Final_Exam_Nursing_101 Practice Questions
28.A client has an external fixation device on his leg due to a compound fracture. The client says that the device and swelling makes his leg look ugly. Which nursing diagnosis should the nurse document in his care plan based on the client’s concern?
A) Impaired physical mobility
B) Disturbed body image
C) Risk for infection
D) Risk for social isolation
29.A client who has to undergo a parathyroidectomy is worried that he may have to wear a scarf around his neck after surgery. What nursing diagnosis should the nurse document in the care plan?
A) Risk for impaired physical mobility due to surgery
B) Ineffective denial related to poor coping mechanisms
C) Disturbed body image related to the incision scar
D) Risk of injury related to surgical outcomes
30.A nurse who is caring for an unresponsive client formulates the nursing diagnosis, “Risk for Aspiration related to reduced level of consciousness.” The nurse documents this nursing diagnosis as correct based on the understanding that which of the following is a characteristic of this type of diagnosis?
A) Is written as a two-part statement
B) Describes human response to a health problem
C) Describes potential for enhancement to a higher state
D) Made when not enough evidence supports the problem
31.After assessing a client, the nurse formulates several nursing diagnoses. Which of the following would the nurse identify as an actual nursing diagnosis? A) Impaired urinary elimination
B) Readiness for enhanced sleep
C) Risk for infection
D) Possible impaired adjustment
32. What is the nurse accountable for, according to the state nurse practice act?
A) Continuing education
B) Nursing diagnoses
C) Prescribing medicationsD) Mentoring other nurses
33. A client is experiencing shortness of breath, lethargy, and cyanosis. These three cues provide organization or … A) Categorizing
B) Diagnosing
C) Grouping
D) Clustering
34.The nurse is providing care for a client who experienced an ischemic stroke five days ago. Which of the following diagnoses would the nurse be justified in identifying and documenting in the care of this client? Select all that apply.
A) Dysphagia
B) Bowel Incontinence
C) Impaired Swallowing
D) Impaired Physical Mobility
E) Risk for Hemiparesis
35. Which of the following reflects the diagnosis phase?
A) The nurse identifies that the client does not tolerate activity.
B) The nurse performs wound care using sterile technique.
C) The nurse sets a tolerable pain rating with the client.
D) The nurse documents the client’s response to pain medication.
Chapter 13, Outcome Identification and Planning
1.The nurse develops long-term and short-term outcomes for a client admitted with asthma. Which of the following is an example of a long-term goal?
A) Client returns home verbalizing an understanding of contributing factors, medications, and signs and symptoms of anasthma attack.
B) By day 3 of hospitalization, the client verbalizes knowledge of factors that exacerbate the symptoms of asthma.
C) Within one hour of a nebulizer treatment, adventitious breath sounds and cough are decreased.
D) Within 72 hours of admission, the client’s respiratory rate returns to normal and retractions disappear.
2.Nurses make common errors in the identification and development of outcomes. Which of the following is a common error made when writing client outcomes?
A) The nurse expresses the client outcome as a nursing intervention.
B) The nurse develops measurable outcomes using verbs that are observable.
C) The nurse develops a target time when the client is expected to achieve that outcome.
D) The outcome should include a subject, verb, conditions, performance criteria, and target time.
3.Increasingly, health care institutions are implementing computerized plans of nursing care. A benefit of using computerized plans includes which of the following?
A) Reduction in the time spent on care planning
B) Increased autonomy related to the nursing care planning process
C) Enhanced individualization of a care plan
D) Increased nursing expertise in care planning
4.The nurse is planning the care of a male client who is receiving treatment for acute renal failure and who has begun dialysis three times weekly. The nurse has identified the following outcome: “Client will demonstrate the appropriate care of his arteriovenous fistula.” This outcome is classified as which of the following?
A) Psychomotor
B) Affective
C) CognitiveD) Holistic
5.The nurse is caring for a client who has been newly diagnosed with diabetes. One of the outcomes the nurse read on the client’s plan of care this morning was: “Client will demonstrate correct technique for self-injecting insulin.” The client required insulin prior to his lunch and successfully drew up and administered his insulin while the nurse observed. How should the nurse follow up this observation?
A) Record an evaluative statement in the client’s plan of care.
B) Remove the outcome from the client’s care plan.
C) Ask the nurse who wrote the plan of care to document this development.
D) Reassess the client’s psychomotor skills at dinner time.
6.A male client is scheduled to be fitted with a prosthesis following the loss of his nondominant hand in a farm accident several weeks earlier. Nurses have documented the following outcome during this stage of his care: “After attending an educational session, client will demonstrate correct technique for applying his prosthesis.” Which of this client’s following statements would signal a need to amend this outcome?
A) “I’m not interested one bit in wearing an artificial hand.”
B) “I’m worried that I’m going to get some really strange looks when I wear this thing.”
C) “I don’t have a clue how this thing goes on and comes off.”
D) “I don’t understand the technology that’s used in this artificial hand.”
