Question 1

When a patient plan of care has been written,it:

Accepted Answer

A)  Is continually reviewed and evaluated. 
B)  Must be reviewed by the primary caregiver. 
C)  Remains in effect until the patient is discharged. 
D)  Can only be changed by the initiating nurse. 
A)  Is continually reviewed and evaluated. 
B)  Must be reviewed by the primary caregiver. 
C)  Remains in effect until the patient is discharged. 
D)  Can only be changed by the initiating nurse. A

Question 2

Characteristics of critical thinking include:

Accepted Answer

A)  Interpretation, analysis, and evaluation 
B)  Patient-centered criteria and problem solving 
C)  Realistic outcomes and frequent evaluation 
D)  Data gathering and assessment 
A)  Interpretation, analysis, and evaluation 
B)  Patient-centered criteria and problem solving 
C)  Realistic outcomes and frequent evaluation 
D)  Data gathering and assessment A

Question 3

Problem-oriented medical records (POMRs):

Accepted Answer

A)  Focus on patient response to treatment. 
B)  Is source-oriented charting. 
C)  Reflect the patient's current problems. 
D)  Focus on medical diagnosis. 
A)  Focus on patient response to treatment. 
B)  Is source-oriented charting. 
C)  Reflect the patient's current problems. 
D)  Focus on medical diagnosis. C

Question 4

An example of a complete nursing diagnosis is:

Accepted Answer

A)  Peripheral neurovascular dysfunction 
B)  Peripheral neurovascular dysfunction exhibited by patient complaint 
C)  Peripheral neurovascular dysfunction related to decreased sensation, exhibited by the statement, "My feet are tingling." 
D)  Peripheral neurovascular dysfunction exhibited by patient statement 
A)  Peripheral neurovascular dysfunction 
B)  Peripheral neurovascular dysfunction exhibited by patient complaint 
C)  Peripheral neurovascular dysfunction related to decreased sensation, exhibited by the statement, "My feet are tingling." 
D)  Peripheral neurovascular dysfunction exhibited by patient statement

Question 5

Documentation should include:

Accepted Answer

A)  Objective and subjective data 
B)  Observations made by other nursing staff 
C)  Information that is accurate and complete 
D)  Incidence reports 
A)  Objective and subjective data 
B)  Observations made by other nursing staff 
C)  Information that is accurate and complete 
D)  Incidence reports

Question 6

The nurse is aware of the goal that reads,"The patient will eat at least 50% of all meals." The nurse has observed the patient eating over 50% of all meals for 2 days.The evaluation statement should read:

Accepted Answer

A)  Ate well for all meals. 
B)  Problem is resolved; goal is met. 
C)  Goal is met; patient ate 50% of all meals on 7/12 and 7/13. 
D)  Ate 50% of meals. 
A)  Ate well for all meals. 
B)  Problem is resolved; goal is met. 
C)  Goal is met; patient ate 50% of all meals on 7/12 and 7/13. 
D)  Ate 50% of meals.

Question 7

The nurse uses palpation for the purpose of:

Accepted Answer

A)  Determining areas of tenderness. 
B)  Differentiating between fluid- and air-filled organs. 
C)  Hearing sounds produced by the body. 
D)  Systematically approaching a physical assessment. 
A)  Determining areas of tenderness. 
B)  Differentiating between fluid- and air-filled organs. 
C)  Hearing sounds produced by the body. 
D)  Systematically approaching a physical assessment.

Question 8

The most effective documentation is:

Accepted Answer

A)  7/27; 9:45 AM; pt. vomited; pt. looked better after episode-A. Nurse, LPN 
B)  7/27; 9:45 AM; pt. vomited large amount; reduced nausea 
C)  7/27; 9:45 AM; pt. reported less nausea after vomiting-A. Nurse, LPN 
D)  7/27; 0945; pt. vomited 200 ml of partially digested food; pt. states nausea has diminished-A. Nurse, LPN 
A)  7/27; 9:45 AM; pt. vomited; pt. looked better after episode-A. Nurse, LPN 
B)  7/27; 9:45 AM; pt. vomited large amount; reduced nausea 
C)  7/27; 9:45 AM; pt. reported less nausea after vomiting-A. Nurse, LPN 
D)  7/27; 0945; pt. vomited 200 ml of partially digested food; pt. states nausea has diminished-A. Nurse, LPN

