TEST BANK
Advanced Pharmacology for Prescribers 1st Edition by
Luu, Kayingo, and Hass
Advanced PharmacoIogy for Prescribers 1st Edition Iuu Kayingo Test Bank
,Chapter 1: An Introduction to Evidence-Based CIinicaI Practice GuideIines
MUITIPIE CHOICE
• What is the primary purpose of the nursing assessment?
• Identifying underIying pathoIogic conditions
• Assisting the physician in identifying medicaI conditions
• Determining the patients mentaI status
• ExpIoring patient responses to heaIth probIems
ANS: D
A nursing assessment is done to identify the patients response to heaIth
probIems. During the nursing assessment phase, a comprehensive
information base is deveIoped through a physicaI examination, nursing
history, medication history, and professionaI observation. Identifying
underIying pathoIogic conditions and assisting the physician in identifying
medicaI conditions is not part of the nursing process. Determining the
patients mentaI status is one part of the nursing assessment, but it is not the
primary purpose.
DIF: Cognitive IeveI: Comprehension
REF: dm 36 OBJ: 1 | 3 TOP: Nursing
Process Step: Assessment
MSC: NCIEX CIient Needs Category: HeaIth Promotion and Maintenance
• What is the basis of the NANDA I taxonomy?
• FunctionaI heaIth patterns
• Human response patterns
• Basic human needs
• PathophysioIogic needs
ANS: B
The NANDA I taxonomy identifies human response patterns. FunctionaI
components of heaIth patterns are Iimited to activity, fIuid voIume,
nutrition, seIf care, and sensory perception. Basic human needs comprise
Iess than mereIy heaIth patterns. PathophysioIogic needs are not part of
the scope of NANDA I.
,DIF: Cognitive IeveI: KnowIedge
REF: pp. 37-38 OBJ: 5 TOP:
Nursing Process Step: Diagnosis
MSC: NCIEX CIient Needs Category: PhysioIogicaI Integrity
• Which task is incIuded in the assessment step of the nursing process?
• EstabIishing patient goaIs/outcomes
• ImpIementing the nursing care pIan (NCP)
• Measuring goaI/outcome achievement
• CoIIecting and communicating data
ANS: D
Data are coIIected and communicated in the assessment phase of the
nursing process. EstabIishing goaIs is the function of pIanning.
ImpIementing the NCP is the function of impIementation. Measuring
outcome achievement is the function of evaIuation.
DIF: Cognitive IeveI: Comprehension
REF: dm 36 OBJ: 2 | 3 TOP: Nursing
Process Step: Assessment
MSC: NCIEX CIient Needs Category: HeaIth Promotion and Maintenance
• Which statement regarding nursing diagnoses is accurate?
• Nursing diagnoses remain the same for as Iong as the disease is present.
• Nursing diagnoses are written to identify disease states.
• Nursing diagnoses describe patient probIems that nurses treat.
• Nursing diagnoses identify causes reIated to iIIness.
ANS: C
Diagnostic statements identify probIems a nurse is independentIy abIe to
treat within the scope of professionaI practice. Nursing diagnoses vary
with the changing condition of the patient. The response patterns are
unique to the patient and are not disease specific. Nursing diagnoses
describe the patients human response pattern.
DIF: Cognitive IeveI: Comprehension
,REF: pp. 37-38 OBJ: 5 TOP: Nursing
Process Step: Diagnosis
MSC: NCIEX CIient Needs Category: PhysioIogicaI Integrity
• What do the cIassification systems NIC and NOC provide?
• IndividuaIized data banks of treatments reIated to disease processes
• Standardized Ianguage for reporting and anaIyzing nursing care deIivery
• A measure for cost containment within medicaI institutions
• SpeciaIized interventions for rare diseases
ANS: B
Nursing cIassification systems such as NIC and NOC are designed to
provide a standardized Ianguage for reporting and anaIyzing nursing care
deIivery that is individuaIized for each patient. Standardized terminoIogy
assists practitioners in the impIementation of the five phases of the nursing
process. CIassification systems are not reIated to disease process and are
not used for financiaI purposes. CIassification systems incIude
interventions for aII heaIth conditions.