7. What is the primary purpose of the outcome identification and planning step of the nursing process?
A) To collect and analyze data to establish a database
B) To interpret and analyze data so as to identify health problems
C) To write appropriate client-centered nursing diagnoses
D) To design a plan of care for and with the client
8.Critical thinking is an essential component in all phases of the nursing process. What question might be used to facilitate critical thinking during outcome identification and planning? A) “How do I best cluster these data and cues to identify problems?”
B) “What problems require my immediate attention or that of the team?”
C) “What major defining characteristics are present for a nursing diagnosis?”
D) “How do I document care accurately and legally?”
9. A nurse is discharging a client from the hospital. When should discharge planning be initiated?
A) At the time of discharge from an acute health care setting
B) At the time of admission to an acute health care setting
C) Before admission to an acute health care setting
D) When the client is at home after acute care
10.The nursing diagnosis Impaired Gas Exchange, prioritized by Maslow’s hierarchy of basic human needs, is appropriate for what level of needs?
A) Physiologic
B) Safety
C) Love and belongingD) Self-actualization
11.A resident of a long-term care facility refuses to eat until she has had her hair combed and her make-up applied. In this case, what client need should have priority? A) The need to have nutrition
B) The need to feel good about oneself
C) The need to live in a safe environment
D) The need for love from others
12. During outcome identification and planning, from what part of the nursing diagnoses are outcomes derived? A) The defining characteristics
B) The related factors
C) The problem statement
D) The database
13.A nurse is developing outcomes for a specific problem statement. What is one of the most important considerations the nurse should have?
A) The written outcomes are designed to meet nursing goals
B) To encourage the client and family to be involved
C) To discourage additions by other healthcare providers
D) Why the nurse believes the outcome is important
14. Which of the following outcomes is correctly written? A) Abdominal incision will show no signs of infection.
B) On discharge, client will be free of infection.
C) On discharge, client will be able to list five symptoms of infection.
D) During home care, nurse will not observe symptoms of infection.
15. Which of the following illustrates a common error when writing client outcomes? A) Client will drink 100 mL of fluid every 2 hours from 6 a.m. to 9 p.m.
B) Client will demonstrate correct sequence of exercises by next office visit.
C) Client will be less anxious and fearful before and after surgery.
D) On discharge, client will list five symptoms of infection to report.
16. Which of the following groups of terms best describes a nurse-initiated intervention?
A) Dependent, physician-ordered, recovery
B) Autonomous, clinical judgment, client outcomes
C) Medical diagnosis, medication administration
D) Other health care providers, skill acquisition
17. What part of the nursing diagnosis statement suggests the nursing interventions to be included in the plan of care?
A) Problem statement
B) Defining characteristics
C) Etiology of the problemD) Outcomes criteria
18.What name is given to tools that are used to communicate a standardized interdisciplinary plan of care for clients within a case management health care delivery system?
A) Kardex care plans
B) Computerized plans of care
C) Clinical pathways
D) Student care plans
19.A nurse has developed a plan of care with nursing interventions designed to meet specific client outcomes. The outcomes are not met by the time specified in the plan. What should the nurse do now in terms of evaluation? A) Continue to follow the written plan of care.
B) Make recommendations for revising the plan of care.
C) Ask another health care professional to design a plan of care.
D) State “goal will be met at a later date.”
20.Which of the following types of care plans is most likely to enable the nurse to take a holistic view of the client’s situation?
A) Kardex
B) Case management
C) Critical pathways
D) Concept map care plan
21. Which of the following is an example of a well-stated nursing intervention? A) Client will drink 100 mL of water every 2 hours while awake.
B) Offer client 100 mL of water every 2 hours while awake.
C) Offer client water when he complains of thirst.
D) Client will continue to increase oral intake when awake.
22. What common problem is related to outcome identification and planning?
A) Failing to involve the client in the planning process
B) Collecting sufficient data to establish a database
C) Stating specific and measurable outcomes based on nursing diagnoses
D) Writing nursing orders that are clear and resolve the problem
23.A nurse is assigned to care for a client diagnosed with asthma who has just been admitted to the health care facility. The nurse determines the client’s priorities for care using which of the following?
A) Assessment skills
B) Nursing books
C) Client’s records
D) Supervisor’s advice
24.A client is scheduled for surgery for an abdominal hysterectomy. During the preoperative assessment, the client states, “I am very nervous and scared to have surgery.” What client outcome is the priority? A) Evaluate the need for antibiotics.
B) Resolve the client’s anxiety.
C) Provide preoperative education.
D) Prepare the client for surgery.
25. Which of the following client outcomes best describes the parameters for achieving the outcome? A) The client will eat a well-balanced diet.
B) The client will consume a 2,400-calorie diet, with three meals and two snacks, starting tomorrow.
C) The client will cleanse his wound with soap and water and apply a dry sterile dressing.
D) The client will be without pain in 24 hours.
26.Nurses identifying outcomes and related nursing interventions must refer to the standards and agency policies for setting priorities, identifying and recording expected client outcomes, selecting evidence-based nursing interventions, and recording the plan of care. Which of the following are recognized standards? Select all that apply.
