,
,
,
, patients‗NhealthNcareNneeds.‖
d. ―TheNnursingNprocessNisNbasedNonNnursingNtheoryNthatNincorporatesNt
heNbiopsychosocialNnatureNofNhumans.‖
ANSWER:N C
TheNnursingNprocessNisNaNproblem-
solvingNapproachNtoNtheNidentificationNandNtreatmentNofNpatients‗Nproblems.NNursingNproces
sNdoesNnotNrequireNresearchNmethodsNforNdiagnosis.NTheNprimaryNuseNofNtheNnursingNprocess
NisNinNpatientNcare,NnotNtoNestablishNnursingNtheoryNorNexplainNnursingNinterventionsNtoNother
NhealthNcareNprofessionals.
DIF: CognitiveNLevel:NUnderstandN(Comprehension)
TOP:N NursingNProcess:NEvaluationNMSC:N NCLEX:NSafeNandNEffectiveNCareNEnvironment
4. ANpatientNadmittedNtoNtheNhospitalNforNsurgeryNtellsNtheNnurse,N―INdoNnotNfeelNcomfort
ableNleavingNmyNchildrenNwithNmyNparents.‖NWhichNactionNwouldNtheNnurseNtakeNne
xt?
a. ReassureNtheNpatientNthatNtheseNfeelingsNareNcommonNforNparents.
b. HaveNtheNpatientNcallNtheNchildrenNtoNensureNthatNtheyNareNdoingNwell.
c. GatherNinformationNonNtheNpatient‗sNconcernsNaboutNtheNchildNcareNarrangements.
d. CallNtheNpatient‗sNparentsNtoNdetermineNwhetherNadequateNchildNcareNisNbe
ingNprovided.
ANSWER:N C
BecauseNaNcompleteNassessmentNisNnecessaryNinNorderNtoNidentifyNaNproblemNandNchooseNan
NappropriateNintervention,NtheNnurse‗sNfirstNactionNshouldNbeNtoNobtainNmoreNinformation.NT
heNotherNactionsNmayNbeNappropriate,NbutNmoreNassessmentNisNneededNbeforeNtheNbestNinterve
ntionNcanNbeNchosen.
DIF: CognitiveNLevel:NAnalyzeN(Analysis)
TOP:N NursingNProcess:NAssessment MSC:N NCLEX:NPsychosocialNIntegrity
5. ANpatientNwithNaNbacterialNinfectionNisNhypovolemicNdueNtoNaNfeverNandNexcessiveNdiaphor
esis.NWhichNexpectedNoutcomeNwouldNtheNnurseNselectNforNthisNpatient?
a. PatientNhasNaNbalancedNintakeNandNoutput.
b. Patient‗sNbeddingNisNkeptNcleanNandNfreeNofNmoisture.
c. PatientNunderstandsNtheNneedNforNincreasedNfluidNintake.
d. Patient‗sNskinNremainsNcoolNandNdryNthroughoutNhospitalization.
ANSWER:N A
BalancedNintakeNandNoutputNgivesNmeasurableNdataNshowingNresolutionNofNtheNproblemNofNde
, ficientNfluidNvolume.NTheNotherNstatementsNwouldNnotNindicateNthatNtheNproblemNofNhypovol
emiaNwasNresolved.
DIF: CognitiveNLevel:NApplyN(Application)
TOP:N NursingNProcess:NPlanningNMSC:N NCLEX:NPhysiologicalNIntegrity
6. WhichNstatementNdescribesNtheNpurposeNofNtheNevaluationNphaseNofNtheNnursingNprocess?
a. ToNdocumentNtheNnursingNcareNplanNinNtheNprogressNnotesNofNtheNhealthNrecord
b. ToNdetermineNifNinterventionsNhaveNbeenNeffectiveNinNmeetingNpatientNoutcomes
c. ToNdecideNwhetherNtheNpatient‗sNhealthNproblemsNhaveNbeenNcompletelyNresolved
d. ToNestablishNifNtheNpatientNagreesNthatNtheNnursingNcareNprovidedNwasNsatisfactory
ANSWER:N B
, EvaluationNconsistsNofNdeterminingNwhetherNtheNdesiredNpatientNoutcomesNhaveNbeenNmetN
andNwhetherNtheNnursingNinterventionsNwereNappropriate.NTheNotherNresponsesNdoNnotNdesc
ribeNtheNevaluationNphase.
DIF: CognitiveNLevel:NUnderstandN(Comprehension)
TOP:N NursingNProcess:NEvaluationNMSC:N NCLEX:NSafeNandNEffectiveNCareNEnvironment
7. WhichNstatementNdescribesNtheNpurposeNofNtheNassessmentNphaseNofNtheNnursingNprocess?
a. ToNteachNinterventionsNthatNrelieveNhealthNproblems
b. ToNuseNpatientNdataNtoNevaluateNpatientNcareNoutcomes
c. ToNobtainNdataNtoNdiagnoseNpatientNstrengthsNandNproblems
d. ToNhelpNtheNpatientNidentifyNrealisticNoutcomesNforNhealthNproblems
ANSWER:N C
DuringNtheNassessmentNphase,NtheNnurseNgathersNinformationNaboutNtheNpatientNtoNdiagnoseNp
atientNstrengthsNandNproblems.NTheNotherNresponsesNareNexamplesNofNtheNplanning,Nintervent
ion,NandNevaluationNphasesNofNtheNnursingNprocess.
