CORRECT ANSWERS.
A nurse evaluates a patient's response to a nursing intervention. To which
aspect of the nursing process is this evaluation most directly related?
a. Goal
b. Problem
c. Etiology
d. Implementation - CORRECT ANSWER -a. Goal
A nurse is caring for a patient with a urinary elimination problem. Which
are the accurately stated goals?
SELECT ALL THAT APPLY
a. The patient will be taught how to use a bedpan while on bedrest
b. The patient will experience fewer incontinence episodes at night
c. The patient will transfer independently and safely to a toilet before
discharge
d. The patient will be assisted to the commode every 2 hours and whenever
necessary
e. The patient will experience one or less events of urinary incontinence
daily within 6 weeks - CORRECT ANSWER -c. The patient will transfer
independently and safely to a toilet before discharge
e. The patient will experience one or less events of urinary incontinence
daily within 6 weeks
,Which human responses identified by the nurse are examples of objective
data?
SELECT ALL THAT APPLY
a. Irregular radial pulse of 50
b. Wheezing on expiration
c. Temp of 99F
d. Shortness of breath
e. Dizziness - CORRECT ANSWER -a. Irregular radial pulse of 50
b. Wheezing on expiration
c. Temp of 99F
A nurse is interviewing a patient. Which patient statements are examples of
objective data?
SELECT ALL THAT APPLY
a. I am hungry
b. I feel very warm
c. I ate half my lunch
d. I have a rash on my arm
e. I have the urge to urinate
f. I vomit every time I eat something - CORRECT ANSWER -c. I ate half my
lunch
d. I have a rash on my arm
,f. I vomit every time I eat something
A nurse is interviewing a patient at the change of shift. Which patient
statements reflect subjective data?
SELECT ALL THAT APPLY
a. When I lift my head up off the bed I feel like vomiting
b. I just went in the urinal and it needs to be emptied
c. My pain feels like a 5 on a scale of 0-5
d. The physician said I can go home today
e. I ate only 50% of my breakfast - CORRECT ANSWER -a. When I lift my head
up off the bed I feel like vomiting
c. My pain feels like a 5 on a scale of 0-5
The nurse assesses a patient and collects a variety of data. Identify the
human responses that are subjective data.
SELECT ALL THAT APPLY
a. Nausea
b. Jaundice
c. Dizziness
d. Diaphoresis
e. Hypotension - CORRECT ANSWER -a. Nausea
c. Dizziness
, Which early responses indicated to the nurse that the patient is
experiencing hypoxia?
SELECT ALL THAT APPLY
a. Increased heart rate
b. Difficulty breathing
c. Restlessness
d. Bradypnea
e. Irritability - CORRECT ANSWER -a. Increased heart rate
c. Restlessness
e. Irritability
A nurse is assessing several patients who had surgery the previous day.
Which sudden patient response should the nurse identify as a potential life-
threatening event?
a. Slightly elevated temp
b. Separation of wound edges
c. Edema of the legs
d. Chest pain - CORRECT ANSWER -c. Edema of the legs
A nurse must administer a sedative to a patient before surgery. Which
should the nurse do first?
a. Verify that the pre-op checklist is completed
b. Check that the surgical consent is signed