A) Professional physicians’ organizations
B) State Nurse Practice Acts
C) The Joint Commission
D) The Agency for Health Care Research and Quality
E) The Patient Health Partnership
27. In which of the following clients has the order of priorities for nursing diagnoses changed? Select all that apply.
A) A client in a long-term care facility who had a stroke
B) A client who is recovering from a broken leg
C) A client who insists on using the bathroom instead of a bedpan
D) A client who appears confused after taking pain medication
E) A pregnant client whose contractions are progressing as anticipated
28. Which of the following statements accurately describes the impact on nursing of using NIC/NOC standardized languages? Select all that apply.
A) They demonstrate the impact that nurses have on the system of health care delivery.
B) They standardize and define the knowledge base for nursing curricula and practice.
C) They limit the number of appropriate nursing interventions to be selected.
D) They hinder the teaching of clinical decision making to novice nurses.
E) They enable researchers to examine the effectiveness and cost of nursing care.
29. Which of the following is a correctly written client goal? Select all that apply. A) The client will identify five low-sodium foods by October 9.
B) The client will know the signs and symptoms of infection.
C) The client will rate pain as a 3 or less on a 10-point scale by 5 pm today.
D) The client will understand the side effects of digoxin (Lanoxin).
E) The client will eat at least 75% of all meals by May 5.
30. Which intervention does the nurse recognize as a collaborative intervention?
A) Teach the client how to walk with a three-point crutch gait.
B) Administer spironolactone (Aldactone).
C) Perform tracheostomy care every eight hours.
D) Straight catheterize every six hours.
31. Which of the following is a correctly written client goal? A) The client will eliminate a soft formed stool.
B) The client understands what foods are low in sodium.
C) The client will ambulate 10 feet with a walker by October 12.
D) The client correctly self-administers the morning dose of insulin.
32.The nursing student asks the nurse about nurse-initiated and physician-initiated interventions. Which of the following is a physician-initiated intervention?
A) Teach client how to transfer from bed to chair and chair to bed.
B) Administer oxygen 4 L/min per nasal cannula.
C) Assist the client with coughing and deep breathing every hour.
D) Monitor intake and output every 2 hours.
33.The nurse formulates the following client outcome: Client will correctly draw up morning dose of insulin and identify four signs and symptoms of hypoglycemia by September 7. Which error has the nurse made?
A) Expressed the client outcomes as a nursing intervention
B) Wrote vague outcomes that will confuse other nurses
C) Included more than one client behavior in the outcome
D) Used verbs that are not observable and measurable
34. Which of the following is not appropriate in writing client-centered measurable outcomes?
A) The client or a part of the client B) A flexible time frame
C) Observable, measurable terms
D) The action the client will perform
35.While developing the plan of care for a new client on the unit the nurse must identify expected outcomes that are appropriate for the new client. What is a resource for identifying these appropriate outcomes?
A) Community Specific Outcomes Classification (CSO)
B) The Nursing-Sensitive Outcomes Classification (NOC)
C) State Specific Nursing Outcomes Classification (SSNOC)
D) Department of Health and Human Resources Outcomes Classification (HHROC)
Chapter 14, Implementing
1.A client being prepared for discharge to his home will require several interventions in the home environment. The nurse informs the discharge planning team, consisting of a home health care nurse, physical therapist, and speech therapist, of the client’s discharge needs. This interaction is an example of which professional nursing relationship?
A) Nurse-health care team
B) Nurse-patient
C) Nurse-patient-familyD) Nurse-nurse
2.A graduate nurse recently attended a conference on acute coronary syndrome. In preparing a plan of care for a client admitted with acute coronary syndrome, the nurse considers the information she learned at the conference. Which nursing variable is the nurse utilizing in the development of the plan of care?
A) Research findings
B) Resources
C) Current standards of care
D) Ethical and legal guides to practice
3.The American Nurses Association recommends adherence to defined principles when delegating care tasks to unlicensed assistive personnel. According to these principles, who is responsible and accountable for nursing practice?
A) The registered nurse
B) The American Nurses Association
C) The nurse manager
D) The unit’s medical director
4.An older adult client is receiving care on a rehabilitative medicine unit during her recovery from a stroke. She complains that the physical therapist, occupational therapist, neurologist, primary care physician, and speech language pathologist “don’t seem to be on the same page” and that “everyone has their own plan for me.” How can the nurse best respond to the client’s frustration?
A) Facilitate communication between the different professionals and attempt to coordinate care.
B) Educate the client about the unique scope and focus of each member of the healthvcare team.
C) Modify the client’s plan of care to better reflect the commonalities between the different disciplines.
D) Arrange for each professional to perform bedside assessments and interventions simultaneously rather than individually.
5.A male client 30 years of age is postoperative day 2 following a nephrectomy (kidney removal) but has not yet mobilized or dangled at the bedside. Which of the following is the nurse’s best intervention in this client’s care? A) Educate the client about the benefits of early mobilization and offer to assist him.
B) Respect the client’s wishes to remain in his bed and ask him when he would like to begin mobilizing.
C) Show the client the expected outcomes on his clinical pathway that relate to mobilization.
D) Document the client’s noncompliance and reiterate the consequences of delaying mobilization.
