Integrated Exam 2 Practice Questions & Answers

Which of the following items of *subjective data* would be documented in the medical record by the nurse? A. Client's face is pale B. Cervical lymph nodes are palpable C. Nursing assistant reports client refused lunch D. Client feel nauseated - ANSWERSD. Client feel nauseated Rationale: Subjective data includes the client's sensations, feelings, and perception of health status. Subjective data can only be verified by the affected person. Options 1, 2, and 3 represent objective data that can be detected by the nurse or measured against an accepted norm. A nurse explains to a student that the nursing process is a dynamic process. Which of the following actions by the nurse best demonstrates this concept during the work shift? A. Nurse and client agree upon health care goals for the client B. Nurse reviews the client's history on the medical record C. Nurse explains to the client the purpose of each administered medication D. Nurse rapidly reset priorities for client care based on a change in the client's condition - ANSWERSD. Nurse rapidly reset priorities for client care based on a change in the client's condition Rationale: The nursing process is characterized by unique properties that enable it to respond to the changing health status of the client. Options 1, 2, and 3 are appropriate nursing care measures, but do not demonstrate the dynamic nature of the nursing process. The rehabilitation nurse wishes to make the following entry into a client's plan of care: "Client will reestablish a pattern of daily bowel movements without straining within two months." The nurse would write this statement under which section of the plan of care? A. Nursing diagnosis/problem list B. Nursing orders C. Short-term goals D. Long-term goals - ANSWERSD. Long-term goals Rationale: Long-term goals describe changes in client behavior expected over a time frame greater than one week. They are usually designed to restore normal functioning in a problem area and are helpful to other healthcare workers who care for the client, often in a variety of settings. The nursing diagnosis is Risk for impaired skin integrity related to immobility and pressure secondary to pain and presence of a cast. Which of the following desired outcomes should the nurse include in the care plan? A. Client will be able to turn self by day 3 B. Skin will remain intact and without redness during hospital stay C. Client will state pain relieved within 30 minutes after medication D. Pressure will be prevented by repositioning client every 2 hours - ANSWERSB. Skin will remain intact and without redness during hospital stay Rationale: The human response/label is what needs to change (Risk for impaired skin integrity). The label suggests the outcomes. In this case, "skin will remain intact" is the desired outcome for a client at risk for impaired skin integrity. Option 1 addresses immobility. Option 3 addresses pain. Option 4 is an intervention. While assisting a client from bed to chair, the nurse observes that the client looks pale and is beginning to perspire heavily. The nurse would then do which of the following activities as a reassessment? A. Help client into the chair but more quickly B. Document client's vital signs taken just prior to moving the client C. Help client back to bed immediately D. Observe client's skin color and take another set of vital signs - ANSWERSD. Observe client's skin color and take another set of vital signs Rationale: Assessment is ongoing throughout the nurse-client relationship. During re-assessment, the nurse collects additional data to help evaluate the status of problems or identify new problems. Options 1, 2, and 3 are interventions. After instructing the client on crutch walking technique, the nurse should evaluate the client's understanding by using which of the following methods? A. Return demonstration B. Explanation C. Achievement of 90 on written test D. Have client explain produce to the family - ANSWERSA. Return demonstration The nurse would do which of the following during the implementation phase of the nursing process when working with a hospitalized adult? A. Formulate a nursing diagnosis of impaired gas exchange B. Record in the medical record the distance a client ambulated in the hall C. Write individualized nursing orders in the care plan D. Compare client responses to the desired outcomes for pain relief - ANSWERSB. Record in the medical record the distance a client ambulated in the hall Rationale: The implementation phase of the nursing process involves carrying out or delegating the nursing interventions and recording nursing activities and client responses in the medical records. Option 1 represents diagnosing. Option 3 represents planning. Option 4 represents evaluation. A client on the nursing unit is terminally ill but remains alert and oriented. Three days after admission, the nurse observes signs of depression. The client states, "I'm tired of being sick. I wish I could end it all." What is the most accurate and informative way to record this data in a nursing progress note? A. Client appears to be depressed, possibly suicidal B. Client reports being tired