Question 1

The purpose of the Nursing Outcomes Classification (NOC) is to: (Select all that apply.)

Accepted Answer

A)  validate classification by field test. 
B)  identify labels. 
C)  provide language labels for desired outcomes. 
D)  generate a readymade nursing care plan for a patient. 
E)  identify patient outcomes and indicators. 
A)  validate classification by field test. 
B)  identify labels. 
C)  provide language labels for desired outcomes. 
D)  generate a readymade nursing care plan for a patient. 
E)  identify patient outcomes and indicators. A, B, C, E

Question 2

A nurse is caring for a patient with a nursing diagnosis of impaired physical mobility related to neurological impairment and muscular weakness. Appropriate interventions for this patient would include which of the following? (Select all that apply.)

Accepted Answer

A)  Assist with range of motion exercises every 4 hours and as needed. 
B)  Instruct patient to call for assistance when needing to get out of bed. 
C)  Apply wrist and ankle restraints to promote safety and prevent falls. 
D)  Teach about exercises that will strengthen muscles while lying in bed. 
E)  Ambulate with physical therapy assistance at least three times a day. 
A)  Assist with range of motion exercises every 4 hours and as needed. 
B)  Instruct patient to call for assistance when needing to get out of bed. 
C)  Apply wrist and ankle restraints to promote safety and prevent falls. 
D)  Teach about exercises that will strengthen muscles while lying in bed. 
E)  Ambulate with physical therapy assistance at least three times a day. A, B, D, E

Question 3

The statements that are correctly stated as expected outcomes are: (Select all that apply.)

Accepted Answer

A)  patient will be able to void in the bathroom independently. 
B)  patient will be able to ambulate using a walker independently within 3 days. 
C)  the nurse will assist the patient to the bathroom three times a day. 
D)  patient will perform active range of motion (ROM) of her upper extremities independently every 4 hours. 
E)  the family will bring food from home to improve patient appetite. 
A)  patient will be able to void in the bathroom independently. 
B)  patient will be able to ambulate using a walker independently within 3 days. 
C)  the nurse will assist the patient to the bathroom three times a day. 
D)  patient will perform active range of motion (ROM) of her upper extremities independently every 4 hours. 
E)  the family will bring food from home to improve patient appetite. B, D

Question 4

A nurse is caring for a patient with a medical diagnosis of right lower lobe pneumonia. The patient is expectorating thick green mucus, has an oxygen saturation level of 90%, and has audible crackles in the base of the right lung. An appropriate nursing diagnosis for this patient is:

Accepted Answer

A)  Airway clearance, ineffective, related to retained secretions as evidenced by expectoration of thick green mucus, oxygen saturation level of 90%, and audible crackles in the base of the right lung. 
B)  Airway clearance, ineffective, related to right lower lobe pneumonia as evidenced by expectoration of thick green mucus, oxygen saturation level of 90%, and audible crackles in the base of the right lung. 
C)  Right lower lobe pneumonia, related to airway clearance, ineffective, as evidenced by expectoration of thick green mucus, oxygen saturation level of 90%, and audible crackles in the base of the right lung. 
D)  Expectoration of thick green mucus, oxygen saturation level of 90%, and audible crackles in the base of the right lung related to right lower lobe pneumonia as evidenced by airway clearance. 
A)  Airway clearance, ineffective, related to retained secretions as evidenced by expectoration of thick green mucus, oxygen saturation level of 90%, and audible crackles in the base of the right lung. 
B)  Airway clearance, ineffective, related to right lower lobe pneumonia as evidenced by expectoration of thick green mucus, oxygen saturation level of 90%, and audible crackles in the base of the right lung. 
C)  Right lower lobe pneumonia, related to airway clearance, ineffective, as evidenced by expectoration of thick green mucus, oxygen saturation level of 90%, and audible crackles in the base of the right lung. 
D)  Expectoration of thick green mucus, oxygen saturation level of 90%, and audible crackles in the base of the right lung related to right lower lobe pneumonia as evidenced by airway clearance.