6.Many of the homeless clients who are supposed to receive care for HIV/AIDS miss their appointments at a clinic because it is located in a high-rise building on a university campus. Several of the clients state that the clinic is difficult to find and in an intimidating environment. This demonstrates that which of the following variables influencing outcome achievement is being inadequately addressed?
A) Psychosocial background of clients
B) Developmental stage of clients
C) Ethical and legal considerations
D) Resources
7.A female client 89 years of age has been admitted to the hospital with a diagnosis of failure to thrive. She has become constipated in recent days, in spite of maintaining a high fluid intake and taking oral stool softeners. She admits to her nurse that the problem is rooted in the fact that she feels mortified to attempt a bowel movement on a commode at her bedside where staff and other clients can hear her. The nurse should respond by modifying which of the following resources? A) Environment
B) Personnel
C) Equipment
D) Patient and visitors
8. What is the unique focus of nursing implementation?
A) Client response to health and illness
B) Client response to nursing diagnosis
C) Client compliance with treatment regimen
D) Client interview and physical assessment
9.The researchers developing classifications for interventions are also committed to developing a classification of which of the following? A) Diagnoses
B) Outcomes
C) Goals
D) Data clusters
10. What activity is carried out during the implementing step of the nursing process? A) Assessments are made to identify human responses to health problems.
B) Mutual goals are established and desired client outcomes are determined.
C) Planned nursing actions (interventions) are carried out.
D) Desired outcomes are evaluated and, if necessary, the plan is modified.
11. What role of the nurse is crucial to the prevention of fragmentation of care?
A) Advocate
B) Educator
C) Counselor
D) Coordinator
12. A nurse is changing a sterile pressure ulcer dressing based on an established protocol. What does this mean? A) The nurse is using critical thinking to implement the dressing change.
B) The client has specified how the dressing should be changed.
C) Written plans are developed that specify nursing activities for this skill.
D) The physician verbally requested specific steps of the dressing change.
13.A client who was previously awake and alert suddenly becomes unconscious. The nursing plan of care includes an order to increase oral intake. Why would the nurse review the plan of care?
A) To implement evidence-based practice
B) To ensure the order follows hospital policy
C) To be sure interventions are individualized
D) To be sure the intervention is safe
14.A nurse is preparing to insert an intravenous line and begin administering intravenous fluids. The client has visitors in the room. What should the nurse do? A) Ask the visitors to leave the room.
B) Ask the client if visitors should remain in the room.
C) Tell the client to ask the visitors to leave the room.
D) Wait until the visitors leave to begin the procedure.
15.A student is ambulating a client for the first time after surgery. What would the student do to anticipate and plan for an unexpected outcome?
A) Take the client’s vital signs after ambulation.
B) Ask the client’s wife to assist with ambulation.
C) Delay ambulation until the following shift.
D) Ask another student to help with ambulation.
16.The staff in a long-term care facility often plays loud rock music on the radio and designs children’s games as exercise. What is the staff doing in this situation?
A) Considering the hearing level of older adults
B) Failing to consider visual deficits that occur with aging
C) Ignoring the developmental needs of older adults
D) Meeting needs for sensory input and exercise
17.A nurse administers a medication for pain but forgets to document it in the client’s medical record. Legally, what does this mean?
A) Nothing, the nurse’s honesty will not be questioned.
B) The nurse can add the documentation after the client goes home.
C) The physician will verify that the nurse carried out the order.
D) In the eyes of the law, if it is not documented, it was not done.
18. A nurse delegates a specific intervention to a UAP. What implications does this have for the nurse? A) The UAP is responsible and accountable for his or her own actions.
B) Nurses do not have authority to delegate interventions.
C) The nurse transfers responsibility but is accountable for the outcome.
D) The UAP can function in an independent role for all interventions.
19.A nurse on duty finds that a client is anxious about the results of laboratory testing. Which intervention by the nurse reflects a supportive intervention?
A) Sitting with the client to encourage her to talk
B) Telling the laboratory technician to speed up the results
C) Calling the physician for an order for an anxiolytic
D) Educating the client about reducing risk factors
20. Educating clients on their diabetic regimen of administering insulin is the implementation of which skill? A) Intrinsic
B) Technical
C) InterpersonalD) Visual
21.A registered nurse who provides care in a subacute setting is responsible for overseeing and delegating to unlicensed assistive personnel (UAP). Which of the following principles should the nurse follow when delegating to UAP? Select all that apply.
A) Ensure that UAPs closely follow the nursing process when providing care.
B) Audit the client documentation that UAPs record after they perform interventions.
C) Take frequent mini-reports from UAPs to ensure changes in client status are identified.
D) Know what clinical cues the UAP should be alert for and why.
E) Make frequent walking rounds to assess clients.
22.Which of the following statements accurately describes a recommended guideline for implementation? Select all that apply.
A) When implementing nursing care, remember to act independently, regardless of the wishes of the client/family.
B) Before implementing any nursing action, reassess the client to determine whether the action is still needed.
C) Assume that the nursing intervention selected is the best of all possible alternatives.
D) Consult colleagues and the nursing and related literature to see if other approaches might be more successful.
