EXAM 2 REVIEW - INTRO TO CLINICAL
NURSING QUESTIONS AND ANSWERS
Patient continues to report post surgical incision pain at a level of 9 out of 0 after
pain medicine is given. The next dose of pain medicine is not due for another hour.
What should the critically thinking nurse do first? - Answer-Explore other options for
pain relief.
Which order will the nurse use the nursing process steps during the clinical decision-
making process?
1. evaluating goals
2. Assessment patient needs
3. Planning priorities of care
4. Determining nursing diagnoses
5. Implementing nursing interventions - Answer-2, 4, 3, 5, 1
A patient asks the nurse for a non medical approach to cope with excessive worry
and work stress. Which therapy should the nurse recommend? - Answer-Meditation
A nurse is teaching about the therapy that is more effective in treating physical
ailments than in preventing disease or managing chronic illness. Which therapy is
the nursing describing? - Answer-Allopathic
A therapeutic touch practitioner scans the patient's body. What is the purpose of the
practitioner's actions? - Answer-to identify energy obstructions
The nurse is caring for a patient to ease modifiable factors that contribute to pain.
Which areas did the nurse focus on with this patient? - Answer-Anxiety and fear
The nurse is creating a pan of care for a patient with glaucoma. Which nursing
diagnosis will the nurse include in the care plan to address a safety complication of
the sensory deficit? - Answer-Risk for falls
The nurse is caring for a patient who is having difficulty understanding the written
and spoken word. Which type of aphasia will the nurse report to the oncoming shift?
- Answer-Receptive
Nurse is caring for a patient with expressive aphasia from a traumatic brain injury.
Which goal will the nurse include in the plan of care? - Answer-The patient will
communicate nonverbally using communication boards and hand gestures daily
A change nurse is supervising the care of a new nurse. Which action by a new nurse
indicates the charge nurse needs to intervene? - Answer-Making a clinical decision
based on previous shift assessments
A nurse is using the critical thinking skill of evaluation. Which action will the nurse
take? - Answer-Review the effectiveness of nursing actions
, The nurse is gathering data on a patient. Which data will the nurse report as
objective data? - Answer-Respiration of 16
A patient with a spinal cord injury is seeking to enhance urinary elimination abilities
by learning self-catherization versus assisted catherization by home health nurses
and family members. The nurse adds Readiness for enhanced urinary elimination in
the care plan. Which type of diagnosis did the nurse write? - Answer-Health
promotion
Direct care interventions include which of the following? (Select all that apply) -
Answer-- Teaching about medications
- Performing resuscitation
- Inserting a feeding tube
- Ambulating a patient
The nurse is caring for a patient who is taking gentamicin for an infection. Which
assessment is a priority? - Answer-Hearing
A 24 hour timed urine collection can be used to evaluate which of the following? -
Answer-Glucose and Adrnocotiosteroids
Nurse needs to obtain a sterile urine specimen for culture and sensitivity (C&S) from
a patient who has an indwelling catheter. The catheter was placed yesterday. What
must the nurse do to obtain the specimen? - Answer-Clamp the drainage tubing for
10 to 15 minutes
The patient has an order to be off the floor for 15 minutes every 2 hours to smoke a
cigarette. The patient has just returned from her "cigarette break." Which intervention
should the nurse take in order to take an accurate oral temperature? - Answer-Wait
about 15 minutes before taking her temperature
The student nurse is doing clinicals on the general surgical unit and is caring for a
patient who has a right total mastectomy with lymph note removal. What will be
necessary for the nurse to do to accurately assess the patient's blood pressure? -
Answer-Place the blood pressure cuff on the left upper arm
When discussing the collection of a clean-voided urine specimen, what should nurse
instruct the patient to do? - Answer-Void some urine first and then collect the sample
When evaluating the radical pulse measurement technique of the nursing assistant,
the nurse identifies appropriate technique when the assistant does which of the
following actions? - Answer-positions the patient supine or sitting
While evaluating the hygenic care pracitces of a female patient, which of the
following actions by the patient would require further teaching? - Answer-washes the
perineal area from back to front
Which site would the nurse use the best auscultate blood pressure? - Answer-
Brachial
NURSING QUESTIONS AND ANSWERS
Patient continues to report post surgical incision pain at a level of 9 out of 0 after
pain medicine is given. The next dose of pain medicine is not due for another hour.
