Deck 4: The Nursing Process: Critical Thinking and Decision Making

Question 1

The nursing student is preparing a care plan for an assigned client.What should the nurse include that is least likely to be placed on an individualized plan of care for the same client?

A)Numbered day of hospitalization
B)Consistent use of nursing taxonomy
C)Impact of laboratory data on selection of an intervention
D)Generic nursing diagnoses based upon the primary health problem

Answer 1

Impact of laboratory data on selection of an intervention

Question 2

A client has a critical pathway to be used for providing care.Which should the nurse keep in mind when following this plan of care?

A)Care is based upon the day of hospitalization
B)Coordinates nursing problems with medical diagnoses
C)Provides areas for other disciplines to document interventions
D)Uses nursing intervention (NIC)and outcome (NOC)statements

Answer 2

Care is based upon the day of hospitalization

Question 3

The nurse meets with the physical and occupational therapist to plan care for a client with nerve damage caused by a back injury.Which type of intervention will be listed on the plan of care?

A)Direct
B)Dependent
C)Independent
D)Collaborative

Answer 3

Collaborative

Question 4

When preparing a plan of care, the nurse uses skillful reasoning and logical thought to determine the merits of an action.Which action is the nurse performing?

A)Critical thinking
B)Sensory overload
C)Concrete thinking
D)Logical reasoning

Question 5

The nurse is reviewing the NANDA-I list of nursing diagnoses while preparing a client's plan of care.Which term should the nurse search if the client has edema of the legs causing an alteration in perfusion and risk for injury?

A)Risk
B)Edema
C)Perfusion
D)Alteration

Question 6

The nurse prepares a handout about the nursing process for an orientation class of new colleagues.Which should the nurse use to explain this process?

A)Decision-making framework used by nurses to determine the needs of clients
B)Decision-making framework used by social workers when discharging clients
C)Decision-making framework used by nursing assistants when caring for clients
D)Decision-making framework used by physicians to determine the needs of clients

Question 7

The nurse is planning care for an assigned client.Which information indicates that the outcome statements are written correctly? Select all that apply.

A)Action can be measured
B)Action that the client can perform
C)Action that the nurse can delegate
D)Action to be performed by the client
E)Action can be completed with a specific time frame

Question 8

While caring for a newly admitted client, the registered nurse (RN)gathers information by interviewing the client to obtain a health history and reviewing the results of laboratory and diagnostic tests.Which step in the nursing process did this nurse complete?

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

Question 9

While performing a shift assessment, the nurse visually examines a client's body for rashes and breaks in the skin, and looks for normal appearance of eyes, ears, nose, mouth, limbs, and genitals.Which assessment technique is nurse using?

A)Palpation
B)Inspection
C)Percussion
D)Auscultation

Question 10

The nurse reviews a care plan prepared for a client.Which are indirect nursing interventions in this plan of care? Select all that apply.

A)Bathing a client
B)Administering pain medication
C)Documenting a client's bath
D)Listening to a client's complaints
E)Informing the physician about a client's pain

Question 11

The nurse is preparing to instruct a client on how to change an ostomy appliance.What should be addressed prior to beginning this teaching session to ensure optimal learning occurs?

A)Turn off the television
B)Complete morning care
C)Address lower level needs
D)Invite family to participate

Question 12

The nurse reviews problems identified for a client.Which problem should the nurse list as a priority?

A)Has irregular heart rhythm
B)Ambulates with a cane
C)Is separated from the spouse
D)Is unable to use a new glucose meter

Question 13

A client has hyperactive bowel sounds, diarrhea, nausea, vomiting, and has lost five pounds over the last week.Which type of nursing diagnostic statement should be created for this client?

A)Wellness
B)Two-part
C)Syndrome
D)Three-part

Question 14

The student is preparing a concept map prior to caring for a client during the next clinical day.Which should the student do when creating this map?

A)Focus on assessment data
B)Follow the nursing process
C)Evaluate the outcome of care provided
D)Validate the information with laboratory values

Question 15

The nurse is performing a shift assessment on a client.Which information should the nurse identify as objective data?

A)The client reports feelings of depression
B)The client demonstrates facial grimacing
C)The client complains of feeling nauseated
D)The client complains of visual disturbances

Question 16

The nurse reviews outcome statements with a new colleague.Which information about outcome statements should the new nurse identify as being appropriate? Select all that apply.

A)"An outcome statement should be a realistic, specific action."
B)"An outcome statement is an action that is measurable and can be evaluated."
C)"An outcome statement should be an action the client is unable to perform."
D)"An outcome statement should be a specific action to be taken by the nurse."
E)"An outcome statement has a definite time frame for

Question 17

The LPN/LVN assists the RN in completing an admission history with a confused client.Which information should be identified as secondary information?

A)The client reports a history of chest pain.
B)The client complains of chronic constipation.
C)The client verbalizes anxiety about hospitalization.
D)The client's spouse reports experiencing marital issues.

Question 18

The nurse is planning interventions for a client experiencing nausea and vomiting after receiving chemotherapy.Which intervention is individualized for this client?

A)Encourage fluids
B)Avoid taking fluids while eating meals
C)Monitor intake and output and daily weights
D)Provide 8 ounces enriched milkshake mid-morning and mid-afternoon

Question 19

A client with diabetes is being treated for an infected foot wound.Which would be an appropriate short-term goal for this client?

A)Wound is healed
B)Wears footwear in the home at all times
C)No further evidence of skin breakdown on the feet
D)Demonstrates correct technique for self-injection of insulin

Question 20

The nurse reviews a care plan written for a client.Which nursing diagnosis should the nurse delete from this plan?

A)"Pain related to abdominal incision"
B)"Altered sensory perception related to surgery"
C)"Chronic fatigue syndrome related to poor diet"
D)"Altered nutrition related to nausea and vomiting"

Question 21

The nurse is preparing to care for several assigned clients.Which action should be taken to ensure that care is provided in a safe manner? Select all that apply.

A)Follow the directions provided by the charge nurse.
B)Keep the bed in the lowest position throughout the intervention.
C)Perform actions within the scope of practice of the nurse practice act.
D)Plan more time to complete an intervention being done for the first time.
E)Check the client's armband to ensure the correct client is receiving the intervention.

Question 22

The nurse is preparing to care for a client.Which action should be completed before implementing any identified interventions? Select all that apply.

A)Maintain privacy
B)Explain the procedure
C)Gather equipment and supplies
D)Document the procedure completed
E)Check the health-care provider's order