E) Reduce your repertoire of skilled nursing interventions to ensure a greater likelihood of success.
23. Which example reflects client variables that influence outcome achievement? Select all that apply. A) The client was born with cystic fibrosis.
B) The nurse works at a hospital in a diverse community.
C) Nursing interventions are consistent with standards of care.
D) The client is a college graduate and is employed.
E) The client engages in activities associated with Ramadan.
24.The nurse is trying to determine factors influencing a client who is not following the plan of care. Which client statement identifies a potential factor interfering with following the plan of care? Select all that apply. A) I don’t drive so I was unable to fill my prescription.
B) I consult the list of low sodium foods when preparing meals.
C) My social security check does not come until next week.
D) I dropped the strips for my finger-stick blood glucose testing in the bath water.
E) “My daughter helps me with my range of motion exercises every morning and afternoon.”
25.The nurse is caring for a client with a diagnosis of end-stage renal disease. The client has expressed the desire to be kept comfortable and to not continue further treatment. The daughter arrives from out of town and is demanding to have further testing done to determine the best treatment option for the client. What is the best action for the nurse to take at this time?
A) Explain to the daughter the wishes of the client.
B) Arrange a meeting between the physician and daughter.
C) Contact the imaging center to schedule the testing.
D) Persuade the client to agree to the daughter’s request.
26. Which is a responsibility of the nurse in the nurse-client-family team relationship?
A) Provide creative leadership to make the nursing unit a satisfying and challenging place to work.
B) Support the nursing care given by other nursing and non-nursing personnel.
C) Educate the family to be informed and assertive consumers of health care.
D) Coordinate the inputs of the multidisciplinary team into a comprehensive plan of care.
27.The nurse is caring for a client with a diagnosis of colon disease. The client has expressed to various members of the health care team the desire to be kept comfortable and to not continue further treatment. The client asks the nurse to be present when the client discusses the decision with other family members. In which professional nursing relationship is the nurse participating?
A) Nurse-client
B) Nurse-nurse
C) Nurse-client-family
D) Nurse-health care team
28. The nurse is delegating to the unlicensed assistive personnel (UAP). What is the best instruction by the nurse? A) Notify me right away if the client’s systolic blood pressure is 170 or greater.
B) Let me know if the client’s blood pressure becomes elevated.
C) If the client’s blood pressure falls outside normal limits, come get me.
D) I need to know if the client’s blood pressure changes from his normal baseline.
29.The nursing student is caring for a Native American client who is admitted for deep vein thrombosis. The nursing student speaks with a nurse regarding the client’s lack of eye contact with the student. The nurse responds that Native Americans view eye contact as an invasion of privacy. Which error did the nursing student make? A) Failure to act in partnership with the client.
B) Failure to approach the client caringly.
C) Failure to seek the client’s input in the plan of care.
D) Failure to provide culturally sensitive care.
30.The nurse is preparing to implement plans of care with several clients. Which action would be inappropriate for the nurse to perform?
A) Ask the English-as-a-Second-Language (ESOL) client to state in his or her own words what it means to be NPO.
B) Seek input from the family of how the client with aphasia normally communicates at home.
C) Respond to the postoperative client’s question that baths are given only in the morning.
D) Request that family members provide ethnic/cultural foods of the African client’s liking.
31.Nursing students need to learn to nurse themselves in order to prepare to be professional nurses. Which activities would fail to prepare nursing students for the delivery of nursing care?
A) Time management, communication, and establishing a support system.
B) Establishing a support system, a sense of humor, and self-awareness.
C) Self-awareness, preparation for crisis, and stress management.
D) A sense of humor, anticipation of loss, and developing negative body image.
32.The nurse is assessing a client with a diagnosis of hypertension. The client’s blood pressure is 178/88, an increase from 134/78 at the previous clinic visit. The nurse asks the client what has changed from the previous visit. Which client statement identifies a potential factor interfering with the plan of care?
A) My husband has been ill and I don’t have anyone to help me care for him.
B) I have learned to prepare foods differently so they are low in fat.
C) My neighbor walks with me around the neighborhood every morning.
D) I have been taking my hydrochlorothiazide (HydroDIURIL) every day.
33.The nurse overhears two nursing students talking about nursing interventions. Which statement by one of the nursing students indicates further education is required?
A) Nursing interventions must be consistent with standards of care and research findings.
B) Nursing interventions must be culturally sensitive and individualized for the client.
C) Nursing interventions must be compatible with other therapies planned for the client.
D) Nursing interventions must be approved by other members of the health care team.
34.Each time a nurse administers an insulin injection to a client with diabetes, she tells the client what she is doing and demonstrates each step of preparing and giving the injection. What is the nurse promoting in the client? A) Self-care
B) Dependence
C) CompetenceD) Discipline
35. What characteristic of a competent nurse practitioner enables nurses to be role models for clients?
A) Sense of humor
B) Writing ability
C) Organizational skills
D) Good personal health
Chapter 15, Evaluating
1.Upon evaluation of the client’s plan of care, the nurse determines that the expected outcomes have been achieved. Based upon this response, the nurse will do what? A) Terminate the plan of care.
