Question 1

Which statement by the nurse best demonstrates clear communication to nursing assistive personnel (NAP)about delegating a task?

Accepted Answer

A)  "Record how much the patient drinks today,please." 
B)  "Take the patient's vital signs every 2 hours today." 
C)  "Take the patient's temperature every 4 hours; notify me if it is greater than 100.5°F (38.1°
C) ." 
D)  "Assist the patient with all of her meals." 
A)  "Record how much the patient drinks today,please." 
B)  "Take the patient's vital signs every 2 hours today." 
C)  "Take the patient's temperature every 4 hours; notify me if it is greater than 100.5°F (38.1°
C) ." 
D)  "Assist the patient with all of her meals." C

Question 2

Which behavior provides the most valid criterion for determining the status of a patient's anxiety at discharge?

Accepted Answer

A)  Has a relaxed facial expression 
B)  States feeling more relaxed today 
C)  Shows no physiological signs of anxiety 
D)  Has no further questions about home care 
A)  Has a relaxed facial expression 
B)  States feeling more relaxed today 
C)  Shows no physiological signs of anxiety 
D)  Has no further questions about home care B

Question 3

Which nursing intervention is best individualized to meet the needs of a specific client?

Accepted Answer

A)  Suction the client every 2 hours per unit policy. 
B)  Use incentive spirometry every hour while awake per postoperative protocols. 
C)  Institute swallowing precautions. 
D)  Move client out of bed to the chair daily; client prefers to be out of bed for dinner. 
A)  Suction the client every 2 hours per unit policy. 
B)  Use incentive spirometry every hour while awake per postoperative protocols. 
C)  Institute swallowing precautions. 
D)  Move client out of bed to the chair daily; client prefers to be out of bed for dinner. D

Question 4

Which statement accurately describes delegation?

Accepted Answer

A)  Transferring authority to another person to perform a task in a selected situation 
B)  Collaborating with other caregivers to make decisions and plan care 
C)  Scheduling treatments and activities with other departments 
D)  Performing a planned intervention from a critical pathway 
A)  Transferring authority to another person to perform a task in a selected situation 
B)  Collaborating with other caregivers to make decisions and plan care 
C)  Scheduling treatments and activities with other departments 
D)  Performing a planned intervention from a critical pathway

Question 5

Before inserting a nasogastric tube,the nurse reassures the client.Which type of skill did the nurse use to help this client?

Accepted Answer

A)  Psychomotor 
B)  Interpersonal 
C)  Cognitive 
D)  Critical thinking 
A)  Psychomotor 
B)  Interpersonal 
C)  Cognitive 
D)  Critical thinking

Question 6

Which criterion might be used in structure evaluation?

Accepted Answer

A)  Staff refrains from sharing computer password. 
B)  Healthcare provider washes hands with each client contact. 
C)  A defibrillator is accessible on each client care area. 
D)  Nurse verifies client identification before initiating care. 
A)  Staff refrains from sharing computer password. 
B)  Healthcare provider washes hands with each client contact. 
C)  A defibrillator is accessible on each client care area. 
D)  Nurse verifies client identification before initiating care.

Question 7

The nurse documents that a client's nasogastric tube has been removed.Which is the next logical step in the nursing process?

Accepted Answer

A)  Assessment 
B)  Planning 
C)  Evaluation 
D)  Diagnosis 
A)  Assessment 
B)  Planning 
C)  Evaluation 
D)  Diagnosis

Question 8

Which intervention depends almost entirely on the client's adhering to the therapy?

Accepted Answer

A)  Inserting an IV catheter 
B)  Turning a client every 2 hours 
C)  Shortening a surgical drain 
D)  Following a low-fat,low-calorie diet 
A)  Inserting an IV catheter 
B)  Turning a client every 2 hours 
C)  Shortening a surgical drain 
D)  Following a low-fat,low-calorie diet

Question 9

The nurse works with the respiratory therapist to administer a patient's breathing treatments.He reports the patient's breathing status and tolerance of the treatment to the primary care provider.The nurse then discusses with the patient the options for further treatment.What does this scenario demonstrate?