Question 5

During the assessment phase of the nursing process, the nurse:

Accepted Answer

A)  develops a care plan to meet the patient's nursing needs. 
B)  begins to formulate plans for providing nursing intervention. 
C)  establishes a nursing diagnosis for the nursing care plan. 
D)  gathers, organizes, and documents data in a logical database. 
A)  develops a care plan to meet the patient's nursing needs. 
B)  begins to formulate plans for providing nursing intervention. 
C)  establishes a nursing diagnosis for the nursing care plan. 
D)  gathers, organizes, and documents data in a logical database.

Question 6

A patient has a nursing diagnosis of imbalanced nutrition: less than body requirements, related to mental impairment and decreased intake, as evidenced by increasing confusion and weight loss of more than 30 pounds over the last 6 months. An appropriate short-term goal for this patient is to:

Accepted Answer

A)  eat 50% of six small meals every day by the end of 1 week. 
B)  demonstrate progressive weight gain over 6 months. 
C)  eat all of the meals prepared during admission. 
D)  verbalize understanding of caloric needs and intention to eat. 
A)  eat 50% of six small meals every day by the end of 1 week. 
B)  demonstrate progressive weight gain over 6 months. 
C)  eat all of the meals prepared during admission. 
D)  verbalize understanding of caloric needs and intention to eat.

Question 7

An example of a structured format for gathering data that aids in forming a database is:

Accepted Answer

A)  North American Nursing Diagnosis Association-International (NANDA-I). 
B)  Maslow's hierarchy. 
C)  QSENl 
D)  Gordon's 11 Health Patterns. 
A)  North American Nursing Diagnosis Association-International (NANDA-I). 
B)  Maslow's hierarchy. 
C)  QSENl 
D)  Gordon's 11 Health Patterns.

Question 8

The North American Nursing Diagnosis Association-I (NANDA-I) list is revised and updated every:

Accepted Answer

A)  year. 
B)  2 years. 
C)  3 years. 
D)  5 years. 
A)  year. 
B)  2 years. 
C)  3 years. 
D)  5 years.

Question 9

Standardized Nursing Care Plans can:

Accepted Answer

A)  be documented without alteration. 
B)  have items altered or deleted. 
C)  become part of the record without documentation. 
D)  help the family understand the concept of Nursing Care Plans. 
A)  be documented without alteration. 
B)  have items altered or deleted. 
C)  become part of the record without documentation. 
D)  help the family understand the concept of Nursing Care Plans.

Question 10

The nurse should make a point when closing the initial interview to: (Select all that apply.)

Accepted Answer

A)  develop rapport. 
B)  summarize the problems discussed. 
C)  thank the patient for his or her time. 
D)  discuss the nursing goals associated with nursing diagnoses. 
E)  give a copy of the nursing care plan to the patient. 
A)  develop rapport. 
B)  summarize the problems discussed. 
C)  thank the patient for his or her time. 
D)  discuss the nursing goals associated with nursing diagnoses. 
E)  give a copy of the nursing care plan to the patient.

Question 11

The nurse understands that an expected outcome should be: (Select all that apply.)

Accepted Answer

A)  realistic. 
B)  approved by the health care provider. 
C)  attainable. 
D)  within a defined time. 
E)  included after patient collaboration. 
A)  realistic. 
B)  approved by the health care provider. 
C)  attainable. 
D)  within a defined time. 
E)  included after patient collaboration.

Question 12

The seven domains of the Nursing Interventions Classification (NIC) taxonomy include: (Select all that apply.)

Accepted Answer

A)  community. 
B)  health system. 
C)  socioeconomic level. 
D)  safety. 
E)  behavioral. 
A)  community. 
B)  health system. 
C)  socioeconomic level. 
D)  safety. 
E)  behavioral.

