The Nursing Process
1. A client comes to the walk-in clinic with reports of abdominal pain and diarrhea. While taking the client’s vital signs, the nurse is implementing which phase of the nursing process? 1. Assessment
2. The nurse is measuring the client’s urine output and straining the urine to assess for stones. Which of the following should the nurse record as objective data? 1. The client reports abdominal pain
2. The client’s urine output was 450mL
3. The client states, “I didn’t see any stones in my urine.” 4. The client states, “I feel like I have passes a stone.” 3. When evaluating an elderly client’s blood pressure (BP) of 146/78 mmHg, the nurse does which of the following before determining whether the BP is normal or represents hypertension? 1. Compare this reading against defined standards.
2. Compare the reading with one taken in the opposite arm
3. Determine gaps in the vital signs data in the client record. 4. Compare the current measurement with previous ones.
4. Which of the following behaviors by the nurse demonstrates that the nurse is participating in critical thinking? Select all that apply. 1. Admitting not knowing how to do a procedure and requesting help. 2. Using clever and persuasive remarks to support and opinion or position. 3. Accepting without question the values acquired in nursing school. 4. Finding a quick and logical answer, even to complex questions. 5. Gathering three assistants to transfer the client to a stretcher after noting the client weighs 300 pounds. 5. The nurse has documented the following outcome goal in the care plan: “The client will transfer from bed to chair with two-person assist.” The charge nurse tells the nurse to add which of the following to complete the goal. 1. Client behavior
2. Conditions or modifiers
3. Performance criteria
4. Target time
6. The nurse who documents on the client’s care plan the outcome goal “Anxiety will be relieved within 20-40 minutes following administrations of lorazepam (Ativan)” is engaged in which step of the nursing process? 1. Assessment
7. When the client resists taking a liquid medications that is essential to treatment, the nurse demonstrates critical thinking by doing which of the following first? 1. Omitting this dose of the medication and waiting until the client is more cooperative 2. Suggesting the medication can be diluted in a beverage
3. Asking the nurse manager about how to approach the situation 4. Notifying the physician regarding inability to give the client this medication. 8. Which professionally appropriate response should the nurse make when a more stringent policy for the use of restraints is introduced on a surgical unit? 1. Use the previous, less restrictive policy conscientiously. 2. Express immediate disagreement with the new policy
3. Ask for the rationale behind the new policy
4. Obey the policy but continue to voice disapproval of it to co-workers. 9. The nurse assigned to care for the postoperative client has asked an unlicensed assistive person (UAP) to help the client ambulate in the hall. Before delegating this task, the nurse must do which of the following? 1. Assess the client to be sure ambulation with assistance is an appropriate care measure. 2. Ask the client if he or she is ready to ambulate
3. Ask whether the UAP has time to assist the client
4. Ask the charge nurse whether UAPs have ambulated the client during this shift. 10. The nurse makes the following entry on the client’s care plan: “Goal not met. Client refuses to ambulate, stating, “I am too afraid I will fall.” The nurse should take which of the following actions? 1. Notify the physician
2. Reassign the client to another nurse
3. Reexamine the nursing orders
4. Write a new nursing diagnosis
11. In developing a plan of care for a client with chronic hypertension, which nursing activity would be most important? 1. Set...
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