Accepted Answer

A)  Delegation 
B)  Collaboration 
C)  Coordination of care 
D)  Supervision of care 
A)  Delegation 
B)  Collaboration 
C)  Coordination of care 
D)  Supervision of care

Question 10

The nurse reviews a client's care plan.What should the nurse keep in mind when evaluating the outcomes of care?

Accepted Answer

A)  Data are collected after interventions are performed. 
B)  Data are collected before interventions are performed. 
C)  Documentation occurs after evaluation is completed. 
D)  Evaluation involves prioritizing implementation tasks. 
A)  Data are collected after interventions are performed. 
B)  Data are collected before interventions are performed. 
C)  Documentation occurs after evaluation is completed. 
D)  Evaluation involves prioritizing implementation tasks.

Question 11

The nurse needs to insert an indwelling urinary catheter into a client who is confused and combative.Which action should the nurse take first?

Accepted Answer

A)  Ask a colleague for help,because the nurse cannot safely perform the procedure alone. 
B)  Gather the equipment and prepare it before informing the client about the procedure. 
C)  Obtain an order to restrain the client before inserting the urinary catheter. 
D)  Inform the provider that the nurse cannot perform the procedure because the client is confused. 
A)  Ask a colleague for help,because the nurse cannot safely perform the procedure alone. 
B)  Gather the equipment and prepare it before informing the client about the procedure. 
C)  Obtain an order to restrain the client before inserting the urinary catheter. 
D)  Inform the provider that the nurse cannot perform the procedure because the client is confused.

Question 12

The nurse is caring for a client who was newly diagnosed with type 2 diabetes mellitus.Which intervention by the nurse best promotes client cooperation with the treatment plan?

Accepted Answer

A)  Teaching the client that he must lose weight to control his blood sugar 
B)  Informing the client he must exercise at least three times per week 
C)  Explaining to the client that he must come to the diabetic clinic weekly 
D)  Determining the client's main concerns about his diabetes 
A)  Teaching the client that he must lose weight to control his blood sugar 
B)  Informing the client he must exercise at least three times per week 
C)  Explaining to the client that he must come to the diabetic clinic weekly 
D)  Determining the client's main concerns about his diabetes

Question 13

The nurse reviews a client's care plan,goals,and outcomes prior to discharge.Which type of evaluation is the nurse conducting?

Accepted Answer

A)  Process 
B)  Ongoing 
C)  Terminal 
D)  Intermittent 
A)  Process 
B)  Ongoing 
C)  Terminal 
D)  Intermittent

Question 14

Which statement is a client outcome criterion?

Accepted Answer

A)  Central venous catheter site infection does not occur (90% of cases). 
B)  Client will sit out of bed in a chair for 20 minutes three times per day. 
C)  Postoperative phlebitis does not occur (95% of cases). 
D)  Falls will decrease by 2% between January 1 and March 30. 
A)  Central venous catheter site infection does not occur (90% of cases). 
B)  Client will sit out of bed in a chair for 20 minutes three times per day. 
C)  Postoperative phlebitis does not occur (95% of cases). 
D)  Falls will decrease by 2% between January 1 and March 30.

Question 15

A client recovering from colon surgery refuses to look at the site of a newly placed ostomy.What should the nurse do about teaching this client self-care as identified on the critical pathway?

Accepted Answer

A)  Postpone the teaching session until the patient is more receptive. 
B)  Follow the critical pathway for patient teaching about ostomy care. 
C)  Administer a prescribed antidepressant and notify the physician. 
D)  Explain to the patient the importance of skin care around the ostomy site. 
A)  Postpone the teaching session until the patient is more receptive. 
B)  Follow the critical pathway for patient teaching about ostomy care. 
C)  Administer a prescribed antidepressant and notify the physician. 
D)  Explain to the patient the importance of skin care around the ostomy site.

