Skills Check Off Exam 205
A patient comes to the walk-in clinic with reports of abdominal pain and diarrhea. While
taking the patient's vital signs, the nurse is implementing which phase of the nursing
process? - answer Assessment
The first step of the nursing process is assessment. During this phase, the nurse
gathers information about a patient's psychological, physiological, sociological, and
spiritual status. This data can be collected in a variety of ways. Generally, nurses will
conduct a patient interview. Physical examinations, referencing a patient's health
history, obtaining a patient's family history, and general observation can also be used to
gather assessment data.
The nurse is measuring the patient's urine output and straining the urine to assess for
stones. Which of the following should the nurse record as objective data? - answerThe
patient's urine output was 450 mL.
Objective data are observable and measurable data ("signs") obtained through
observation, physical examination, and laboratory and diagnostic testing
Which of the following behaviors by the nurse demonstrates that the nurse is
participating in critical thinking? Select all that apply. - answerGathering three assistants
to transfer the patient to a stretcher after noting the patient weighs 300 pounds.
Admitting not knowing how to do a procedure and requesting help.
The nurse who documents on the patient's care plan the outcome goal "Anxiety will be
relieved within 20 to 40 minutes following administration of lorazepam (Ativan)" is
engaged in which step of the nursing process? - answerPlanning
For the planning phase, nurses generally refer to the evidence-based Nursing Outcome
Classification, which is a set of standardized terms and measurements for tracking
patient wellness.
Twenty minutes after administering pain medication to the patient, the nurse returns to
ask if the patient's level of pain has decreased. The nurse documents the patient's
report as part of which phase of the nursing process? - answerEvaluation
Once all nursing intervention actions have taken place, the nurse completes an
evaluation to determine of the goals for patient wellness have been met. The possible
patient outcomes are generally described under three terms: patient's condition
improved, patient's condition stabilized, and patient's condition deteriorated, died, or
, discharged. In the event the condition of the patient has shown no improvement, or if
the wellness goals were not met, the nursing process begins again from the first step.
When learning how to implement the nursing process into a plan of care for a client, the
student nurse realizes that part of the purpose of the nursing process is to: -
answerIdentify client needs and deliver care to meet those needs.
The purpose of the nursing process is to identify a client's health status and actual or
potential healthcare problems or needs, to establish plans to meet the identified needs,
and to deliver specific nursing interventions to meet those needs.
The nurse selects the nursing diagnosis of Risk for Impaired Skin Integrity related to
immobility, dry skin, and surgical incision. Which of the following represents a properly
stated outcome/goal? The client will: - answerHave healthy intact skin during
hospitalization.
The goal or outcome should state the opposite of the nursing diagnosis stem. Healthy
intact skin is the reverse condition of impaired skin integrity.
The care plan includes a nursing intervention "4/2/14 Measure client's fluid intake and
output. F. Jenkins, RN." What element of a proper nursing intervention has been
omitted? - answerTime
Although there may be standard policies or routines for measuring intake and output,
the nursing intervention should specify whether this is to be done "routinely" or at
specific intervals (e.g., every 4 hours). The nurse is also aware, however, that critical
thinking indicates that the intake and output should be monitored more frequently than
ordered if assessment reveals abnormal findings.
The nurse is teaching a client the dietary measures associated with health promotion.
The nurse plans to ask the client about the types of food the client likes and for
information regarding the client's food budget prior to the teaching. The nurse is
assessing the client in order to: - answerMake a decision about what to teach
Dietary teaching requires the nurse to make decisions about what to teach based on the
client's likes, dislikes, and budget abilities. The nurse then helps the client to make
decisions about the best way to implement the new dietary plan.