B) Modify the plan of care.
C) Continue the plan of care.
D) Re-evaluate the plan of care.
2.Nursing care and client outcomes may be evaluated by use of a retrospective evaluation process. Which of the following is an example of a retrospective evaluation process? A) Postdischarge questionnaire.
B) Direct observation of nursing care.
C) Client interview during hospitalization.
D) Review of client’s chart during hospitalization.
3.An older adult client has lost significant muscle mass during her recovery from a systemic infection. As a result, she has not yet met the outcomes for mobility and activities of daily living that are specified in her nursing plan of care. How should her nurses best respond to this situation?
A) Continue the plan of care with the aim of helping the client achieve the outcomes.
B) Terminate the plan of care since it does not accurately reflect the client’s abilities.
C) Modify the plan of care to better reflect the client’s current functional ability.
D) Replace the client’s individualized plan of care with a clinical pathway.
4.The nurse has responded to a client’s request to view her medical chart by arranging a meeting between the client, the clinical nurse leader, and her primary care physician. The nurse is exemplifying which of the following characteristics of quality health care?
A) Information
B) Science
C) Cooperation
D) Individualization
5.Nurses have identified the following outcome in the care of a client who is recovering from a stroke: “Client will ambulate 100 feet without the use of mobility aids by 12/12/2011.” Several nurses have evaluated the client’s progression towards this outcome at various points during her care. Which of the following evaluative statements is most appropriate?
A) “12/12/2011 – Outcome partially met. Patient ambulated 75 feet without the use of mobility aids”
B) “12/12/2011 – Outcome unmet. Patient’s ambulation remains inadequate.”
C) “12/10/2011 Outcome met, but with the use of a quad cane to assist ambulation.”
D) “12/14/2011 Outcome met.”
6.The nurse witnessed a more senior nurse make six unsuccessful attempts at starting an intravenous (IV) line on a client. The senior nurse persisted, stating, “I refuse to admit defeat.” This resulted in unnecessary pain for the client. How should the first nurse best respond to this colleague’s incompetent practice?
A) Report the nurse’s practice and have the nurse manager address the matter.
B) Encourage the nurse to attend an in-service on IV starts.
C) Reassure the nurse that this is a difficult skill and give her feedback on her performance.
D) Document an unmet outcome in the client’s plan of care.
7.The manager of a medical unit regularly reviews the incident reports that result from errors and near misses that occur on the unit. How should the manager best respond to these incident reports? A) Use them to inform improvements and education on the unit.
B) Use them to identify deficient workers for removal or demotion.
C) Cross-reference them with client satisfaction reports from the unit.
D) Use them to identify individuals who would benefit from probationary measures.
8. What cognitive processes must the nurse use to measure client achievement of outcomes during evaluation? A) Intuitive thinking
B) Critical thinking
C) Traditional knowingD) Rote memory
9.A nurse is evaluating the outcomes of a plan of care to teach an obese client about the calorie content of foods. What type of outcome is this?
A) Psychomotor
B) Affective
C) PhysiologicD) Cognitive
10.A nurse is educating a client on how to administer insulin, with the expected outcome that the client will be able to selfadminister the insulin injection. How would this outcome be evaluated? A) Asking the client to verbally repeat the steps of the injection
B) Asking the client to demonstrate self-injection of insulin
C) Asking family members how much trouble the client is having with injections
D) Asking the client how comfortable he or she is with injections
11.A nurse in a community health center has been having regular meetings with a woman who wants to stop smoking. Which of the following outcome decision options would the nurse document if the woman has not smoked for three months? A) Outcome met
B) Outcome partially met
C) Outcome not met
D) Outcome inappropriate
12.A nurse is interested in improving client care on the unit through performance improvement. What is the first step in this process?
A) Discover the problem.
B) Plan a strategy.
C) Implement a change.
D) Assess the change.
13.A nurse forgets to raise the bed railings of a client who is confused after taking pain medications. The client attempts to get out of bed, and suffers a minor fall. The nurse asks a colleague who witnessed the fall not to mention it to anyone because the client only had minor bruises. What would be the appropriate action of the colleague? A) No other steps need to be taken, since the client was not seriously injured.
B) The colleague should inform the nurse that a full report of the incident needs to be made.
C) The colleague should monitor the client closely for any adverse effects of the fall.
D) The colleague should report the incident in a peer review of the nurse.
14.A nurse is evaluating and revising a plan of care for a client with cardiac catheterization. Which of the following actions should the nurse perform before revising a plan of care? A) Discuss any lack of progress with the client.
B) Collect information on abnormal functions.
C) Identify the client’s health-related problems.
D) Select appropriate nursing interventions.
15.When a charge nurse evaluates the need for additional staff nurses and additional monitoring equipment to meet the client’s needs, the charge nurse is performing an evaluation termed …
A) process evaluation
B) structure evaluation
C) outcome evaluation
D) summary evaluation
16.When a nursing supervisor evaluates the staff nurse’s performance with a group of clients to whom the staff nurse has provided nursing care, the supervisor is performing which type of evaluation?
