NUR 305 ADVANCED HEALTH ASSESSMENT EXAM 1 COMPLETE
EXAM QUESTIONS AND CORRECT ANSWERS
A nurse teaches a patient to use visualization to cope with chronic pain. Which step
of the nursing process is associated with this nursing intervention?
1. Planning
2. Analysis
3. Evaluation
4. Implementation
4. Implementation (answer) (it is part of their care; caring it out)
Which action should be implemented by the nurse when a medication is delivered
by the Z-track method?
1. Use a special syringe designed for Z-track injections
2. Pull the skin laterally away from the injection site before inserting the needle
3. Administer the injection in the muscle on the anterolateral aspect of the thigh
4. Insert the needle in a separate spot for each dose on a z-shaped grid on the
abdomen
2. Pull the skin laterally away from the injection site before inserting the needle
(Answer; used for IM)
The first step in the nursing process
Assessment
Which action reflects the assessment step of the nursing process?
1. Taking a patient's apical pulse rate every 2 hours after being admitted for an
episode of chest pain (implementation)
2. Scheduling a patient's fluid intake over 12 hours when the patient has a fluid
restriction
3. Examining a patient for injury after a patient falls in the bathroom
4. Obtaining a patient's respiratory rate after a nebulizer treatment
3. Examining a patient for injury after a patient falls in the bathroom (answer)
(examining like assessment)
,Which is the primary goal of the assessment phase of the nursing process?
1. Build trust
2. Collect data
3. Establish goals
4. Validate the medical diagnosis
2. Collect data (Answer; primary goal)
What's the fastest rate/route of absorption?
IV
The nurse is using critical thinking skills during the first phase of the nursing
process: which action indicates the nurse is in the first phase?
A. Completes a comprehensive database
B. Identifies pertinent nursing diagnoses
C. Intervenes based on priorities of patient care
D. Determines whether outcomes have been achieved
A. Completes a comprehensive database (Answer)
A patient expresses fear of going home and being alone. Vital signs are stable, and
the incision is nearly completely healed. What can the nurse infer from the
subjective data?
A. the patient can now perform the dressing changes without help
B. the patient can begin retaking all of the previous medications
C. the patient is fearful of being discharged
D. the patient's surgery was not successful
C. the patient is fearful of being discharged (Answer)
The nurse is reviewing a patient's plan of care, which includes the nursing
diagnostic statement, impaired physical mobility related to tibial fracture as
evidenced by patient's inability to ambulate. Which part of the diagnostic statement
does the nurse need to revise?
A. Etiology
B. Nursing diagnosis
C. Collaborative problem
D. Defining characteristic
, A. Etiology (Answer) (tibial fracture is a medical diagnosis) (etiology- is another
word for related to factor)
B. Nursing diagnosis (this is impaired physical mobility related to, as evidenced
by...)
*the nursing diagnosis doesn't need to be revised only the medical diagnosis
portion
A charge nurse is evaluating a new nurse's plan of care. Which finding will cause
the charge nurse to follow up?
A. Assigning a documented nursing diagnosis of Risk for infection for a patient on
intravenous (IV) antibiotics
B. Completing an interview and physical examination before adding a nursing
diagnosis
C. Developing a nursing diagnosis before completing the database
D. Including cultural and religious preferences in the database
C. developing a nursing diagnosis before completing the database (Answer - this is
something the charge nurse would change)
A patient's plan of care includes the goal of increasing mobility in this shift. As the
patient is ambulating to the bathroom at the beginning of the shift, the patient falls.
Which initial action will the nurse take next to most effectively revise the plan of
care?
A. Consult physical therapy
B. Establish a new plan of care
C. Set new priorities for the patient
D. Assess the patient
D. Assess the patient (answer)
The following statements are on a patient's nursing care plan. When creating a
nursing care plan, which statement should the nurse use as an outcome for a goal
of care?
