Adn Nursing
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. Diagnosis
3. Planning
4. Implementation
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
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. Diagnosis
3. Planning
4. Implementation
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