VERSION A
which actions are part of the evaluation step in the nursing process?
a- recognizing the need for modifications in the care plan
b. documenting performed nursing interventions
c- determining if nursing interventions were completed
d- reviewing whether a patient met their short term goal
e- identifying realistic outcomes with patient input – ANSWER- a, d
which action by the day-shift nurse provides objective data that enables
the night-shift nurse to complete an evaluation of the patient’s short term
goals?
a- encouraging the patient to share observations from the day
b- leaving a message with the charge nurse before shift change
c- documenting patient assessment findings in the patients chart
d- checking with the pharmacist regarding possible drug interactions –
ANSWER- c
Which notation is most appropriate for the nurse to include in a patient’s
chart regarding evaluation of the goal, “Patient will ambulate three times
daily in the hallway before discharge without shortness of breath
(SOB)”?
a. Goal not met; patient states he is tired.
b. Goal not met; patient ambulated three times in room.
c. Goal met; patient ambulated three times in the hallway.
d. Goal met; patient ambulated three times in the hallway without SOB.
- ANSWER- d
what situations would necessitate modification of a patient’s plan of
care?
a- decrease in a patient’s level of orientation
b- discharge of a patient to rehab facility
c- patient adherence to established plan of care
d- sudden onset of shortness of breath in patient receiving oxygen –
ANSWER- a, b, d
what is the purpose of the nursing process?
a- providing patient centered care
b- identifying members of the healthcare team
c- organizing the way nurses think about patient care
d- facilitating communication among members of the healthcare team –
ANSWER- c
a patient comes to the ED complaining of n/v, what should the nurse ask
the patient about first?
a- family hx of diabetes
b- medication the patient is taking
c- operations the patient has had in the past
d- severity and duration of the n/v – ANSWER- d
An alert, oriented patient is admitted to the hospital with chest pain.
Who is the best source of primary data on this patient?
a. Family member
b. Physician
c. Another nurse
d. Patient – ANSWER- d
what is the primary purpose of the nursing diagnosis?
a- resolve patient confusion
b- communicating patient needs
c- meeting accreditation requirements
d- articulating the nursing scope of practice – ANSWER- b
On what premise is a nursing diagnosis identified for a patient?
a. First impressions
b. Nursing intuition
c. Clustered data
d. Medical diagnoses – ANSWER- c
which statement is an appropriately written short term goal?
a- pt will walk to bathroom independently without falling within two
days after surgery
b- nurse will watch patient demonstrate proper insulin injection
technique each morning
c- patient’s spouse will express satisfaction with the patient’s progress
before discharge
d- patient’s incision will be well approximated each time it is assessed by
the nurse – ANSWER- a
which nursing action is critical before delegating interventions to
another member of the health care team?
a- locate all members of health care team
b- notify the physical of potential complications
c- know the scope of practice and competency of the other team member
d- call a meeting of the healthcare team to determine needs of patient –
ANSWER- c
what should be the primary focus for nursing interventions?
a- patient needs
b- nurse concerns
c- physician priorities
d- patient’s family requests – ANSWER- a
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