Nurs104 Final UPDATED ACTUAL Exam
Questions and CORRECT Answers
A nurse will arrive at a nursing diagnosis through the nursing process step of: - CORRECT
ANSWER - assessment.
A student nurse can begin to develop critical thinking skills by means of: - CORRECT
ANSWER - listening attentively and focusing on the speaker's words and meaning.
An emergency room nurse will give first priority to the patient with the most critical need, which
is the patient who: - CORRECT ANSWER - complains of severe chest pain.
Constant nursing assessments and evaluations of the patient will most likely result in: -
CORRECT ANSWER - the nursing care plan changing to reflect appropriate priorities.
Descriptions of the activities involved in the nursing diagnosis step of the nursing process are:
(Select all that apply.) - CORRECT ANSWER - determination of potential health
problems., clustering of related assessments.
In the collaborative process of delivering care based on the nursing process, the responsibility of
the LPN/LVN is to: - CORRECT ANSWER - collect data of health status.
Once the nursing plan has been initiated, the nursing care plan will: - CORRECT
ANSWER - change as the patient's condition changes.
The activity that is implementation in nursing care is: - CORRECT ANSWER - changing
the patient's surgical dressing.
The effect of using a scientific problem-solving approach in nursing care will cause decision
making to be: - CORRECT ANSWER - improved nursing care outcomes.
,The nurse who uses the nursing process will: - CORRECT ANSWER - approach the
patient's disorder in a step-by-step method.
The order in which the nursing process is approached is: - CORRECT ANSWER -
assessment, nursing diagnosis, planning, implementation, evaluation.
The participants of the planning stage of the nursing process during which the health goals are
defined include the: - CORRECT ANSWER - health team, the patient, and the patient's
family.
When a nurse prioritizes the patient care, consideration is given to: - CORRECT
ANSWER - considering situations that may result in an alteration of health.
When a patient states, "I can't walk very well," the first problem-solving step would be to: -
CORRECT ANSWER - find out what the problem is, such as weakness or poor balance.
When a resident in the nursing home complains of constipation, the nurse performs a digital
rectal examination and finds a hard fecal mass. This is an example of: - CORRECT
ANSWER - assessment.
When the nurse checks to see whether a patient has had relief 45 minutes after administering
pain medication, the nurse is performing a(n): - CORRECT ANSWER - evaluation.
A nursing care plan consists of: - CORRECT ANSWER - nursing orders for
individualized interventions to assist the patient to meet expected outcomes.
A nursing diagnosis consists of: - CORRECT ANSWER - diagnostic labels formulated by
the North American Nursing Diagnosis Association-International (NANDA-I).
A patient with visual impairment is identified as at risk for falls related to blindness. An
appropriate intervention would be to: - CORRECT ANSWER - arrange furnishings in
room to provide clear pathways and orient the patient to these.
, An elderly patient with a medical diagnosis of chronic lung disease has developed pneumonia.
She is coughing frequently and expectorating thick, sticky secretions. She is very short of breath,
even with oxygen running, and she is exhausted and says she "can't breathe." Based on this
information, an appropriately worded nursing diagnosis for this patient is - CORRECT
ANSWER - Airway clearance, ineffective, related to lung secretions as evidenced by
cough and shortness of breath.
During the assessment phase of the nursing process, the nurse - CORRECT ANSWER -
gathers, organizes, and documents data in a logical database.
The statements that are correctly stated as expected outcomes are: (Select all that apply.) -
CORRECT ANSWER - Patient will be able to ambulate using a walker independently
within 3 days., Patient will perform active range of motion (ROM) of her upper extremities
independently every 4 hours.
A nurse is caring for a patient with a medical diagnosis of right lower lobe pneumonia. The
patient is expectorating thick green mucus, has an oxygen saturation level of 90%, and has
audible crackles in the base of the right lung. An appropriate nursing diagnosis for this patient is:
- CORRECT ANSWER - Airway clearance, ineffective, related to retained secretions as
evidenced by expectoration of thick green mucus, oxygen saturation level of 90%, and audible
crackles in the base of the right lung.
A nursing care plan consists of: - CORRECT ANSWER - nursing orders for
individualized interventions to assist the patient to meet expected outcomes.
A nursing diagnosis consists of: - CORRECT ANSWER - diagnostic labels formulated by
the North American Nursing Diagnosis Association-International (NANDA-I).
A patient has a nursing diagnosis of Imbalanced nutrition: less than body requirements, related to
mental impairment and decreased intake, as evidenced by increasing confusion and weight loss
of more than 30-pounds over the last 6 months. An appropriate short-term goal for this patient is
to: - CORRECT ANSWER - eat 50% of six small meals each day by the end of 1 week.