A. The patient will verbalize a decreased pain level less than 3 on a 0 to 10 scale
EXAM QUESTIONS AND CORRECT ANSWERS
A nurse teaches a patient to use visualization to cope with chronic pain. Which step
of the nursing process is associated with this nursing intervention?
1. Planning
2. Analysis
3. Evaluation
4. Implementation
4. Implementation (answer) (it is part of their care; caring it out)
Which action should be implemented by the nurse when a medication is delivered
by the Z-track method?
1. Use a special syringe designed for Z-track injections
2. Pull the skin laterally away from the injection site before inserting the needle
3. Administer the injection in the muscle on the anterolateral aspect of the thigh
4. Insert the needle in a separate spot for each dose on a z-shaped grid on the
abdomen
2. Pull the skin laterally away from the injection site before inserting the needle
(Answer; used for IM)
The first step in the nursing process
Assessment
Which action reflects the assessment step of the nursing process?
1. Taking a patient's apical pulse rate every 2 hours after being admitted for an
episode of chest pain (implementation)
2. Scheduling a patient's fluid intake over 12 hours when the patient has a fluid
restriction
3. Examining a patient for injury after a patient falls in the bathroom
4. Obtaining a patient's respiratory rate after a nebulizer treatment
3. Examining a patient for injury after a patient falls in the bathroom (answer)
(examining like assessment)
,Which is the primary goal of the assessment phase of the nursing process?
1. Build trust
2. Collect data
3. Establish goals
4. Validate the medical diagnosis
2. Collect data (Answer; primary goal)
What's the fastest rate/route of absorption?
IV
The nurse is using critical thinking skills during the first phase of the nursing
process: which action indicates the nurse is in the first phase?
A. Completes a comprehensive database
B. Identifies pertinent nursing diagnoses
C. Intervenes based on priorities of patient care
D. Determines whether outcomes have been achieved
A. Completes a comprehensive database (Answer)
A patient expresses fear of going home and being alone. Vital signs are stable, and
the incision is nearly completely healed. What can the nurse infer from the
subjective data?
A. the patient can now perform the dressing changes without help
B. the patient can begin retaking all of the previous medications
C. the patient is fearful of being discharged
D. the patient's surgery was not successful
C. the patient is fearful of being discharged (Answer)
The nurse is reviewing a patient's plan of care, which includes the nursing
diagnostic statement, impaired physical mobility related to tibial fracture as
evidenced by patient's inability to ambulate. Which part of the diagnostic statement
does the nurse need to revise?
A. Etiology
B. Nursing diagnosis
C. Collaborative problem
D. Defining characteristic
, A. Etiology (Answer) (tibial fracture is a medical diagnosis) (etiology- is another
word for related to factor)
B. Nursing diagnosis (this is impaired physical mobility related to, as evidenced
by...)
*the nursing diagnosis doesn't need to be revised only the medical diagnosis
portion
A charge nurse is evaluating a new nurse's plan of care. Which finding will cause
the charge nurse to follow up?
A. Assigning a documented nursing diagnosis of Risk for infection for a patient on
intravenous (IV) antibiotics
B. Completing an interview and physical examination before adding a nursing
diagnosis
C. Developing a nursing diagnosis before completing the database
D. Including cultural and religious preferences in the database
C. developing a nursing diagnosis before completing the database (Answer - this is
something the charge nurse would change)
A patient's plan of care includes the goal of increasing mobility in this shift. As the
patient is ambulating to the bathroom at the beginning of the shift, the patient falls.
Which initial action will the nurse take next to most effectively revise the plan of
care?
A. Consult physical therapy
B. Establish a new plan of care
C. Set new priorities for the patient
D. Assess the patient
D. Assess the patient (answer)
The following statements are on a patient's nursing care plan. When creating a
nursing care plan, which statement should the nurse use as an outcome for a goal
of care?
A. The patient will verbalize a decreased pain level less than 3 on a 0 to 10 scale
