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Nursing Process Exam Review

Quiz by Cindy Dubs

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20 questions
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  • Q1
    Once a nurse assesses a client’s condition and identifies appropriate nursing diagnoses, a:
    List of priorities is determined.
    Review of the assessment is conducted with other team members.
    Plan is developed for nursing care.
    Physical assessment begins.
  • Q2
    Which of the following nursing interventions are written correctly?
    Change dressing once a shift
    Apply continuous passive motion machine during day
    Elevate head of bed 30 degrees before meals
    Perform neurovascular checks
  • Q3
    When developing a nursing care plan for a client with a fractured right tibia, the nurse includes in the plan of care independent nursing interventions, including:
    Administer aspirin 325 mg every 4 hours as needed
    Elevate the leg 5 inches above the heart.
    Perform range of motion to right leg every 4 hours.
    Apply a cold pack to the tibia.
  • Q4
    When establishing realistic goals, the nurse:
    Must have a client who is physically and emotionally stable.
    Must have the client’s cooperation.
    Knows the resources of the health care facility, family, and the client.
    Bases the goals on the nurse’s personal knowledge.
  • Q5
    For clients to participate in goal setting, they should be:
    Ambulatory and mobile.
    Able to speak and write.
    Alert and have some degree of independence.
    Able to read and write.
  • Q6
    The planning step of the nursing process includes which of the following activities?
    Performing nursing actions and documenting them
    Setting goals and selecting interventions
    Assessing and diagnosing
    Evaluating goal achievement
  • Q7
    The nurse writes a goal statement in measurable terms. An example is:
    Client will report pain acuity less than 4 on a scale of 0-10
    Client will take pain medication every 4 hours around the clock
    Client will be pain free.
    Client will have less pain
  • Q8
    A client centered goal is a specific and measurable behavior or response that reflects a client’s:
    Desire for specific health care interventions.
    Physician’s goal for the specific client.
    Highest possible level of wellness and independence in function.
    Response when compared to another client with a like problem.
  • Q9
    A client’s wound is not healing and appears to be worsening with the current treatment. The nurse first considers:
    Consulting with another nurse
    Calling the wound care nurse
    Notifying the physician
    Changing the wound care treatment
  • Q10
    Collaborative interventions are therapies that require:
    Physician and nurse interventions.
    Multiple health care professionals.
    Nurse and client interventions.
    Client and Physician intervention.
  • Q11
    As goals, outcomes, and interventions are developed, the nurse must:
    Be in control of all interventions for the client.
    Not change the plan of care for the client.
    Be in charge of all care and planning for the client.
    Be aware of and committed to accepted standards of practice from nursing and other disciples.
  • Q12
    Mr. Jones comes into the doctor’s office with his wife. During the initial interview with the nurse assessing the reason for the visit, the wife says that her husband has been feeling bad for three days. The nurse knows this is what type of data?
    Secondary subjective data
    Primary subjective data
    Secondary objective data
    Primary objective data
  • Q13
    The CNA reports that the patient who is scheduled to be discharge at 11:00 has a blood pressure of 160/90. What is the nurses first action?
    Call the physician
    Get the charge nurse
    Check the medication list to see if there is any medication to give for high blood pressure
    Check the blood pressure
  • Q14
    Pain is always which kind of symptom?
  • Q15
    Mr. Anderson says that his head has been hurting for 3 weeks. The nurse knows this is what kind of data?
    Secondary objective data
    Primary subjective data
    Secondary subjective data
    Primary objective data

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