of being ill and wants to die C. Client does not want to live any longer and is tired of being ill D. Client states, "I'm tired of being sick. I wish I could end it all." - ANSWERSD. Client states, "I'm tired of being sick. I wish I could end it all." Rationale: Subjective data includes thoughts, beliefs, feelings, perceptions, and sensations that are apparent only to the person affected and cannot be measured, seen, or felt by the nurse. This information should be documented using the client's exact words in quotes. The other options indicate that the nurse has drawn the conclusion that the client no longer wishes to live. From the data provided, the cues do not support this assumption. A more complete assessment should be conducted to determine if the client is suicidal. After change of shift, you are assigned to care for the following patients. Which patient should you assess first? A. A 60-year old patient on a ventilator for whom a sterile sputum specimen must be sent to the lab B. A 55-year old with COPD and a pulse oximetry reading from the previous shift of 90% saturation C. A 70-year old with pneumonia who needs to be started on intravenous (IV) antibiotics D. A 50-year old with asthma who complains of shortness of breath after using a bronchodilator - ANSWERSD. A 50-year old with asthma who complains of shortness of breath after using a bronchodilator Rationale: The patient with asthma did not achieve relief from shortness of breath after using the bronchodilator and is at risk for respiratory complications. This patient's needs are urgent. The other patients need to be assessed as soon as possible, but none of their situations are urgent. in COPD patients pulse oximetry oxygen saturations of more than 90% are acceptable. The nurse plans care for a client in the post anesthesia care unit. The nurse should assess first the client's: A. respiratory status. B. level of consciousness. C. level of pain. D. reflexes and movement of extremities. - ANSWERSA. respiratory status Rationale: Assessing respiratory status is the first priority. Remember ABC. Nurse Channing is caring for four clients and is preparing to do his initial rounds. Which client should the nurse assess first? A. A client with diabetes being discharged today. B. A 35-year-old male with tracheostomy and copious secretions. C. A teenager scheduled for physical therapy this morning. D. A 78-year-old female client with pressure ulcer that needs dressing change. - ANSWERSB. A 35-year-old male with tracheostomy and copious secretions. Rationale: The patient with problem of the airway should be given highest priority. Remember Airway, Breathing, and Circulation (ABC) is a priority. Nurse Skye is on the cardiac unit caring for four clients. He is preparing to do initial rounds. Which client should the nurse assess first? A. A client scheduled for cardiac ultrasound this morning. B. A client with syncope being discharged today. C. A client with chronic bronchitis on nasal oxygen. D. A client with diabetic foot ulcer that needs a dressing change. - ANSWERSC. A client with chronic bronchitis on nasal oxygen. Rationale: A client with airway problems should be attended first. Once a nurse assesses a client's condition and identifies appropriate nursing diagnoses, a: A. Plan is developed for nursing care. B. Physical assessment begins C. List of priorities is determined. D. Review of the assessment is conducted with other team members. - ANSWERSA. Plan is developed for nursing care. Planning is a category of nursing behaviors in which: A. The nurse determines the health care needed for the client. B. The Physician determines the plan of care for the client. C. Client-centered goals and expected outcomes are established. D. The client determines the care needed. - ANSWERSC. Client-centered goals and expected outcomes are established. Priorities are established to help the nurse anticipate and sequence nursing interventions when a client has multiple problems or alterations. Priorities are determined by the client's: A. Physician B. Non Emergent, non-life threatening needs C. Future well-being. D. Urgency of problems - ANSWERSD. Urgency of problems A client centered goal is a specific and measurable behavior or response that reflects a client's: A. Desire for specific health care interventions B. Highest possible level of wellness and independence in function. C. Physician's goal for the specific client. D. Response when compared to another client with a like problem. - ANSWERSB. Highest possible level of wellness and independence in function. The nurse writes an expected outcome statement in measurable terms. An example is: A. Client will have less pain. B. Client will be pain free. C. Client will report pain acuity less than 4 on a scale of 0-10. D. Client will take pain medication every 4 hours around the clock. - ANSWERSC. Client will report pain acuity less than 4 on a scale of 0-10. As goals, outcomes, and interventions are developed, the nurse must: A. Be in charge of all care and planning for the client. B. Be aware of and committed to accepted standards of practice from nursing and other disciples. C. Not change the plan of care for the client.