A) Outcome evaluation
B) Summary evaluation
C) Structure evaluationD) Process evaluation
17.A nurse working in a hospital setting discovers problems with the delivery of nursing care on the pediatric unit. Which of the following suggestions from the Institute of Medicine’s Committee on Quality of Health Care in America (Kohn, Corrigan, & Donaldson, 2000) could help redesign and improve care? Select all that apply. A) Base care on continuous healing relationships.
B) Customize care based on available resources.
C) Keep the nurse as the source of control.
D) Share knowledge and allow for free flow of information.
E) Practice evidence-based decision making.
18.A nurse is counseling a novice nurse who gives 150% effort at all times and is becoming frustrated with a health care system that provides substandard care to clients. Which of the following advice would be appropriate in this situation?
Select all that apply.
A) Tell the new nurse to help other nurses perform their jobs, thus ensuring quality client care is being delivered.
B) Encourage the new nurse to leave her problems at work behind, instead of rehashing them at home.
C) After establishing a reputation for delivering quality nursing care, have her seek creative solutions for nursing problems.
D) Tell her to view nursing care concerns as challenges rather than overwhelming obstacles, and seek help for solutions.E)State that if resources do not permit quality care, it is not the role of the new nurse to explore change strategies within the institution.
19. Which activity does the nurse perform during the evaluating stage? Select all that apply. A) Validates with the client the problem of constipation.
B) Collects data to determine the number of catheter-associated infections on the nursing unit.
C) Increases the frequency of repositioning from every two hours to every one hour.
D) Sets a goal of ambulating from bed to room door and back to bed.
E) Identifies smoking and sedentary lifestyle as risk factors for hypertension.
20. Which activity does the nurse engage in during evaluation? Select all that apply. A) Collect data to determine whether desired outcomes are met.
B) Assess the effectiveness of planned strategies.
C) Adjust the time frame to achieve the desired outcomes.
D) Involve the client and family in formulating desired outcomes.
E) Initiate activities to achieve the desired outcomes.
21. Which client outcome is a physiologic outcome? Select all that apply. A) The client’s HA1c is 7.4%.
B) The client’s blood pressure is 118/74.
C) The client rates his or her pain rating as 6.
D) The client self-administers insulin subcutaneously.
E) The client describes manifestations of wound infection.
22. Which activity is a possible solution for inadequate nursing staffing? A) Identify the kind and amount of nursing services required.
B) Learn to give quality care during designated work period.
C) Use a team conference to develop a consistent plan of care.
D) Educate the client to become an assertive health care consumer.
23.The nurse assesses urine output following administration of a diuretic. Which step of the nursing process does this nursing action reflect?
A) Assessment
B) Outcome identification
C) Implementation
D) Evaluation
24.The nurse participates in a quality assurance program. Data from the previous year indicates a 2% reduction in the number of repeat admissions for clients who underwent hip replacement surgery. The nurse recognizes this is which type of evaluation? A) Design evaluation
B) Process evaluation
C) Outcome evaluation
D) Structure evaluation
25. The nurse participates in a quality assurance program and reviews evaluation data for the previous month. Which of the following does the nurse recognize as an example of process evaluation?
A) A 10% reduction in the number of ventilator-associated pneumonia
B) A 5% increase in the number of nosocomial catheter-related urinary tract infections
C) 40% of all client rooms in the facility are private and equipped with a computer
D) A nursing care plan was developed within the eight hours of admission for 97% of all admissions.
26.The client’s expected outcome is The client will maintain skin integrity by discharge. Which of the following measures is best in evaluating the outcome?
A) The client’s ability to reposition self in bed.
B) Pressure-relieving mattress on the bed.
C) Percent intake of a diet high in protein.
D) Condition of the skin over bony prominences.
27.An expected client outcome is, The client will remain free of infection by discharge. When evaluating the client’s progress, the nurse notes the client’s vital signs are within normal limits, the white blood cell count is 12,000, and the client’s abdominal wound has a half-inch gap at the lower end with yellow-green discharge. Which statement would be an appropriate evaluation statement?
A) Goal partially met; client identified fever and presence of wound discharge.
B) Client understands the signs and symptoms of infection.
C) Goal partially met; client able to perform activities of daily living.
D) Goal not met; white blood cell count elevated, presence of yellow-green discharge from wound.
28.The nurse is caring for a client who is experiencing an asthma attack. Ten minutes after administering an inhaled bronchodilator to the client, the nurse returns to ask if the client’s breathing is easier. The nurse is engaging in which phase of the nursing process?
A) Assessment
B) Diagnosing
C) Planning
D) ImplementingE) Evaluating
29.The nurse is preparing to mail a client satisfaction questionnaire to a client who was discharged from the hospital four days ago. Which type of evaluation is the nurse conducting?
A) Retrospective evaluation
B) Peer review
C) Nursing audit
D) Concurrent evaluation
30.The nurse is caring for the client with pneumonia. An expected client outcome is, The client will maintain adequate oxygenation by discharge. Which outcome criterion indicates the goal is met? A) Client taking antibiotic as ordered.
B) Client identifies signs and symptoms of recurrence of infection.