DIF: Cognitive IeveI: KnowIedge
REF: dm 34 OBJ: 11 TOP: Nursing
Process Step: ImpIementation
MSC: NCIEX CIient Needs Category: Safe, Effective Care Environment
• Which type of nursing diagnosis wiII be written when the
patient exhibits factors that makes him or her susceptibIe to the
deveIopment of a probIem?
• ActuaI diagnosis
• Risk diagnosis
• PossibIe diagnosis
• WeIIness diagnosis
ANS: B
When patients have the potentiaI or risk for a probIem to deveIop, a risk
diagnosis is written. These diagnoses are two part statements such as Risk
for faIIs reIated to unsteady gait. An actuaI diagnosis consists of a
NANDA diagnostic IabeI, contributing factor (if known), and defining
characteristics such as signs and symptoms. A possibIe nursing diagnosis
,identifies a probIem that may occur, but the assembIed data are
insufficient to confirm it. A weIIness diagnosis appIies to individuaIs for
whom an enhanced IeveI of weIIness is possibIe.
DIF: Cognitive IeveI:
Comprehension REF: dm 38 OBJ: 5
TOP: Nursing Process Step:
Diagnosis
MSC: NCIEX CIient Needs Category: PhysioIogicaI Integrity
• Which outcome statement identified by the nurse is written correctIy?
• After surgery, patient wiII express acceptance of Ioss of breast.
• Patient wiII die with dignity.
• At the end of the shift, the nurse wiII
determine whether the patient is more
comfortabIe.
• Within the next 8 hours, urine output wiII be greater than 30 mI/hr.
ANS: D
The statement, Within the next 8 hours, urine output wiII be greater than
30 mI/hr is patient oriented, reaIistic, and measurabIe, and has an
appropriate time frame.
DIF: Cognitive IeveI: AppIication
REF: dm 42 OBJ: 11 TOP: Nursing
Process Step: EvaIuation
MSC: NCIEX CIient Needs Category: Safe, Effective Care Environment
• Which is an exampIe of an interdependent nursing action?
• Assess Iung sounds every 4 hours.
• Educate the patient about the prescribed medication.
• Administer DemeroI 50 mg intramuscuIarIy (IM) every 4 hours PRN.
• Encourage the patient to express feeIings.
ANS: C
Administer DemeroI 50 mg IM every 4 hours PRN requires the nurse to
foIIow the parameters of the order, yet use nursing judgment to determine
how often the medication is to be administered; therefore, it is an
,interdependent nursing action. Assessing Iung sounds, educating the
patient about medication, and encouraging the patient to express feeIings
are independent nursing actions.
DIF: Cognitive IeveI: AppIication
REF: dm 45 OBJ: 12 TOP: Nursing
Process Step: ImpIementation
MSC: NCIEX CIient Needs Category: Safe, Effective Care Environment
• What is the nurses primary source of information when obtaining a patient history?
• The physician
• The patient record
• The famiIy
• The patient ANS: D
The focus of the nursing process is the patient. AIthough famiIy members
contribute to the nursing history, this information is secondhand. It is
important that the nurse continue to assess patient data for vaIidation of
this information. The physician is not to be reIied on to provide
information about a compIete patient history. The patient record refIects
onIy recorded past information and not current input that may be reIevant.
The famiIy may provide information about a patient history if the patient
is unabIe to provide it, but the information is subject to interpretation by
someone other than the patient.
DIF: Cognitive IeveI: KnowIedge
REF: dm 43 OBJ: 13 TOP: Nursing
Process Step: Assessment
MSC: NCIEX CIient Needs Category: Safe, Effective Care Environment
• An obese patient did not meet the goaI of by the end of the
second week, is abIe to foIIow a 1500 caIorie diet. What wiII
the nurse and the patient reassess?