Question 13

The nurse performing an admission interview on an older adult person should:

Accepted Answer

A)  rush through the interview to avoid tiring the patient. 
B)  direct questions to the family rather than the patient. 
C)  allow more time for a response to questions. 
D)  prompt the patient to speed recall. 
A)  rush through the interview to avoid tiring the patient. 
B)  direct questions to the family rather than the patient. 
C)  allow more time for a response to questions. 
D)  prompt the patient to speed recall.

Question 14

Reginald is a nurse caring for a 56-year-old man who is admitted with an acute MI. As he completes the initial assessment, he knows that concerning the practice of nursing, the purpose of the assessment on admission is to:

Accepted Answer

A)  gather data so that the patient's response to the treatment can be evaluated. 
B)  gather data for the health care provider, to make decisions based on the condition of the patient. 
C)  establish rapport with the patient so that he/she can feel safe and secure in the acute health care setting. 
D)  begin the care plan and set the patient on the road to recovery. 
A)  gather data so that the patient's response to the treatment can be evaluated. 
B)  gather data for the health care provider, to make decisions based on the condition of the patient. 
C)  establish rapport with the patient so that he/she can feel safe and secure in the acute health care setting. 
D)  begin the care plan and set the patient on the road to recovery.

Question 15

The nurse clarifies that nursing orders are also called:

Accepted Answer

A)  goals. 
B)  qualifiers. 
C)  interventions. 
D)  measurement criteria. 
A)  goals. 
B)  qualifiers. 
C)  interventions. 
D)  measurement criteria.

Question 16

The major goal of the admission interview (usually performed by the RN) is to:

Accepted Answer

A)  establish rapport. 
B)  help the patient understands the objectives of care. 
C)  identify the patient's major complaints. 
D)  initiate nursing care plan forms. 
A)  establish rapport. 
B)  help the patient understands the objectives of care. 
C)  identify the patient's major complaints. 
D)  initiate nursing care plan forms.

Question 17

A patient with visual impairment is identified as at-risk for falls related to blindness. An appropriate intervention would be:

Accepted Answer

A)  assist the patient with feeding herself at the end of the meal. 
B)  arrange furnishings in room to provide clear pathways and orient the patient to these. 
C)  take the patient's blood pressure before she gets up in the morning. 
D)  report any falls immediately to the charge nurse and the doctor. 
A)  assist the patient with feeding herself at the end of the meal. 
B)  arrange furnishings in room to provide clear pathways and orient the patient to these. 
C)  take the patient's blood pressure before she gets up in the morning. 
D)  report any falls immediately to the charge nurse and the doctor.

Question 18

A nursing diagnosis identifies: (Select all that apply.)

Accepted Answer

A)  patient's response to illness. 
B)  related signs and symptoms. 
C)  underlying medical diagnosis. 
D)  causative factors. 
E)  potential risk for health problems. 
A)  patient's response to illness. 
B)  related signs and symptoms. 
C)  underlying medical diagnosis. 
D)  causative factors. 
E)  potential risk for health problems.

Question 19

A nursing diagnosis consists of:

Accepted Answer

A)  the health care provider's medical diagnosis listed as the nursing diagnosis. 
B)  diagnostic labels formulated by the North American Nursing Diagnosis Association-International (NANDA-I). 
C)  the patient's explanation of his or her "chief complaint" or "current complaint." 
D)  the results of the nursing assessment without consideration of doctor's orders. 
A)  the health care provider's medical diagnosis listed as the nursing diagnosis. 
B)  diagnostic labels formulated by the North American Nursing Diagnosis Association-International (NANDA-I). 
C)  the patient's explanation of his or her "chief complaint" or "current complaint." 
D)  the results of the nursing assessment without consideration of doctor's orders.

Question 20

A nursing care plan consists of:

Accepted Answer

A)  nursing orders for individualized interventions to assist the patient to meet expected outcomes. 
B)  orders for diagnostic and therapeutic procedures such as laboratory tests or radiographs. 
C)  the health care provider's history and physical examination, as well as medical diagnoses. 
D)  laboratory and radiograph reports, pathology reports, and the medication record. 
A)  nursing orders for individualized interventions to assist the patient to meet expected outcomes. 
B)  orders for diagnostic and therapeutic procedures such as laboratory tests or radiographs. 
C)  the health care provider's history and physical examination, as well as medical diagnoses. 
D)  laboratory and radiograph reports, pathology reports, and the medication record.

