an improved appetite for food would be appropriate. The patient's
depression probably contributes to the loss of appetite, but being able to
discuss the source of depression is not an outcome for improving her baseline
weight. Being able to identify protein sources would improve any knowledge
deficit the patient might have but would not help her gain weight.
A manager who is reviewing the nurses' notes in a patient's medical record
finds the following entry, "Patient is difficult to care for, refuses suggestion for
improving appetite." Which of the following directions does the manager give
to the staff nurse who entered the note?
A. Avoid rushing when charting an entry.
B. Use correction fluid to remove the entry.
C. Draw a single line through the statement and initial it.
D. Enter only objective and factual information about the patient. -
------------ANS: D. Enter only objective and factual information about the
patient
-Nurses should enter only objective and factual information about patients.
Opinions have no place in the medical record. Because the information has
already been entered and is not incorrect, it should be left on the record.
Never use correction fluid in a written medical record.
, A new graduate nurse is providing a telephone report to a patient's health care
provider and accepting telephone orders from the provider. Which of the
following actions requires the new nurse's preceptor to intervene? The new
nurse:
A. Uses SBAR (Situation-Background-Assessment-Recommendation) as a
format when providing the report.
B. Gives a newly ordered medication before entering the order in the patient's
medical record.
C. Reads the orders back to the health care provider after receiving them and
verifies their accuracy.
D. Asks the preceptor to listen in on the phone conversation. - ------------ANS:
B. Gives a newly ordered medication before entering the order in the patient's
medical record
-Nurses enter orders into the computer or write them on the order sheet as
they are being given to allow the read-back process to occur.
A nurse assesses a 78-year-old patient who weighs 240 pounds (108.9 kg)
and is partially immobilized because of a stroke. The nurse turns the patient
and finds that the skin over the sacrum is very red and the patient does not
feel sensation in the area. The patient has had fecal incontinence on and off
for the last 2 days. The nurse identifies the nursing diagnosis of risk for
impaired skin integrity. Which of the following goals are appropriate for the
patient? (Select all that apply.)
A. Patient will be turned every 2 hours within 24 hours.
B. Patient will have normal bowel function within 72 hours.
C. Patient's skin will remain intact through discharge.
D. Patient's skin condition will improve by discharge. - ------------ANS: B & C
-The skin remaining intact is an appropriate goal for the patient's at-risk
diagnosis. A return of normal bowel functioning is also appropriate since it
indicates removal of a risk factor. Turning the patient is an intervention; skin
condition improving by discharge is a poorly written goal that is not
measurable.
A nurse assesses a patient who comes to the pulmonary clinic. "I see that it's
been over 6 months since you've been in, but your appointment was for every
2 months. Tell me about that. Also I see from your last visit that the doctor
recommended routine exercise. Can you tell me how successful you have
been following his plan?" The nurse's assessment covers which of Gordon's
functional health patterns?
A. Value-belief pattern
correct Answers (Chamberlain
University-Illinois)
.A goal specifies the expected behavior or response that indicates:
A. The specific nursing action was completed.
B. The validation of the nurse's physical assessment.
C. The nurse has made the correct nursing diagnoses.
D. Resolution of a nursing diagnosis or maintenance of a healthy state. -
------------ANS: D. Resolution of a nursing diagnosis or maintenance of a
healthy state
-The success in meeting a goal is reflected in achieving expected
outcomes—the physiological responses or behaviors that indicate that a
nursing diagnosis has been resolved and the patient's health is improving.
.A nurse who is working on a surgical unit is caring for four different patients.
Patient A will be discharged home and is in need of instruction about wound
care. Patients B and C have returned from the operating room within an hour
of each other, and both require vital signs and monitoring of their intravenous
(IV) lines. Patient D is resting following a visit by physical therapy. Which of
the following activities by the nurse represent(s) use of clinical decision
making for groups of patients? (Select all that apply.)
A. Consider how to involve patient A in deciding whether to involve the family
caregiver in wound care instruction.
B. Think about past experience with patients who develop postoperative
complications.
C. Decide which activities can be combined for patients B and C.
D. Carefully gather any assessment information and identify patient problems.
- ------------ANS: A & C
-Considering how to involve patients in decisions and how to combine nursing
activities to be more organized and allow for resolving more than one problem
at a time are examples of clinical decision making for groups of patients.
Thinking about past experience with patients is an example of reflection, an
approach to strengthen critical thinking skills. Gathering assessment
information is part of the process of diagnostic reasoning, which should be
applied to each patient.
,.The nurse reviews a patient's medical record and sees that tube feedings are
to begin after a feeding tube is inserted. In recent past experiences the nurse
has seen patients on the unit develop diarrhea from tube feedings. The nurse
consults with the dietitian and physician to determine the initial rate that will be
ordered for the feeding to lessen the chance of diarrhea. This is an example of
what type of direct care measure?
A. Preventive
B. Controlling for an adverse reaction
C. Consulting
D. Counseling - ------------ANS: B. Controlling for an adverse reaction
-Anticipating the need to start the feeding at a slower rate is an example of
controlling for an adverse reaction, which in this case would be a harmful or
unintended effect (diarrhea) of therapeutic intervention.