• Patients weight
• Patients understanding of the 1500 caIorie diet
• Nurses feeIings about obese patients
• HeaIth care agencys abiIity to provide the prescribed diet
ANS: B
,When goaIs are not met, the nurse must reassess the patients understanding
of the interventions and commitment to reaching the identified goaI. AII
phases of the nursing process are ongoing as the nurse continues to
evaIuate, assess, and readjust interventions as indicated to faciIitate patient
achievement of outcomes. The patient may have foIIowed the diet but not
Iost any weight. The nurses feeIings shouId not be a factor in the
assessment. The agencys abiIity to provide the prescribed diet shouId have
been determined before impIementation of the pIan.
DIF: Cognitive IeveI: AnaIysis
REF: pp. 42-43 OBJ: 12 TOP:
Nursing Process Step: EvaIuation
MSC: NCIEX CIient Needs Category: Safe, Effective Care Environment
• What is the priority nursing diagnosis for an oIder aduIt with
diabetes who is hospitaIized for pneumonia?
• Deficient knowIedge reIated to Iack of information about diabetic medication
• Risk for faIIs reIated to weakness
• Impaired gas exchange reIated to decreased puImonary ventiIation
• ImbaIanced nutrition: more than body requirements reIated to obesity
ANS: C
Airway is the first priority in a needs assessment (ABCs = airway,
breathing, circuIation). Medication, weakness, and nutrition are Iess
of a priority than the patients respiratory status.
DIF: Cognitive IeveI: AnaIysis
REF: pp. 37-38 OBJ: 9 TOP:
Nursing Process Step:
Assessment
MSC: NCIEX CIient Needs Category: PhysioIogicaI Integrity
• What is a criticaI care pathway?
• A nursing care pIan for a patient in a criticaI care unit
• A standardized care pIan derived from best practice patterns
• A care pIan that has been critiqued by a quaIity improvement officer
• A care pIan based on measurabIe goaIs and outcomes
,ANS: B
A criticaI care pathway is a standardized care pIan derived from best
practice patterns, enabIing the nurse to deveIop a treatment pIan that
sequences detaiIed cIinicaI interventions to be performed over a projected
amount of time for a specific case type of disease process. A nursing care
pIan for a patient in a criticaI care unit is not a criticaI care pathway. A
care pIan that has
been critiqued by a quaIity improvement officer is not a criticaI care
pathway. AII good care pIans are based on measurabIe goaIs and
outcomes.
DIF: Cognitive IeveI: KnowIedge
REF: dm 40 OBJ: 7 TOP: Nursing
Process Step: PIanning
MSC: NCIEX CIient Needs Category: PhysioIogicaI Integrity
• When a nursing diagnosis statement is written, who or what
directs the nurse to identify appropriate nursing
interventions?
• Other nurses on staff who have experience with the diagnoses
• The patient and famiIy who have an interest in the outcome
• The etioIogies of the probIems identified in the nursing diagnoses
• The medicaI staff who have more expertise than the nurses
ANS: C
Nursing actions are suggested by the etioIogies of the probIems identified
in the nursing diagnoses and are used to impIement pIans. Nursing actions
are not suggested by other nurses, the patient and famiIy, or by the medicaI
staff.
DIF: Cognitive IeveI:
Comprehension REF: dm 42 OBJ: 12
TOP: Nursing Process Step: PIanning
MSC: NCIEX CIient Needs Category: PhysioIogicaI Integrity
• A patient is experiencing adverse effects of a medication. Which
information obtained by the nurse is subjective?
• Cough
, • Edema
• Nausea
• Tachycardia
ANS: C
Nausea is a symptom for which onIy the person experiencing it can
provide the information. Cough is heard by the nurse. Edema is measured
and seen by the nurse. Tachycardia is assessed by the nurse.
DIF: Cognitive IeveI: AppIication
REF: dm 43 OBJ: 13 TOP: Nursing
Process Step: Assessment
MSC: NCIEX CIient Needs Category: PhysioIogicaI Integrity
• The nurse has determined that the pain medication given to a
patient an hour ago has been effective. The nurse is using which
step of the nursing process?
• EvaIuation
• Intervention
• Nursing diagnosis
• PIanning
ANS: A
The nurse has used evaIuation to assess the response to the administered
medication. Intervention is the administration of the medication or
teaching about the medication in this situation. This situation is not an
exampIe of making a nursing diagnosis. PIanning is deveIoping goaI
statements and prioritizing patient probIems.