C) Client coughing and deep breathing every one hour.
D) Client no longer requires oxygen.
31.The client reports participating in water aerobics for 60 minutes three times each week. This is an example of what type of outcome? A) Affective outcome
B) Psychomotor outcome
C) Physiologic outcomeD) Cognitive outcome
32.The client’s pulse oximetry reading is 97% on room air 30 minutes after removal of a nasal cannula. This is an example of what type of outcome? A) Affective outcome
B) Psychomotor outcome
C) Physiologic outcomeD) Cognitive outcome
33.The nurse is giving a shift report to the oncoming nurse who will be caring for a client with a portacath access device. The oncoming nurse states, I have never taken care of a client with a portacath. Would you give me the basics, so I know what to do? Which standard for establishing and sustaining healthy work environments is the oncoming nurse breaching?
A) Appropriate staffing
B) Effective decision making
C) True collaboration
D) Skilled communication
34.The correct sequence of steps for performance improvement is:
1. Discover a problem.
2. Plan a strategy using indicators.
3. Implement a change.
4. Assess the change.
A) 1, 2, 3, 4
B) 1, 4, 2, 3
C) 4, 1, 2, 3
D) 1, 2, 4, 3 E) 1, 3, 2, 4
Chapter 16, Documenting, Reporting, Conferring, and Using Informatics
1. A client’s diagnosis of pneumonia requires treatment with antibiotics. The corresponding order in the client’s chart should be written as …
A) Avelox (moxifloxacin) 400 mg daily
B) Avelox (moxifloxacin) 400 mg Q.D.
C) Avelox (moxifloxacin) 400 mg qd
D) Avelox (moxifloxacin) 400 mg OD
2.The nurses who provide care in a large, long-term care facility utilize charting by exception (CBE) as the preferred method of documentation. This documentation method may have which of the following drawbacks?
A) Vulnerability to legal liability since nurse’s safe, routine care is not recorded
B) Increased workload for nurses in order to complete necessary documentation
C) Failure to identify and record client problems and associated interventions
D) Significant differences in the charting between nurses due to lack of standardization
3.The nurse managers of a home health care office wish to maximize nurses’ freedom to characterize and record client conditions and situations in the nurses’ own terms. Which of the following documentation formats is most likely to promote this goal? A) Narrative notes
B) SOAP notes
C) Focus charting
D) Charting by exception
4.A hospital utilizes the SOAP method of charting. Within this model, which of the nurse’s following statements would appear at the beginning of a charting entry?
A) “Client complaining of abdominal pain rated at 8/10.”
B) “Client is guarding her abdomen and occasionally moaning.”
C) “Client has a history of recent abdominal pain.”
D) “2 mg Dilaudid PO administered with good effect”
5. What is the nurse’s best defense if a client alleges nursing negligence?
A) Testimony of other nurses
B) Testimony of expert witnesses
C) Client’s recordD) Client’s family
6. A nurse is documenting the intensity of a client’s pain. What would be the most accurate entry?
A) “Client complaining of severe pain.”
B) “Client appears to be in a lot of pain and is crying.”
C) “Client states has pain; walking in hall with ease.”
D) “Client states pain is a 9 on a scale of 1 to 10.”
7. Which of the following data entries follows the recommended guidelines for documenting data?
A) “Client is overwhelmed by the diagnosis of pancreatic cancer.”
B) “Client’s kidneys are producing sufficient amount of measured urine.”
C) “Following oxygen administration, vital signs returned to baseline.”
D) “Client complained about the quality of the nursing care provided on previous shift.”
8. Alice Jones, a registered nurse, is documenting assessments at the beginning of her shift. How should she sign the entry? A) Alice J, RN
B) A. Jones, RN
C) Alice JonesD) AJRN
9.A student has reviewed a client’s chart before beginning assigned care. Which of the following actions violates client confidentiality?
A) Writing the client’s name on the student care plan
B) Providing the instructor with plans for care
C) Discussing the medications with a unit nurse
D) Providing information to the physician about laboratory data
10. A physician’s order reads “up ad lib.” What does this mean in terms of client activity?
A) May walk twice a day
B) May be up as desired
C) May only go to the bathroom
D) Must remain on bed rest
11. In what type of documentation method would a nurse document narrative notes in a nursing section?
A) Problem-oriented medical record
B) Source-oriented record
C) PIE charting systemD) Focus charting
12.Which one of the following methods of documentation is organized around client diagnoses rather than around patient information?
A) Problem-oriented medical record (POMR)
B) Source-oriented record
C) PIE charting systemD) focus charting
13. A nurse organizes client data using the SOAP format. Which of the following would be recorded under “S” of this acronym? A) Client complaints of pain
B) Client history
C) Client’s chief complaintD) Client interventions
14.Which of the following methods of documenting client data is least likely to hold up in court if a case of negligence is brought against a nurse? A) Problem-oriented medical record
B) Charting by exception
C) PIE charting systemD) Focus charting
15. A nurse has access to computerized standardized plans of care. After printing one for a client, what must be done next? A) Date it and put it in the client’s record.
B) Sign it and put it in the Kardex.