A 58-year-old patient with nerve deafness has come to his doctor's office for a
routine examination. The patient wears two hearing aids. The advanced
practice nurse who is conducting the assessment uses which of the following
approaches while conducting the interview with this patient? (Select all that
apply.)
A. Maintain a neutral facial expression
B. Lean forward when interacting with the patient
C. Acknowledge the patient's answers through head nodding
D. Limit direct eye contact - ------------ANS: B & C
-Leaning forward shows that the nurse is aware and attending to what the
patient is saying. The use of head nodding regulates the interaction and
makes it easier for the patient to know the nurse's responses to his comments.
A neutral expression does not express warmth or immediacy, which is needed
to establish a positive relationship. Good eye contact communicates the
nurse's interest in what the patient has to say.
A child's immunization may cause discomfort during administration, but the
benefits of protection from disease, both for the individual and society,
outweigh the temporary discomforts. Which principle is involved in this
situation?
A. Fidelity
B. Beneficence
C. Nonmaleficence
D. Respect for autonomy - ------------ANS: B. Beneficence
-The immunization is a clear effort to provide benefit. Beneficence refers to
"doing good." Fidelity refers more to keeping promises. Nonmaleficence refers
,to the commitment to avoid harm. Respect for autonomy refers to the
commitment to include patients in the decision-making process regarding
health care plans.
A clinic nurse assesses a patient who reports a loss of appetite and a
15-pound weight loss since 2 months ago. The patient is 5 feet 10 inches tall
and weighs 135 pounds (61.2 kg). She shows signs of depression and does
not have a good understanding of foods to eat for proper nutrition. The nurse
makes the nursing diagnosis of imbalanced nutrition: less than body
requirements related to reduced intake of food. For the goal of, "Patient will
return to baseline weight in 3 months," which of the following outcomes would
be appropriate? (Select all that apply.)
A. Patient will discuss source of depression by next clinic visit.
B. Patient will achieve a calorie intake of 2400 daily in 2 weeks.
C. Patient will report improvement in appetite in 1 week.
D. Patient will identify food protein sources. - ------------ANS: B & C
-With the related factor of reduced intake of food, the outcomes should focus
on behaviors that reflect an increase in intake. Thus achieving an increase in
calories and an improved appetite for food would be appropriate. The patient's
depression probably contributes to the loss of appetite, but being able to
discuss the source of depression is not an outcome for improving her baseline
weight. Being able to identify protein sources would improve any knowledge
deficit the patient might have but would not help her gain weight.
A manager who is reviewing the nurses' notes in a patient's medical record
finds the following entry, "Patient is difficult to care for, refuses suggestion for
improving appetite." Which of the following directions does the manager give
to the staff nurse who entered the note?
A. Avoid rushing when charting an entry.
B. Use correction fluid to remove the entry.
C. Draw a single line through the statement and initial it.
D. Enter only objective and factual information about the patient. -
------------ANS: D. Enter only objective and factual information about the
patient
-Nurses should enter only objective and factual information about patients.
Opinions have no place in the medical record. Because the information has
already been entered and is not incorrect, it should be left on the record.
Never use correction fluid in a written medical record.
, A new graduate nurse is providing a telephone report to a patient's health care
provider and accepting telephone orders from the provider. Which of the
following actions requires the new nurse's preceptor to intervene? The new
nurse:
A. Uses SBAR (Situation-Background-Assessment-Recommendation) as a
format when providing the report.
B. Gives a newly ordered medication before entering the order in the patient's
medical record.
C. Reads the orders back to the health care provider after receiving them and
verifies their accuracy.
D. Asks the preceptor to listen in on the phone conversation. - ------------ANS:
B. Gives a newly ordered medication before entering the order in the patient's
medical record
-Nurses enter orders into the computer or write them on the order sheet as
they are being given to allow the read-back process to occur.
A nurse assesses a 78-year-old patient who weighs 240 pounds (108.9 kg)
and is partially immobilized because of a stroke. The nurse turns the patient
and finds that the skin over the sacrum is very red and the patient does not
feel sensation in the area. The patient has had fecal incontinence on and off
for the last 2 days. The nurse identifies the nursing diagnosis of risk for
impaired skin integrity. Which of the following goals are appropriate for the
patient? (Select all that apply.)
A. Patient will be turned every 2 hours within 24 hours.
B. Patient will have normal bowel function within 72 hours.
C. Patient's skin will remain intact through discharge.
D. Patient's skin condition will improve by discharge. - ------------ANS: B & C
-The skin remaining intact is an appropriate goal for the patient's at-risk
diagnosis. A return of normal bowel functioning is also appropriate since it
indicates removal of a risk factor. Turning the patient is an intervention; skin
condition improving by discharge is a poorly written goal that is not
measurable.
A nurse assesses a patient who comes to the pulmonary clinic. "I see that it's
been over 6 months since you've been in, but your appointment was for every
2 months. Tell me about that. Also I see from your last visit that the doctor
recommended routine exercise. Can you tell me how successful you have
been following his plan?" The nurse's assessment covers which of Gordon's
functional health patterns?
A. Value-belief pattern
