Nursing Process Implementation
complete 130 questions and
correct answers
1.The nurse in charge identifies a patient's responses to actual or potential
health problems during which step of the nursing process?
A. Assessing
B. Diagnosing
C. Planning
D. Evaluating
Answer: ) B
(Rationale- The nurse identifies human responses to actual or potential
health problems during the nursing diagnoses step of the nursing process.
During the assessment step, the nurse collects data. During the planning
step, the nurse develops strategies to resolve or decrease the patient's
problem. During evaluation, the nurse determines the effectiveness of the
plan of care.)
(Answer: ) D
(Rationale: This answer takes highest priority because venous inflammation
and clot formation impede blood flow in a patient with deep-vein thrombosis.
,Option A is incorrect because impaired gas exchange is related to decreased,
not increased, blood flow. Option B is inappropriate because no evidence
suggests that this patient has a fluid volume excess. Option C may be
warranted but is secondary to altered tissue perfusion)
2.A female patient is diagnosed with deep-vein thrombosis. Which nursing
diagnosis should receive the highest priority at this time?
A. Impaired gas exchange related to increased blood flow
B. Fluid volume excess related to peripheral vascular disease
C. Risk for injury related to edema
D. Altered peripheral tissue perfusion related to venous congestion
(Answer: ) D
(Rationale: During the evaluation step of the nursing process the nurse
determines whether the goals established have been achieved, and
evaluates the success of the plan. Answer A involves data collection. Answer
B involves setting priorities, and Answer C is the actual intervention.)
A nurse is revising a client's care plan. During which step of the nursing
process does such 3.a revision take place?
A. Assessment
B. Planning
C. Implementation
D. Evaluation
(Answer: ) D
, (Rationale: You should begin with the simplest interventions. Answer A is
incorrect because medications should be avoided whenever possible. Answer
B would be a thorough sleep assessment, and should be done only after
common sense interventions fail. Answer C would be appropriate only after
common sense interventions fail.)
4.Which intervention should the nurse in charge try first for a client that
exhibits signs of sleep disturbance?
A. Administer sleeping medication before bedtime
B. Ask the client each morning to describe the quantity of sleep the night
before
C. Teach the client relaxation techniques, such as guided imagery and
progressive muscle relaxation
D. Provide the client normal sleep aids, such as pillows, back rubs, and
snacks
(Answer: ) C
(Rationale- Making appropriate referrals is a valid part of planning the client's
care. The nurse normally does not provide sex counseling. While providing
time for privacy and providing support for the spouse is important, it is not
as important as referring the client to a sex counselor/appropriate
professional)
5.A nurse is assigned to care for a postoperative male client who has
diabetes mellitus. During the assessment interview, the client reports that
he's impotent and says he's concerned about the effect on his marriage. In
planning this client's care, the most appropriate intervention would be to:
A. Encourage the client to ask questions about personal sexuality
B. Provide time for privacy
C. Suggest referral to a sex counselor or other appropriate professional
complete 130 questions and
correct answers
1.The nurse in charge identifies a patient's responses to actual or potential
health problems during which step of the nursing process?
A. Assessing
B. Diagnosing
C. Planning
D. Evaluating
Answer: ) B
(Rationale- The nurse identifies human responses to actual or potential
health problems during the nursing diagnoses step of the nursing process.
During the assessment step, the nurse collects data. During the planning
step, the nurse develops strategies to resolve or decrease the patient's
problem. During evaluation, the nurse determines the effectiveness of the
plan of care.)
(Answer: ) D
(Rationale: This answer takes highest priority because venous inflammation
and clot formation impede blood flow in a patient with deep-vein thrombosis.
,Option A is incorrect because impaired gas exchange is related to decreased,
not increased, blood flow. Option B is inappropriate because no evidence
suggests that this patient has a fluid volume excess. Option C may be
warranted but is secondary to altered tissue perfusion)
2.A female patient is diagnosed with deep-vein thrombosis. Which nursing
diagnosis should receive the highest priority at this time?
A. Impaired gas exchange related to increased blood flow
B. Fluid volume excess related to peripheral vascular disease
C. Risk for injury related to edema
D. Altered peripheral tissue perfusion related to venous congestion
(Answer: ) D
(Rationale: During the evaluation step of the nursing process the nurse
determines whether the goals established have been achieved, and
evaluates the success of the plan. Answer A involves data collection. Answer
B involves setting priorities, and Answer C is the actual intervention.)
A nurse is revising a client's care plan. During which step of the nursing
process does such 3.a revision take place?
A. Assessment
B. Planning
C. Implementation
D. Evaluation
(Answer: ) D
, (Rationale: You should begin with the simplest interventions. Answer A is
incorrect because medications should be avoided whenever possible. Answer
B would be a thorough sleep assessment, and should be done only after
common sense interventions fail. Answer C would be appropriate only after
common sense interventions fail.)
4.Which intervention should the nurse in charge try first for a client that
exhibits signs of sleep disturbance?
A. Administer sleeping medication before bedtime
B. Ask the client each morning to describe the quantity of sleep the night
before
C. Teach the client relaxation techniques, such as guided imagery and
progressive muscle relaxation
D. Provide the client normal sleep aids, such as pillows, back rubs, and
snacks
(Answer: ) C
(Rationale- Making appropriate referrals is a valid part of planning the client's
care. The nurse normally does not provide sex counseling. While providing
time for privacy and providing support for the spouse is important, it is not
as important as referring the client to a sex counselor/appropriate
professional)
5.A nurse is assigned to care for a postoperative male client who has
diabetes mellitus. During the assessment interview, the client reports that
he's impotent and says he's concerned about the effect on his marriage. In
planning this client's care, the most appropriate intervention would be to:
A. Encourage the client to ask questions about personal sexuality
B. Provide time for privacy
C. Suggest referral to a sex counselor or other appropriate professional