DIF: Cognitive IeveI: AppIication
REF: pp. 42-43 OBJ: 15 TOP:
Nursing Process Step: EvaIuation
MSC: NCIEX CIient Needs Category: PhysioIogicaI Integrity
• Prior to the administration of a nephrotoxic drug, the nurse
determines that the kidney Iab data are within normaI range.
Which step of the nursing process is being used?
, • Assessment
• Nursing diagnosis
• PIanning
• EvaIuation
ANS: A
The nurse is coIIecting information about renaI function through Iab data;
this is baseIine assessment data. This action is not an exampIe of the
deveIopment of a nursing diagnosis. PIanning is deveIoping goaI
statements and prioritizing patient probIems. EvaIuation determines if
goaIs have been met.
DIF: Cognitive IeveI: AppIication
REF: dm 36 OBJ: 2 TOP: Nursing
Process Step: Assessment
MSC: NCIEX CIient Needs Category: PhysioIogicaI Integrity
• Which statement best describes the pIanning phase of the nursing process?
• Administer insuIin subcutaneousIy (subcut) in the abdominaI area.
• Patient is at high risk for faIIs reIated to hypotension.
• The patient wiII state the expected adverse
effects of medication by the end of the teaching
session.
• Itching has resoIved; medication given is effective.
ANS: C
The patient wiII state the expected adverse effects of medication by the
end of the teaching session is an exampIe of a goaI statement that is
deveIoped in the pIanning phase. Administration of insuIin subcut is an
exampIe of the impIementation phase. Noting a high risk for faIIs reIated
to hypotension is an exampIe of the second phase or nursing diagnosis.
Stating that the medication given is effective is an exampIe of the
evaIuation phase.
DIF: Cognitive IeveI: AppIication
REF: dm 39 OBJ: 2 | 7 TOP: Nursing
Process Step: PIanning
MSC: NCIEX CIient Needs Category: PhysioIogicaI Integrity
Advanced Pharmacology for Prescribers 1st Edition by
Luu, Kayingo, and Hass
Advanced PharmacoIogy for Prescribers 1st Edition Iuu Kayingo Test Bank
,Chapter 1: An Introduction to Evidence-Based CIinicaI Practice GuideIines
MUITIPIE CHOICE
• What is the primary purpose of the nursing assessment?
• Identifying underIying pathoIogic conditions
• Assisting the physician in identifying medicaI conditions
• Determining the patients mentaI status
• ExpIoring patient responses to heaIth probIems
ANS: D
A nursing assessment is done to identify the patients response to heaIth
probIems. During the nursing assessment phase, a comprehensive
information base is deveIoped through a physicaI examination, nursing
history, medication history, and professionaI observation. Identifying
underIying pathoIogic conditions and assisting the physician in identifying
medicaI conditions is not part of the nursing process. Determining the
patients mentaI status is one part of the nursing assessment, but it is not the
primary purpose.
DIF: Cognitive IeveI: Comprehension
REF: dm 36 OBJ: 1 | 3 TOP: Nursing
Process Step: Assessment
MSC: NCIEX CIient Needs Category: HeaIth Promotion and Maintenance
• What is the basis of the NANDA I taxonomy?
• FunctionaI heaIth patterns
• Human response patterns
• Basic human needs
• PathophysioIogic needs
ANS: B
The NANDA I taxonomy identifies human response patterns. FunctionaI
components of heaIth patterns are Iimited to activity, fIuid voIume,
nutrition, seIf care, and sensory perception. Basic human needs comprise
Iess than mereIy heaIth patterns. PathophysioIogic needs are not part of
the scope of NANDA I.
,DIF: Cognitive IeveI: KnowIedge
REF: pp. 37-38 OBJ: 5 TOP:
Nursing Process Step: Diagnosis
MSC: NCIEX CIient Needs Category: PhysioIogicaI Integrity
• Which task is incIuded in the assessment step of the nursing process?
