Nursing Process Test 2 CH 4,5,6,7
Solved 100% Correct
A nurse begins rounds on a medicalsurgical nursing unit. Review the following patients
on her assignment. Prioritize the order in which the patients should be assessed, based
on their descriptions. (Separate letters with a comma and space as follows: A, B, C, D.)
- ANSWER-A. A 22-year-old patient who is awakening from neck surgery.
D. A 35-year-old patient admitted for an injury to his left femoral artery, which required
surgical repair 8 hours ago following an ice-skating accident.
C. A 44-year-old patient with dehydration from vomiting and diarrhea, who was admitted
3 days ago and who has an IV infusion of fluids.
B. An 82-year-old patient who is blind and needs discharge instructions.
A nurse begins the shift caring for a patient who has just returned from the recovery
room after surgery. It is most important to document: - ANSWER-an initial assessment
of the patient and a plan based on the needs of the patient as assessed at the
beginning of the shift.
A nurse enters a notation in a patients chart but then discovers that the notation was
made in the wrong chart. The nurse correctly: - ANSWER-draws a single line through
the notation so that it is still readable and writes mistaken entry, his signature, and the
date and time.
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: - 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 nurse is caring for a patient with a nursing diagnosis of impaired physical mobility
related to neurologic impairment and muscular weakness. Appropriate interventions for
this patient would include which of the following? (Select all that apply.) - ANSWER-
Assist with range-of-motion exercises every 4 hours and as needed.
Instruct patient to call for assistance when needing to get out of bed.
Teach about exercises that will strengthen muscles while lying in bed.
Ambulate with physical therapy assistance at least three times a day.
A nurse tells her neighbor personal information about a hospitalized patient. Telling her
neighbor about this indicates that the: - ANSWER-nurse has violated the confidentiality
of the patient by discussing personal information about the patient with his neighbor.
A nurse understands that the physicians directives for patient care are also referred to
as the: - ANSWER-physicians orders.
, A nurse will arrive at a nursing diagnosis through the nursing process step of: -
ANSWER-assessment.
A nursing care plan consists of: - ANSWER-nursing orders for individualized
interventions to assist the patient to meet expected outcomes.
A nursing diagnosis consists of: - ANSWER-diagnostic labels formulated by the North
American Nursing Diagnosis AssociationInternational (NANDA-I).
A nursing diagnosis identifies: (Select all that apply.) - ANSWER-patients response to
illness.
related signs and symptoms.
causative factors.
potential risk for health problems.
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: - ANSWER-eat 50% of six small meals
each day by the end of 1 week.
A patient who is very angry and is leaving the hospital against medical advice (AMA)
demands to have the medical chart to take, because it is her personal property. An
appropriate response would be: - ANSWER-You are entitled to the information in your
chart, but the chart is the property of the hospital. I will see about having a copy made
for you.
A patient with a nursing diagnosis of Skin integrity, impaired, related to surgery as
evidenced by disruption of skin surface has the following nursing documentation:
Incision clean, dry, intact. No pain or tenderness. Instructed to keep area dry, may wear
light dressing to protect from clothing. Verbalizes understanding of wound care and
ability to manage at home. Wound healing without complication. This documentation is:
- ANSWER-evidence of the use of the nursing process.
A patient with visual impairment is identified as at risk for falls related to blindness. An
appropriate intervention would be to: - ANSWER-arrange furnishings in room to provide
clear pathways and orient the patient to these.
A resident in a skilled nursing facility for a short-term rehabilitation following a hip
replacement says to the nurse, I dont want to have you draw any more blood for those
useless tests. When the nurse fails to convince the patient to have the blood drawn, the
most appropriate documentation would be: - ANSWER-Refuses to have blood drawn;
says tests are useless. Doctor notified.
A review of a patients nursing care plan before beginning care allows the nurse to: -
ANSWER-use critical thinking skills to organize care for the patient.
Solved 100% Correct
A nurse begins rounds on a medicalsurgical nursing unit. Review the following patients
on her assignment. Prioritize the order in which the patients should be assessed, based
on their descriptions. (Separate letters with a comma and space as follows: A, B, C, D.)
- ANSWER-A. A 22-year-old patient who is awakening from neck surgery.
D. A 35-year-old patient admitted for an injury to his left femoral artery, which required
surgical repair 8 hours ago following an ice-skating accident.
C. A 44-year-old patient with dehydration from vomiting and diarrhea, who was admitted
3 days ago and who has an IV infusion of fluids.
B. An 82-year-old patient who is blind and needs discharge instructions.
A nurse begins the shift caring for a patient who has just returned from the recovery
room after surgery. It is most important to document: - ANSWER-an initial assessment
of the patient and a plan based on the needs of the patient as assessed at the
beginning of the shift.
A nurse enters a notation in a patients chart but then discovers that the notation was
made in the wrong chart. The nurse correctly: - ANSWER-draws a single line through
the notation so that it is still readable and writes mistaken entry, his signature, and the
date and time.
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: - 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 nurse is caring for a patient with a nursing diagnosis of impaired physical mobility
related to neurologic impairment and muscular weakness. Appropriate interventions for
this patient would include which of the following? (Select all that apply.) - ANSWER-
Assist with range-of-motion exercises every 4 hours and as needed.
Instruct patient to call for assistance when needing to get out of bed.
Teach about exercises that will strengthen muscles while lying in bed.
Ambulate with physical therapy assistance at least three times a day.
A nurse tells her neighbor personal information about a hospitalized patient. Telling her
neighbor about this indicates that the: - ANSWER-nurse has violated the confidentiality
of the patient by discussing personal information about the patient with his neighbor.
A nurse understands that the physicians directives for patient care are also referred to
as the: - ANSWER-physicians orders.
, A nurse will arrive at a nursing diagnosis through the nursing process step of: -
ANSWER-assessment.
A nursing care plan consists of: - ANSWER-nursing orders for individualized
interventions to assist the patient to meet expected outcomes.
A nursing diagnosis consists of: - ANSWER-diagnostic labels formulated by the North
American Nursing Diagnosis AssociationInternational (NANDA-I).
A nursing diagnosis identifies: (Select all that apply.) - ANSWER-patients response to
illness.
related signs and symptoms.
causative factors.
potential risk for health problems.
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: - ANSWER-eat 50% of six small meals
each day by the end of 1 week.
A patient who is very angry and is leaving the hospital against medical advice (AMA)
demands to have the medical chart to take, because it is her personal property. An
appropriate response would be: - ANSWER-You are entitled to the information in your
chart, but the chart is the property of the hospital. I will see about having a copy made
for you.
A patient with a nursing diagnosis of Skin integrity, impaired, related to surgery as
evidenced by disruption of skin surface has the following nursing documentation:
Incision clean, dry, intact. No pain or tenderness. Instructed to keep area dry, may wear
light dressing to protect from clothing. Verbalizes understanding of wound care and
ability to manage at home. Wound healing without complication. This documentation is:
- ANSWER-evidence of the use of the nursing process.
A patient with visual impairment is identified as at risk for falls related to blindness. An
appropriate intervention would be to: - ANSWER-arrange furnishings in room to provide
clear pathways and orient the patient to these.
A resident in a skilled nursing facility for a short-term rehabilitation following a hip
replacement says to the nurse, I dont want to have you draw any more blood for those
useless tests. When the nurse fails to convince the patient to have the blood drawn, the
most appropriate documentation would be: - ANSWER-Refuses to have blood drawn;
says tests are useless. Doctor notified.
A review of a patients nursing care plan before beginning care allows the nurse to: -
ANSWER-use critical thinking skills to organize care for the patient.