Exam 5: Assessment, Nursing Diagnosis, and Planning

The purpose of the Nursing Outcomes Classification (NOC) is to: (Select all that apply.)

A nurse is caring for a patient with a nursing diagnosis of impaired physical mobility related to neurological impairment and muscular weakness. Appropriate interventions for this patient would include which of the following? (Select all that apply.)

The statements that are correctly stated as expected outcomes are: (Select all that apply.)

A nurse is caring for a patient with a medical diagnosis of right lower lobe pneumonia. The patient is expectorating thick green mucus, has an oxygen saturation level of 90%, and has audible crackles in the base of the right lung. An appropriate nursing diagnosis for this patient is:

During the assessment phase of the nursing process, the nurse:

A patient has a nursing diagnosis of imbalanced nutrition: less than body requirements, related to mental impairment and decreased intake, as evidenced by increasing confusion and weight loss of more than 30 pounds over the last 6 months. An appropriate short-term goal for this patient is to:

An example of a structured format for gathering data that aids in forming a database is:

The North American Nursing Diagnosis Association-I (NANDA-I) list is revised and updated every:

Standardized Nursing Care Plans can:

The nurse should make a point when closing the initial interview to: (Select all that apply.)

The nurse understands that an expected outcome should be: (Select all that apply.)

The seven domains of the Nursing Interventions Classification (NIC) taxonomy include: (Select all that apply.)

The nurse performing an admission interview on an older adult person should:

Reginald is a nurse caring for a 56-year-old man who is admitted with an acute MI. As he completes the initial assessment, he knows that concerning the practice of nursing, the purpose of the assessment on admission is to:

The nurse clarifies that nursing orders are also called:

The major goal of the admission interview (usually performed by the RN) is to:

A patient with visual impairment is identified as at-risk for falls related to blindness. An appropriate intervention would be:

A nursing diagnosis identifies: (Select all that apply.)

A nursing diagnosis consists of:

A nursing care plan consists of:

Nursing and the Health Care System

Concepts of Health, Illness, Stress, and Health Promotion

Legal and Ethical Aspects of Nursing

The Nursing Process and Critical Thinking

Implementation and Evaluation

Documentation of Nursing Care

Communication and the Nurse Patient Relationship

Patient Education and Health Promotion

Delegation, Leadership, and Management

Growth and Development: Infancy Through Adolescence

Adulthood and the Family

Promoting Healthy Adaptation to Aging

Cultural and Spiritual Aspects of Patient Care

Loss, Grief, and End-of-Life Care

Infection Prevention and Control: Protective Mechanisms and Asepsis

Infection Prevention and Control in the Hospital and Home

Safe Lifting, Moving, and Positioning of Patients

Assisting with Hygiene Personal Care Skin Care and the Prevention of Pressure Ulcers

Patient Environment and Safety

Measuring Vital Signs

Assessing Health Status

Admitting Transferring and Discharging Patients

Diagnostic Tests and Specimen Collection

Fluid, Electrolyte, and Acid-Base Balance

Concepts of Basic Nutrition and Cultural Considerations

Nutritional Therapy and Assisted Feeding

Assisting with Respiration and Oxygen Delivery

Promoting Urinary Elimination

Promoting Bowel Elimination

Pain Comfort and Sleep

Complementary and Alternative Therapies

Pharmacology and Preparation for Drug Administration

Administering Oral, Topical, and Inhalant Medications

Administering Intradermal, Subcutaneous, and Intramuscular Injections

Administering Intravenous Solutions and Medications

Care of the Surgical Patient

Providing Wound Care and Treating Pressure Ulcers

Promoting Musculoskeletal Function

Common Physical Care Problems of the Older Adult

Common Psychosocial Care Problems of Older Adults

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