Before completing a nursing diagnosis, the nurse must first: - answerPerform an
assessment
When taking the tympanic temperature of a child under 3-year-old, the pinna should be
pulled in what direction? - answerDown and back
Pulling the pinna down and back straightens the ear canal
A patient comes to the walk-in clinic with reports of abdominal pain and diarrhea. While
taking the patient's vital signs, the nurse is implementing which phase of the nursing
process? - answer Assessment
The first step of the nursing process is assessment. During this phase, the nurse
gathers information about a patient's psychological, physiological, sociological, and
spiritual status. This data can be collected in a variety of ways. Generally, nurses will
conduct a patient interview. Physical examinations, referencing a patient's health
history, obtaining a patient's family history, and general observation can also be used to
gather assessment data.
The nurse is measuring the patient's urine output and straining the urine to assess for
stones. Which of the following should the nurse record as objective data? - answerThe
patient's urine output was 450 mL.
Objective data are observable and measurable data ("signs") obtained through
observation, physical examination, and laboratory and diagnostic testing
Which of the following behaviors by the nurse demonstrates that the nurse is
participating in critical thinking? Select all that apply. - answerGathering three assistants
to transfer the patient to a stretcher after noting the patient weighs 300 pounds.
Admitting not knowing how to do a procedure and requesting help.
The nurse who documents on the patient's care plan the outcome goal "Anxiety will be
relieved within 20 to 40 minutes following administration of lorazepam (Ativan)" is
engaged in which step of the nursing process? - answerPlanning
For the planning phase, nurses generally refer to the evidence-based Nursing Outcome
Classification, which is a set of standardized terms and measurements for tracking
patient wellness.
Twenty minutes after administering pain medication to the patient, the nurse returns to
ask if the patient's level of pain has decreased. The nurse documents the patient's
report as part of which phase of the nursing process? - answerEvaluation
Once all nursing intervention actions have taken place, the nurse completes an
evaluation to determine of the goals for patient wellness have been met. The possible
patient outcomes are generally described under three terms: patient's condition
improved, patient's condition stabilized, and patient's condition deteriorated, died, or
, discharged. In the event the condition of the patient has shown no improvement, or if
the wellness goals were not met, the nursing process begins again from the first step.
When learning how to implement the nursing process into a plan of care for a client, the
student nurse realizes that part of the purpose of the nursing process is to: -
answerIdentify client needs and deliver care to meet those needs.
The purpose of the nursing process is to identify a client's health status and actual or
potential healthcare problems or needs, to establish plans to meet the identified needs,
and to deliver specific nursing interventions to meet those needs.
The nurse selects the nursing diagnosis of Risk for Impaired Skin Integrity related to
immobility, dry skin, and surgical incision. Which of the following represents a properly
stated outcome/goal? The client will: - answerHave healthy intact skin during
hospitalization.
The goal or outcome should state the opposite of the nursing diagnosis stem. Healthy
intact skin is the reverse condition of impaired skin integrity.
The care plan includes a nursing intervention "4/2/14 Measure client's fluid intake and
output. F. Jenkins, RN." What element of a proper nursing intervention has been
omitted? - answerTime
Although there may be standard policies or routines for measuring intake and output,
the nursing intervention should specify whether this is to be done "routinely" or at
specific intervals (e.g., every 4 hours). The nurse is also aware, however, that critical
thinking indicates that the intake and output should be monitored more frequently than
ordered if assessment reveals abnormal findings.
The nurse is teaching a client the dietary measures associated with health promotion.
The nurse plans to ask the client about the types of food the client likes and for
information regarding the client's food budget prior to the teaching. The nurse is
assessing the client in order to: - answerMake a decision about what to teach
Dietary teaching requires the nurse to make decisions about what to teach based on the
client's likes, dislikes, and budget abilities. The nurse then helps the client to make
decisions about the best way to implement the new dietary plan.
Before completing a nursing diagnosis, the nurse must first: - answerPerform an
assessment
When taking the tympanic temperature of a child under 3-year-old, the pinna should be
pulled in what direction? - answerDown and back
Pulling the pinna down and back straightens the ear canal