Question 16

A client is prescribed oral aripiprazole 10 mg daily; however,the nurse is unfamiliar with the medication and cannot find it in the hospital formulary.Which action should the nurse take?

Accepted Answer

A)  Administer the medication as prescribed. 
B)  Hold the medication and notify the prescriber. 
C)  Consult with a pharmacist before administering it. 
D)  Ask the client's nurse for information about the medication. 
A)  Administer the medication as prescribed. 
B)  Hold the medication and notify the prescriber. 
C)  Consult with a pharmacist before administering it. 
D)  Ask the client's nurse for information about the medication.

Question 17

Which task can be delegated to nursing assistive personnel (NAP)?

Accepted Answer

A)  Turn and reposition the client every 2 hours. 
B)  Assess the client's skin condition. 
C)  Change pressure ulcer dressings every shift. 
D)  Apply hydrocolloid dressing to the pressure ulcer. 
A)  Turn and reposition the client every 2 hours. 
B)  Assess the client's skin condition. 
C)  Change pressure ulcer dressings every shift. 
D)  Apply hydrocolloid dressing to the pressure ulcer.

Question 18

When should the nurse collect evaluation data for this expected outcome: Patient will maintain urine output of at least 30 mL/hour?

Accepted Answer

A)  At the end of the shift 
B)  Every 24 hours 
C)  Every 4 hours 
D)  Every hour 
A)  At the end of the shift 
B)  Every 24 hours 
C)  Every 4 hours 
D)  Every hour

Question 19

Who is responsible for evaluating the outcome of a task delegated to the nursing assistive personnel (NAP)?

Accepted Answer

A)  Nurse who delegated the task 
B)  Licensed practical nurse working with the NAP 
C)  Unit nurse manager 
D)  Charge nurse for the shift 
A)  Nurse who delegated the task 
B)  Licensed practical nurse working with the NAP 
C)  Unit nurse manager 
D)  Charge nurse for the shift

Question 20

Which type of client-centered evaluation is performed at specific,scheduled times?

Accepted Answer

A)  Intermittent 
B)  Ongoing 
C)  Terminal 
D)  Process 
A)  Intermittent 
B)  Ongoing 
C)  Terminal 
D)  Process

Exam 7: Implementation Evaluation

Which statement by the nurse best demonstrates clear communication to nursing assistive personnel (NAP)about delegating a task?

Which behavior provides the most valid criterion for determining the status of a patient's anxiety at discharge?

Which nursing intervention is best individualized to meet the needs of a specific client?

Which statement accurately describes delegation?

Before inserting a nasogastric tube,the nurse reassures the client.Which type of skill did the nurse use to help this client?

Which criterion might be used in structure evaluation?

The nurse documents that a client's nasogastric tube has been removed.Which is the next logical step in the nursing process?

Which intervention depends almost entirely on the client's adhering to the therapy?

The nurse reviews a client's care plan.What should the nurse keep in mind when evaluating the outcomes of care?

The nurse needs to insert an indwelling urinary catheter into a client who is confused and combative.Which action should the nurse take first?

The nurse is caring for a client who was newly diagnosed with type 2 diabetes mellitus.Which intervention by the nurse best promotes client cooperation with the treatment plan?

The nurse reviews a client's care plan,goals,and outcomes prior to discharge.Which type of evaluation is the nurse conducting?

Which statement is a client outcome criterion?

A client recovering from colon surgery refuses to look at the site of a newly placed ostomy.What should the nurse do about teaching this client self-care as identified on the critical pathway?

A client is prescribed oral aripiprazole 10 mg daily; however,the nurse is unfamiliar with the medication and cannot find it in the hospital formulary.Which action should the nurse take?

Which task can be delegated to nursing assistive personnel (NAP)?

When should the nurse collect evaluation data for this expected outcome: Patient will maintain urine output of at least 30 mL/hour?

Who is responsible for evaluating the outcome of a task delegated to the nursing assistive personnel (NAP)?

Which type of client-centered evaluation is performed at specific,scheduled times?

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