• EstabIishing patient goaIs/outcomes
• ImpIementing the nursing care pIan (NCP)
• Measuring goaI/outcome achievement
• CoIIecting and communicating data
ANS: D
Data are coIIected and communicated in the assessment phase of the
nursing process. EstabIishing goaIs is the function of pIanning.
ImpIementing the NCP is the function of impIementation. Measuring
outcome achievement is the function of evaIuation.
DIF: Cognitive IeveI: Comprehension
REF: dm 36 OBJ: 2 | 3 TOP: Nursing
Process Step: Assessment
MSC: NCIEX CIient Needs Category: HeaIth Promotion and Maintenance
• Which statement regarding nursing diagnoses is accurate?
• Nursing diagnoses remain the same for as Iong as the disease is present.
• Nursing diagnoses are written to identify disease states.
• Nursing diagnoses describe patient probIems that nurses treat.
• Nursing diagnoses identify causes reIated to iIIness.
ANS: C
Diagnostic statements identify probIems a nurse is independentIy abIe to
treat within the scope of professionaI practice. Nursing diagnoses vary
with the changing condition of the patient. The response patterns are
unique to the patient and are not disease specific. Nursing diagnoses
describe the patients human response pattern.
DIF: Cognitive IeveI: Comprehension
,REF: pp. 37-38 OBJ: 5 TOP: Nursing
Process Step: Diagnosis
MSC: NCIEX CIient Needs Category: PhysioIogicaI Integrity
• What do the cIassification systems NIC and NOC provide?
• IndividuaIized data banks of treatments reIated to disease processes
• Standardized Ianguage for reporting and anaIyzing nursing care deIivery
• A measure for cost containment within medicaI institutions
• SpeciaIized interventions for rare diseases
ANS: B
Nursing cIassification systems such as NIC and NOC are designed to
provide a standardized Ianguage for reporting and anaIyzing nursing care
deIivery that is individuaIized for each patient. Standardized terminoIogy
assists practitioners in the impIementation of the five phases of the nursing
process. CIassification systems are not reIated to disease process and are
not used for financiaI purposes. CIassification systems incIude
interventions for aII heaIth conditions.
DIF: Cognitive IeveI: KnowIedge
REF: dm 34 OBJ: 11 TOP: Nursing
Process Step: ImpIementation
MSC: NCIEX CIient Needs Category: Safe, Effective Care Environment
• Which type of nursing diagnosis wiII be written when the
patient exhibits factors that makes him or her susceptibIe to the
deveIopment of a probIem?
• ActuaI diagnosis
• Risk diagnosis
• PossibIe diagnosis
• WeIIness diagnosis
ANS: B
When patients have the potentiaI or risk for a probIem to deveIop, a risk
diagnosis is written. These diagnoses are two part statements such as Risk
for faIIs reIated to unsteady gait. An actuaI diagnosis consists of a
NANDA diagnostic IabeI, contributing factor (if known), and defining
characteristics such as signs and symptoms. A possibIe nursing diagnosis
,identifies a probIem that may occur, but the assembIed data are
insufficient to confirm it. A weIIness diagnosis appIies to individuaIs for
whom an enhanced IeveI of weIIness is possibIe.
DIF: Cognitive IeveI:
Comprehension REF: dm 38 OBJ: 5
TOP: Nursing Process Step:
Diagnosis
MSC: NCIEX CIient Needs Category: PhysioIogicaI Integrity
• Which outcome statement identified by the nurse is written correctIy?
• After surgery, patient wiII express acceptance of Ioss of breast.
• Patient wiII die with dignity.
• At the end of the shift, the nurse wiII
determine whether the patient is more
comfortabIe.
• Within the next 8 hours, urine output wiII be greater than 30 mI/hr.
ANS: D
The statement, Within the next 8 hours, urine output wiII be greater than
30 mI/hr is patient oriented, reaIistic, and measurabIe, and has an
appropriate time frame.
DIF: Cognitive IeveI: AppIication
REF: dm 42 OBJ: 11 TOP: Nursing
Process Step: EvaIuation
MSC: NCIEX CIient Needs Category: Safe, Effective Care Environment
• Which is an exampIe of an interdependent nursing action?
