Nursing process 2
1. 3: Which feature is true about standing orders?
1
Meet instrumental activities of daily living.
2
Ensure familiarity with evidence-based guidelines for nursing care. 3
Allow a quick response to a rapidly changing clinical situation. 4
Minimize documentation issues for nurses.
2. 1,2,4: Which action would the nurse perform when revising a nursing care plan? Select all
that apply. One, some, or all responses may be correct. 1
Revise the nursing diagnoses.
2
Add new data with appropriate dates.
3
Maintain irrelevant nursing diagnoses.
4
Choose the method of evaluation for monitoring patient outcomes.
3. 1,4,5: Which action is an example of an independent nursing intervention? Select all that
apply. One, some, or all responses may be correct.
1
Provide health education
2
Start intravenous (IV) fluids
,3
Administer a hypertension agent
4
Assist with daily activities
5
Reposition a patient
4. 1: Which problem would the nurse add to the care plan after evaluating a diabetic patient
who had a problem with glucose control but is now restless and asking many questions
about an upcoming procedure on the big toe?
1
Anxiety
2
Glucose control
3
Diabetes
4
Risk of toe infection
5. 4: Setting a time frame for outcomes of care determines which purpose?
1
The priority level
2
Time it takes to complete an intervention
3
How long the nurse is scheduled to care for a patient
4
, Nursing process 2
When the patient is expected to respond in the desired manner
6. 3: Which action would the nurse take for a patient who agrees with the nurse that
expected outcomes were met?
1
Modify the care plan.
2
Revise the plan of care.
3
Discontinue the care plan.
4
Continue with the plan of care.
7. 3: Which response would the nurse make for a patient who expresses confusion about
how to manage a leg wound after discharge?
1
Provide a written document that contains the necessary instructions. 2
Tell the patient that a relative will be taught how to take care of the wound.
3
Explain and demonstrate the necessary action to the patient. 4
Inform the patient that it will be explained later during discharge.
8. 3: The nurse would evaluate which goal based upon the following reassessment: upon
removal of the intravenous (IV) line from the right arm, the site was clean and dry with no
signs of redness or tenderness?
1
Patient expresses acceptance of health status by day of discharge. 2
, Patient's surgical wound will be free of drainage.
3
Patient's IV site will remain free of infection.
4
Patient understands when to call the health care provider to report complications.
9. 2: Which priority action would the nurse take before administering a new drug?
1
Confer with a colleague before giving the medication. 2
Consult with a pharmacist to obtain knowledge about the medication. 3
Ask the patient about the medication.
4
Administer the medication as prescribed and on time.
10. 1: Which expected outcome would be appropriate for a patient who is vomiting?
1
Patient stops vomiting in 2 hours.
2
The antiemetic (drug to stop vomiting) will be administered every 6 hours.
3
The antiemetic will not produce side effects in the patient. 4
Patient will not vomit again.
11. 3,4,5: Which intervention performed by the nurse is an interdependent intervention?
Select all that apply. One, some, or all responses may be correct.
1
Preparing the patient for diagnostic tests
1. 3: Which feature is true about standing orders?
1
Meet instrumental activities of daily living.
2
Ensure familiarity with evidence-based guidelines for nursing care. 3
Allow a quick response to a rapidly changing clinical situation. 4
Minimize documentation issues for nurses.
2. 1,2,4: Which action would the nurse perform when revising a nursing care plan? Select all
that apply. One, some, or all responses may be correct. 1
Revise the nursing diagnoses.
2
Add new data with appropriate dates.
3
Maintain irrelevant nursing diagnoses.
4
Choose the method of evaluation for monitoring patient outcomes.
3. 1,4,5: Which action is an example of an independent nursing intervention? Select all that
apply. One, some, or all responses may be correct.
1
Provide health education
2
Start intravenous (IV) fluids
,3
Administer a hypertension agent
4
Assist with daily activities
5
Reposition a patient
4. 1: Which problem would the nurse add to the care plan after evaluating a diabetic patient
who had a problem with glucose control but is now restless and asking many questions
about an upcoming procedure on the big toe?
1
Anxiety
2
Glucose control
3
Diabetes
4
Risk of toe infection
5. 4: Setting a time frame for outcomes of care determines which purpose?
1
The priority level
2
Time it takes to complete an intervention
3
How long the nurse is scheduled to care for a patient
4
, Nursing process 2
When the patient is expected to respond in the desired manner
6. 3: Which action would the nurse take for a patient who agrees with the nurse that
expected outcomes were met?
1
Modify the care plan.
2
Revise the plan of care.
3
Discontinue the care plan.
4
Continue with the plan of care.
7. 3: Which response would the nurse make for a patient who expresses confusion about
how to manage a leg wound after discharge?
1
Provide a written document that contains the necessary instructions. 2
Tell the patient that a relative will be taught how to take care of the wound.
3
Explain and demonstrate the necessary action to the patient. 4
Inform the patient that it will be explained later during discharge.
8. 3: The nurse would evaluate which goal based upon the following reassessment: upon
removal of the intravenous (IV) line from the right arm, the site was clean and dry with no
signs of redness or tenderness?
1
Patient expresses acceptance of health status by day of discharge. 2
, Patient's surgical wound will be free of drainage.
3
Patient's IV site will remain free of infection.
4
Patient understands when to call the health care provider to report complications.
9. 2: Which priority action would the nurse take before administering a new drug?
1
Confer with a colleague before giving the medication. 2
Consult with a pharmacist to obtain knowledge about the medication. 3
Ask the patient about the medication.
4
Administer the medication as prescribed and on time.
10. 1: Which expected outcome would be appropriate for a patient who is vomiting?
1
Patient stops vomiting in 2 hours.
2
The antiemetic (drug to stop vomiting) will be administered every 6 hours.
3
The antiemetic will not produce side effects in the patient. 4
Patient will not vomit again.
11. 3,4,5: Which intervention performed by the nurse is an interdependent intervention?
Select all that apply. One, some, or all responses may be correct.
1
Preparing the patient for diagnostic tests