Question 9

The nurse notes the previous 24-hour urine output was 950 ml,well below the normal of 1500 ml.An effective nursing order to remedy the impending dehydration would be to:

Accepted Answer

A)  Offer more fluids daily. 
B)  Offer 8 ounces of juice or tea at 0800 (8 AM), 1200 (12 noon), 1600 (4 PM), and 2000 (8 PM). 
C)  Request extra fluid on a diet tray from the kitchen. 
D)  Place a large water pitcher at the bedside during each shift. 
A)  Offer more fluids daily. 
B)  Offer 8 ounces of juice or tea at 0800 (8 AM), 1200 (12 noon), 1600 (4 PM), and 2000 (8 PM). 
C)  Request extra fluid on a diet tray from the kitchen. 
D)  Place a large water pitcher at the bedside during each shift.

Question 10

The best example of a nursing order is:

Accepted Answer

A)  Perform deep breathing exercises twice daily at 10 AM and 2 PM. 
B)  Administer Tylenol every 4 hours as needed for headache. 
C)  Assess skin integrity and risk for impairment. 
D)  Patient will frequently perform quadriceps-setting exercises. 
A)  Perform deep breathing exercises twice daily at 10 AM and 2 PM. 
B)  Administer Tylenol every 4 hours as needed for headache. 
C)  Assess skin integrity and risk for impairment. 
D)  Patient will frequently perform quadriceps-setting exercises.

Question 11

Evidence-based practice supports effective nursing care through:

Accepted Answer

A)  Research on nursing care topics 
B)  Directives from the Boards of Nursing 
C)  Summation of studies 
D)  Recommendations for nursing care 
E)  Funding research 
A)  Research on nursing care topics 
B)  Directives from the Boards of Nursing 
C)  Summation of studies 
D)  Recommendations for nursing care 
E)  Funding research

Question 12

In PIE documentation,a type of POMR,the acronym PIE stands for ____________________,____________________ and ____________________.

Accepted Answer

Problem; Interventio

Question 13

The nurse assisting with prioritizing nursing diagnoses would select which of the following as the highest priority?

Accepted Answer

A)  Impaired adjustment 
B)  Acute pain 
C)  Risk for imbalanced body temperature 
D)  Ineffective airway clearance 
A)  Impaired adjustment 
B)  Acute pain 
C)  Risk for imbalanced body temperature 
D)  Ineffective airway clearance

Question 14

When the postsurgical patient complains of shortness of breath,the nurse should immediately:

Accepted Answer

A)  Raise the head of the bed to 30 degrees. 
B)  Take vital signs. 
C)  Perform a focused assessment. 
D)  Inform the charge nurse. 
A)  Raise the head of the bed to 30 degrees. 
B)  Take vital signs. 
C)  Perform a focused assessment. 
D)  Inform the charge nurse.

Question 15

The primary purpose of incorporating the nursing process into the care of patients is to:

Accepted Answer

A)  Establish a basis of communication with other nursing staff members. 
B)  Maintain compliance with existing national nursing standards. 
C)  Provide structure and organization to the delivery of medical care to the patient. 
D)  Address current health issues, as well as health maintenance and rehabilitation. 
A)  Establish a basis of communication with other nursing staff members. 
B)  Maintain compliance with existing national nursing standards. 
C)  Provide structure and organization to the delivery of medical care to the patient. 
D)  Address current health issues, as well as health maintenance and rehabilitation.