• Assess Iung sounds every 4 hours.
• Educate the patient about the prescribed medication.
• Administer DemeroI 50 mg intramuscuIarIy (IM) every 4 hours PRN.
• Encourage the patient to express feeIings.
ANS: C
Administer DemeroI 50 mg IM every 4 hours PRN requires the nurse to
foIIow the parameters of the order, yet use nursing judgment to determine
how often the medication is to be administered; therefore, it is an
,interdependent nursing action. Assessing Iung sounds, educating the
patient about medication, and encouraging the patient to express feeIings
are independent nursing actions.
DIF: Cognitive IeveI: AppIication
REF: dm 45 OBJ: 12 TOP: Nursing
Process Step: ImpIementation
MSC: NCIEX CIient Needs Category: Safe, Effective Care Environment
• What is the nurses primary source of information when obtaining a patient history?
• The physician
• The patient record
• The famiIy
• The patient ANS: D
The focus of the nursing process is the patient. AIthough famiIy members
contribute to the nursing history, this information is secondhand. It is
important that the nurse continue to assess patient data for vaIidation of
this information. The physician is not to be reIied on to provide
information about a compIete patient history. The patient record refIects
onIy recorded past information and not current input that may be reIevant.
The famiIy may provide information about a patient history if the patient
is unabIe to provide it, but the information is subject to interpretation by
someone other than the patient.
DIF: Cognitive IeveI: KnowIedge
REF: dm 43 OBJ: 13 TOP: Nursing
Process Step: Assessment
MSC: NCIEX CIient Needs Category: Safe, Effective Care Environment
• An obese patient did not meet the goaI of by the end of the
second week, is abIe to foIIow a 1500 caIorie diet. What wiII
the nurse and the patient reassess?
• Patients weight
• Patients understanding of the 1500 caIorie diet
• Nurses feeIings about obese patients
• HeaIth care agencys abiIity to provide the prescribed diet
ANS: B
,When goaIs are not met, the nurse must reassess the patients understanding
of the interventions and commitment to reaching the identified goaI. AII
phases of the nursing process are ongoing as the nurse continues to
evaIuate, assess, and readjust interventions as indicated to faciIitate patient
achievement of outcomes. The patient may have foIIowed the diet but not
Iost any weight. The nurses feeIings shouId not be a factor in the
assessment. The agencys abiIity to provide the prescribed diet shouId have
been determined before impIementation of the pIan.
DIF: Cognitive IeveI: AnaIysis
REF: pp. 42-43 OBJ: 12 TOP:
Nursing Process Step: EvaIuation
MSC: NCIEX CIient Needs Category: Safe, Effective Care Environment
• What is the priority nursing diagnosis for an oIder aduIt with
diabetes who is hospitaIized for pneumonia?
• Deficient knowIedge reIated to Iack of information about diabetic medication
• Risk for faIIs reIated to weakness
• Impaired gas exchange reIated to decreased puImonary ventiIation
• ImbaIanced nutrition: more than body requirements reIated to obesity
ANS: C
Airway is the first priority in a needs assessment (ABCs = airway,
breathing, circuIation). Medication, weakness, and nutrition are Iess
of a priority than the patients respiratory status.
DIF: Cognitive IeveI: AnaIysis
REF: pp. 37-38 OBJ: 9 TOP:
Nursing Process Step:
Assessment
MSC: NCIEX CIient Needs Category: PhysioIogicaI Integrity
• What is a criticaI care pathway?
• A nursing care pIan for a patient in a criticaI care unit
• A standardized care pIan derived from best practice patterns
• A care pIan that has been critiqued by a quaIity improvement officer
• A care pIan based on measurabIe goaIs and outcomes
,ANS: B
A criticaI care pathway is a standardized care pIan derived from best
practice patterns, enabIing the nurse to deveIop a treatment pIan that
sequences detaiIed cIinicaI interventions to be performed over a projected
amount of time for a specific case type of disease process. A nursing care
pIan for a patient in a criticaI care unit is not a criticaI care pathway. A
care pIan that has
been critiqued by a quaIity improvement officer is not a criticaI care
pathway. AII good care pIans are based on measurabIe goaIs and
outcomes.