What should the critically thinking nurse do first? - Answer-Explore other options for
pain relief.
Which order will the nurse use the nursing process steps during the clinical decision-
making process?
1. evaluating goals
2. Assessment patient needs
3. Planning priorities of care
4. Determining nursing diagnoses
5. Implementing nursing interventions - Answer-2, 4, 3, 5, 1
A patient asks the nurse for a non medical approach to cope with excessive worry
and work stress. Which therapy should the nurse recommend? - Answer-Meditation
A nurse is teaching about the therapy that is more effective in treating physical
ailments than in preventing disease or managing chronic illness. Which therapy is
the nursing describing? - Answer-Allopathic
A therapeutic touch practitioner scans the patient's body. What is the purpose of the
practitioner's actions? - Answer-to identify energy obstructions
The nurse is caring for a patient to ease modifiable factors that contribute to pain.
Which areas did the nurse focus on with this patient? - Answer-Anxiety and fear
The nurse is creating a pan of care for a patient with glaucoma. Which nursing
diagnosis will the nurse include in the care plan to address a safety complication of
the sensory deficit? - Answer-Risk for falls
The nurse is caring for a patient who is having difficulty understanding the written
and spoken word. Which type of aphasia will the nurse report to the oncoming shift?
- Answer-Receptive
Nurse is caring for a patient with expressive aphasia from a traumatic brain injury.
Which goal will the nurse include in the plan of care? - Answer-The patient will
communicate nonverbally using communication boards and hand gestures daily
A change nurse is supervising the care of a new nurse. Which action by a new nurse
indicates the charge nurse needs to intervene? - Answer-Making a clinical decision
based on previous shift assessments
A nurse is using the critical thinking skill of evaluation. Which action will the nurse
take? - Answer-Review the effectiveness of nursing actions
, The nurse is gathering data on a patient. Which data will the nurse report as
objective data? - Answer-Respiration of 16
A patient with a spinal cord injury is seeking to enhance urinary elimination abilities
by learning self-catherization versus assisted catherization by home health nurses
and family members. The nurse adds Readiness for enhanced urinary elimination in
the care plan. Which type of diagnosis did the nurse write? - Answer-Health
promotion
Direct care interventions include which of the following? (Select all that apply) -
Answer-- Teaching about medications
- Performing resuscitation
- Inserting a feeding tube
- Ambulating a patient
The nurse is caring for a patient who is taking gentamicin for an infection. Which
assessment is a priority? - Answer-Hearing
A 24 hour timed urine collection can be used to evaluate which of the following? -
Answer-Glucose and Adrnocotiosteroids
Nurse needs to obtain a sterile urine specimen for culture and sensitivity (C&S) from
a patient who has an indwelling catheter. The catheter was placed yesterday. What
must the nurse do to obtain the specimen? - Answer-Clamp the drainage tubing for
10 to 15 minutes
The patient has an order to be off the floor for 15 minutes every 2 hours to smoke a
cigarette. The patient has just returned from her "cigarette break." Which intervention
should the nurse take in order to take an accurate oral temperature? - Answer-Wait
about 15 minutes before taking her temperature
The student nurse is doing clinicals on the general surgical unit and is caring for a
patient who has a right total mastectomy with lymph note removal. What will be
necessary for the nurse to do to accurately assess the patient's blood pressure? -
Answer-Place the blood pressure cuff on the left upper arm
When discussing the collection of a clean-voided urine specimen, what should nurse
instruct the patient to do? - Answer-Void some urine first and then collect the sample
When evaluating the radical pulse measurement technique of the nursing assistant,
the nurse identifies appropriate technique when the assistant does which of the
following actions? - Answer-positions the patient supine or sitting
While evaluating the hygenic care pracitces of a female patient, which of the
following actions by the patient would require further teaching? - Answer-washes the
perineal area from back to front
Which site would the nurse use the best auscultate blood pressure? - Answer-
Brachial