Question 16

The nursing process is based on:

Accepted Answer

A)  Medical diagnosis of the patient 
B)  Identified physiologic and psychologic needs of the patient 
C)  Standards of nursing care provided by the American Nurses' Association 
D)  Orders of the primary care provider 
A)  Medical diagnosis of the patient 
B)  Identified physiologic and psychologic needs of the patient 
C)  Standards of nursing care provided by the American Nurses' Association 
D)  Orders of the primary care provider

Question 17

When percussing the patient's abdomen,the nurse anticipates a note that is:

Accepted Answer

A)  Flat 
B)  Dull 
C)  Tympanic 
D)  Resonant 
A)  Flat 
B)  Dull 
C)  Tympanic 
D)  Resonant

Question 18

The patient will maintain an adequate nutritional state without nausea or vomiting is an example of a nursing:

Accepted Answer

A)  Intervention 
B)  Process 
C)  Diagnosis 
D)  Goal 
A)  Intervention 
B)  Process 
C)  Diagnosis 
D)  Goal

Question 19

Nursing outcome classification (NOC)is a method of classifying a nursing:

Accepted Answer

A)  Process 
B)  Care plan 
C)  Goal 
D)  Intervention outcome 
A)  Process 
B)  Care plan 
C)  Goal 
D)  Intervention outcome

Question 20

The patient complains of a headache.This information would be classified as:

Accepted Answer

A)  Subjective 
B)  Objective 
C)  Pain assessment 
D)  Undifferentiated 
A)  Subjective 
B)  Objective 
C)  Pain assessment 
D)  Undifferentiated

Exam 12: The Nursing Process and Critical Thinking

When a patient plan of care has been written,it:

Characteristics of critical thinking include:

Problem-oriented medical records (POMRs):

An example of a complete nursing diagnosis is:

Documentation should include:

The nurse is aware of the goal that reads,"The patient will eat at least 50% of all meals." The nurse has observed the patient eating over 50% of all meals for 2 days.The evaluation statement should read:

The nurse uses palpation for the purpose of:

The most effective documentation is:

The nurse notes the previous 24-hour urine output was 950 ml,well below the normal of 1500 ml.An effective nursing order to remedy the impending dehydration would be to:

The best example of a nursing order is:

Evidence-based practice supports effective nursing care through:

In PIE documentation,a type of POMR,the acronym PIE stands for ____________________,____________________ and ____________________.

The nurse assisting with prioritizing nursing diagnoses would select which of the following as the highest priority?

When the postsurgical patient complains of shortness of breath,the nurse should immediately:

The primary purpose of incorporating the nursing process into the care of patients is to:

The nursing process is based on:

When percussing the patient's abdomen,the nurse anticipates a note that is:

The patient will maintain an adequate nutritional state without nausea or vomiting is an example of a nursing:

Nursing outcome classification (NOC)is a method of classifying a nursing:

The patient complains of a headache.This information would be classified as:

The Health Care System

Patient Care Settings

Legal and Ethical Considerations

The Leadership Role of the Licensed Practical Nurse

The Nurse-Patient Relationship

Cultural Aspects of Nursing Care

The Nurse and the Family

Health and Illness

Nutrition

Developmental Processes

The Older Patient

Inflammation, infection, and Immunity

Fluids and Electrolytes

Pain Management

First Aid, emergency Care, and Disaster Management

Surgical Care

Intravenous Therapy

Shock

Falls

Immobility

Confusion

Incontinence

Loss, death, and End-Of-Life Care

The Patient With Cancer

The Patient With an Ostomy

Neurologic Disorders

Cerebrovascular Accident

Spinal Cord Injury

Acute Respiratory Disorders

Chronic Respiratory Disorders

Hematologic Disorders

Immunologic Disorders

Human Immunodeficiency Virus and Acquired Immunodeficiency Syndrome

Cardiac Disorders

Vascular Disorders

Hypertension

Digestive Tract Disorders

Disorders of the Liver, gallbladder, and Pancreas

Urologic Disorders

Connective Tissue Disorders

Fractures

Amputations

Pituitary and Adrenal Disorders

Thyroid and Parathyroid Disorders

Diabetes Mellitus and Hypoglycemia

Female Reproductive Disorders

Male Reproductive Disorders

Sexually Transmitted Infections

Skin Disorders

Eye and Vision Disorders

Ear and Hearing Disorders

Nose, sinus, and Throat Disorders

Psychologic Responses to Illness

Psychiatric Disorders

Substance-Related Disorders

Filters

In PIE documentation,a type of POMR,the acronym PIE stands for , and .