DIF: CognitiveNLevel:NUnderstandN(Comprehension)
TOP:N NursingNProcess:NAssessment MSC:N NCLEX:NSafeNandNEffectiveNCareNEnvironment
8. WhenNdevelopingNtheNplanNofNcare,NwhichNcomponentsNwouldNtheNnurseNincludeNinNtheNclin
icalNproblemNstatement?
a. TheNproblemNandNtheNsuggestedNpatientNgoalsNorNoutcomes
b. TheNproblem,NitsNcauses,NandNtheNsignsNandNsymptomsNofNtheNproblem
c. TheNproblemNwithNtheNpossibleNetiologyNandNtheNplannedNinterventions
d. TheNproblem,NitsNpathophysiology,NandNtheNexpectedNoutcome
ANSWER:N B
WhenNwritingNclinicalNproblemsNorNnursingNdiagnoses,NtheNsubjectiveNasNwellNasNobjectiveNd
ataNtoNsupportNtheNproblem‗sNexistenceNshouldNbeNincluded.NGoals,Noutcomes,NandNinterventi
onsNareNnotNincludedNinNtheNproblemNstatement.
DIF: CognitiveNLevel:NUnderstandN(Comprehension)
TOP:N NursingNProcess:NDiagnosisNMSC:N NCLEX:NSafeNandNEffectiveNCareNEnvironment
9. WhichNpatientNcareNtaskNwouldNtheNnurseNdelegateNtoNexperiencedNassistiveNpersonnelN(AP)?
a. InstructNtheNpatientNaboutNtheNneedNtoNalternateNactivityNandNrest.
b. MonitorNlevelNofNshortnessNofNbreathNorNfatigueNafterNambulation.
c. ObtainNtheNpatient‗sNbloodNpressureNandNpulseNrateNafterNambulation.
d. DetermineNwhetherNtheNpatientNisNreadyNtoNincreaseNtheNactivityNlevel.
,ANSWER:N C
APNeducationNincludesNaccurateNvitalNsignNmeasurement.NAssessmentNandNpatientNteachingNr
equireNregisteredNnurseNeducationNandNscopeNofNpracticeNandNcannotNbeNdelegated.
DIF: CognitiveNLevel:NApplyN(Application)
TOP:N NursingNProcess:NPlanningNMSC:N NCLEX:NSafeNandNEffectiveNCareNEnvironment
, 10. ANnurseNisNcaringNforNaNgroupNofNpatientsNonNtheNmedical-
surgicalNunitNwithNtheNhelpNofNoneNfloatNregisteredNnurseN(RN),NoneNassistiveNpersonnelN(AP)
,NandNoneNlicensedNpractical/vocationalNnurseN(LPN/VN).NWhichNassignment,NifNdelegatedNb
yNtheNnurse,NwouldNbeNoutsideNthatNindividual‗sNscopeNofNpractice?
a. CheckNforNtheNpresenceNofNbowelNsoundsNbyNAP
b. AdministrationNofNoralNmedicationsNbyNLPN/VN
c. InsulinNadministrationNbyNfloatNRNNfromNtheNpediatricNunit
d. MeasurementNofNaNpatient‗sNurinaryNcatheterNoutputNbyNAP
ANSWER:N A
AssessmentNrequiresNRNNeducationNandNscopeNofNpracticeNsoNitNcannotNbeNdelegatedNtoNanN
LPN/VNNorNAP.NTheNotherNassignmentsNmadeNbyNtheNRNNareNappropriateNforNtheNroleNofNthe
NteamNmember.
DIF: CognitiveNLevel:NApplyN(Application)
TOP:N NursingNProcess:NPlanningNMSC:N NCLEX:NSafeNandNEffectiveNCareNEnvironment
11. WhichNtaskNisNappropriateNforNtheNnurseNtoNdelegateNtoNaNlicensedNpractical/vocationalNn
urseN(LPN/VN)?
a. CompleteNtheNinitialNadmissionNassessmentNandNplanNofNcare.
b. MeasureNbedsideNbloodNglucoseNbeforeNadministeringNinsulin.
c. DocumentNteachingNcompletedNbeforeNaNdiagnosticNprocedure.
d. InstructNaNpatientNaboutNlow-fat,NreducedNsodiumNdietaryNrestrictions.
ANSWER:N B
TheNeducationNandNscopeNofNpracticeNofNtheNLPN/LVNNincludeNactivitiesNsuchNasNobtaining
NglucoseNtestingNusingNaNfingerNstickNandNadministeringNinsulin.NPatientNteachingNandNtheNinit
ialNassessmentNandNdevelopmentNofNtheNplanNofNcareNareNnursingNactionsNthatNrequireNregiste
redNnurseNeducationNandNscopeNofNpractice.
DIF: CognitiveNLevel:NApplyN(Application)
TOP:N NursingNProcess:NPlanningNMSC:N NCLEX:NSafeNandNEffectiveNCareNEnvironment
12. ANnurseNisNassignedNasNaNcaseNmanagerNforNaNhospitalizedNpatientNwhoNhasNaNspinalNcordNin
jury.NWhichNactivityNcanNtheNpatientNexpectNtheNnurseNinNthisNroleNtoNperform?
a. CareNforNtheNpatientNduringNhospitalizationNforNtheNinjuries.
b. AssistNtheNpatientNwithNhomeNcareNactivitiesNduringNrecovery.
c. CoordinateNtheNservicesNtheNpatientNreceivesNinNtheNhospitalNandNatNhome.
d. DetermineNwhatNmedicalNcareNtheNpatientNneedsNforNoptimalNrehabilitation.
ANSWER:N C