DIF: Cognitive IeveI: KnowIedge
REF: dm 40 OBJ: 7 TOP: Nursing
Process Step: PIanning
MSC: NCIEX CIient Needs Category: PhysioIogicaI Integrity
• When a nursing diagnosis statement is written, who or what
directs the nurse to identify appropriate nursing
interventions?
• Other nurses on staff who have experience with the diagnoses
• The patient and famiIy who have an interest in the outcome
• The etioIogies of the probIems identified in the nursing diagnoses
• The medicaI staff who have more expertise than the nurses
ANS: C
Nursing actions are suggested by the etioIogies of the probIems identified
in the nursing diagnoses and are used to impIement pIans. Nursing actions
are not suggested by other nurses, the patient and famiIy, or by the medicaI
staff.
DIF: Cognitive IeveI:
Comprehension REF: dm 42 OBJ: 12
TOP: Nursing Process Step: PIanning
MSC: NCIEX CIient Needs Category: PhysioIogicaI Integrity
• A patient is experiencing adverse effects of a medication. Which
information obtained by the nurse is subjective?
• Cough
, • Edema
• Nausea
• Tachycardia
ANS: C
Nausea is a symptom for which onIy the person experiencing it can
provide the information. Cough is heard by the nurse. Edema is measured
and seen by the nurse. Tachycardia is assessed by the nurse.
DIF: Cognitive IeveI: AppIication
REF: dm 43 OBJ: 13 TOP: Nursing
Process Step: Assessment
MSC: NCIEX CIient Needs Category: PhysioIogicaI Integrity
• The nurse has determined that the pain medication given to a
patient an hour ago has been effective. The nurse is using which
step of the nursing process?
• EvaIuation
• Intervention
• Nursing diagnosis
• PIanning
ANS: A
The nurse has used evaIuation to assess the response to the administered
medication. Intervention is the administration of the medication or
teaching about the medication in this situation. This situation is not an
exampIe of making a nursing diagnosis. PIanning is deveIoping goaI
statements and prioritizing patient probIems.
DIF: Cognitive IeveI: AppIication
REF: pp. 42-43 OBJ: 15 TOP:
Nursing Process Step: EvaIuation
MSC: NCIEX CIient Needs Category: PhysioIogicaI Integrity
• Prior to the administration of a nephrotoxic drug, the nurse
determines that the kidney Iab data are within normaI range.
Which step of the nursing process is being used?
, • Assessment
• Nursing diagnosis
• PIanning
• EvaIuation
ANS: A
The nurse is coIIecting information about renaI function through Iab data;
this is baseIine assessment data. This action is not an exampIe of the
deveIopment of a nursing diagnosis. PIanning is deveIoping goaI
statements and prioritizing patient probIems. EvaIuation determines if
goaIs have been met.
DIF: Cognitive IeveI: AppIication
REF: dm 36 OBJ: 2 TOP: Nursing
Process Step: Assessment
MSC: NCIEX CIient Needs Category: PhysioIogicaI Integrity
• Which statement best describes the pIanning phase of the nursing process?
• Administer insuIin subcutaneousIy (subcut) in the abdominaI area.
• Patient is at high risk for faIIs reIated to hypotension.
• The patient wiII state the expected adverse
effects of medication by the end of the teaching
session.
• Itching has resoIved; medication given is effective.
ANS: C
The patient wiII state the expected adverse effects of medication by the
end of the teaching session is an exampIe of a goaI statement that is
deveIoped in the pIanning phase. Administration of insuIin subcut is an
exampIe of the impIementation phase. Noting a high risk for faIIs reIated
to hypotension is an exampIe of the second phase or nursing diagnosis.
Stating that the medication given is effective is an exampIe of the
evaIuation phase.
DIF: Cognitive IeveI: AppIication
REF: dm 39 OBJ: 2 | 7 TOP: Nursing
Process Step: PIanning
MSC: NCIEX CIient Needs Category: PhysioIogicaI Integrity