Questions and CORRECT Answers
A nurse will arrive at a nursing diagnosis through the nursing process step of: - CORRECT
ANSWER - assessment.
A student nurse can begin to develop critical thinking skills by means of: - CORRECT
ANSWER - listening attentively and focusing on the speaker's words and meaning.
An emergency room nurse will give first priority to the patient with the most critical need, which
is the patient who: - CORRECT ANSWER - complains of severe chest pain.
Constant nursing assessments and evaluations of the patient will most likely result in: -
CORRECT ANSWER - the nursing care plan changing to reflect appropriate priorities.
Descriptions of the activities involved in the nursing diagnosis step of the nursing process are:
(Select all that apply.) - CORRECT ANSWER - determination of potential health
problems., clustering of related assessments.
In the collaborative process of delivering care based on the nursing process, the responsibility of
the LPN/LVN is to: - CORRECT ANSWER - collect data of health status.
Once the nursing plan has been initiated, the nursing care plan will: - CORRECT
ANSWER - change as the patient's condition changes.
The activity that is implementation in nursing care is: - CORRECT ANSWER - changing
the patient's surgical dressing.
The effect of using a scientific problem-solving approach in nursing care will cause decision
making to be: - CORRECT ANSWER - improved nursing care outcomes.
,The nurse who uses the nursing process will: - CORRECT ANSWER - approach the
patient's disorder in a step-by-step method.
The order in which the nursing process is approached is: - CORRECT ANSWER -
assessment, nursing diagnosis, planning, implementation, evaluation.
The participants of the planning stage of the nursing process during which the health goals are
defined include the: - CORRECT ANSWER - health team, the patient, and the patient's
family.
When a nurse prioritizes the patient care, consideration is given to: - CORRECT
ANSWER - considering situations that may result in an alteration of health.
When a patient states, "I can't walk very well," the first problem-solving step would be to: -
CORRECT ANSWER - find out what the problem is, such as weakness or poor balance.
When a resident in the nursing home complains of constipation, the nurse performs a digital
rectal examination and finds a hard fecal mass. This is an example of: - CORRECT
ANSWER - assessment.
When the nurse checks to see whether a patient has had relief 45 minutes after administering
pain medication, the nurse is performing a(n): - CORRECT ANSWER - evaluation.
A nursing care plan consists of: - CORRECT ANSWER - nursing orders for
individualized interventions to assist the patient to meet expected outcomes.
A nursing diagnosis consists of: - CORRECT ANSWER - diagnostic labels formulated by
the North American Nursing Diagnosis Association-International (NANDA-I).
A patient with visual impairment is identified as at risk for falls related to blindness. An
appropriate intervention would be to: - CORRECT ANSWER - arrange furnishings in
room to provide clear pathways and orient the patient to these.
, An elderly patient with a medical diagnosis of chronic lung disease has developed pneumonia.
She is coughing frequently and expectorating thick, sticky secretions. She is very short of breath,
even with oxygen running, and she is exhausted and says she "can't breathe." Based on this
information, an appropriately worded nursing diagnosis for this patient is - CORRECT
ANSWER - Airway clearance, ineffective, related to lung secretions as evidenced by
cough and shortness of breath.
During the assessment phase of the nursing process, the nurse - CORRECT ANSWER -
gathers, organizes, and documents data in a logical database.
The statements that are correctly stated as expected outcomes are: (Select all that apply.) -
CORRECT ANSWER - Patient will be able to ambulate using a walker independently
within 3 days., Patient will perform active range of motion (ROM) of her upper extremities
independently every 4 hours.
A nurse is caring for a patient with a medical diagnosis of right lower lobe pneumonia. The
patient is expectorating thick green mucus, has an oxygen saturation level of 90%, and has
audible crackles in the base of the right lung. An appropriate nursing diagnosis for this patient is:
- CORRECT ANSWER - Airway clearance, ineffective, related to retained secretions as
evidenced by expectoration of thick green mucus, oxygen saturation level of 90%, and audible
crackles in the base of the right lung.
A nursing care plan consists of: - CORRECT ANSWER - nursing orders for
individualized interventions to assist the patient to meet expected outcomes.
A nursing diagnosis consists of: - CORRECT ANSWER - diagnostic labels formulated by
the North American Nursing Diagnosis Association-International (NANDA-I).
A patient has a nursing diagnosis of Imbalanced nutrition: less than body requirements, related to
mental impairment and decreased intake, as evidenced by increasing confusion and weight loss
of more than 30-pounds over the last 6 months. An appropriate short-term goal for this patient is
to: - CORRECT ANSWER - eat 50% of six small meals each day by the end of 1 week.
