Deck 12: The Nursing Process: Your Role

Question 1

When a nurse uses Maslow's Hierarchy of Needs to prioritize patient problems, which problem would be considered the highest priority?

A) The patient is unsteady and may become injured.
B) The patient is experiencing marital difficulties.
C) The patient has deficient knowledge about the condition.
D) The patient is acutely short of breath.

Answer 1

The patient is acutely short of breath.

Question 2

During the assessment phase of the nursing process, the LPN/LVN is expected to

A) establish goals and outcome criteria.
B) collect data about the patient.
C) determine whether established goals have been met.
D) plan interventions to implement for the patient.

Answer 2

collect data about the patient.

Question 3

The patient's problem has been identified as insufficient intake of oral fluids. The best outcome statement is

A) the patient will ingest 1500 mL of oral fluids during each 24-hour period.
B) the patient will request fluids when thirsty.
C) the nurse will encourage fluid intake by the patient.
D) the nurse will provide the patient with 100 mL of fluid hourly.

Answer 3

the patient will ingest 1500 mL of oral fluids during each 24-hour period.

Question 4

How does the LPN/LVN use nursing diagnosis in patient care?

A) To set patient-centered goals
B) To convert nursing diagnoses to patient problems
C) To implement independent nursing interventions
D) To justify participation in data collection

Question 5

Which of the following is the primary reason that LPN/LVNs are taught to use the nursing process?

A) To diagnose disease
B) To provide reimbursement
C) To resolve patient problems
D) To communicate with health team members

Question 6

The student nurse asks, "How does knowing the nursing diagnosis assist the LPN/LVN?" The best response is based on understanding that

A) a nursing diagnosis identifies the patient's problems.
B) it permits the practical nurse to go beyond the scope of practice.
C) this step makes the practical nurse equal to the medical doctor.
D) knowledge of the nursing diagnosis ensures a cure for the patient.

Question 7

The nursing care plan requires the nurse to ambulate the patient twice daily. The phase of the nursing process in which the nurse is participating is

A) assessment.
B) planning.
C) implementation.
D) evaluation.

Question 8

A student nurse asks, "What's the primary purpose of the evaluation phase of the nursing process?" The best response is

A) to establish a time frame for completion of goals.
B) to determine whether the nurse completed all nursing interventions.
C) to determine which nurses are eligible for raises or promotion.
D) to compare actual patient outcomes with desired outcomes.

Question 9

A blood pressure of 110/70 at 8 PM is most accurately described as an example of

A) planning data.
B) subjective data.
C) objective data.
D) reassessment data.

Question 10

Which of the following are considered subjective data?

A) The patient tells the nurse that he has a headache.
B) The nursing assistant tells the nurse that the patient vomited.
C) The patient's mother tells the nurse that the patient needs a ride to the clinic for follow-up.
D) The physician tells the nurse that the patient needs a chest x-ray.

Question 11

A nurse expresses difficulty deciding which nursing interventions to suggest for a patient with arthritic pain during an upcoming patient-centered conference. A peer suggests referring to the Nursing Interventions Classification (NIC) taxonomy. This would provide the nurse with information on

A) how to provide basic care to patients.
B) identification of nursing measures to help patients progress toward goals.
C) a language for measuring patients' response to nursing interventions.
D) how to translate nursing diagnoses into nursing problems.

Question 12

The phases of the nursing process in which the LPN/LVN participates with the greatest degree of independence are

A) goal setting and evaluation.
B) planning and implementation.
C) data collection and implementation.
D) evaluation and data collection.

Question 13

"I feel like I can't catch my breath" is an example of

A) effective data.
B) objective data.
C) subjective data.
D) evaluative data.

Question 14

The RN head nurse is having a busy day. When the LPN/LVN reports data she has collected, the RN states, "Incorporate that into the nursing care plan and write down the intervention you'd use. I'll cosign the entry." The LPN/LVN should

A) do as requested.
B) ask the advice of the shift supervisor later in the shift.
C) tell the RN that this action is not within the LPN/LVN scope of practice.
D) write a letter to the state board of nursing to report the RN's unprofessional conduct.

Question 15

Which of the following statements regarding short-term goals is accurate?

A) Short-term goals are broad rather than specific.
B) Short-term goals can be accomplished within days or hours.
C) Short-term goals must be accomplished while the patient is hospitalized.
D) Short-term goals are less realistic than long-term goals.

Question 16

An LPN/LVN demonstrates to a new mother how to safely bathe her infant. This is an example of the phase of the nursing process called

A) assessment.
B) nursing diagnosis.
C) planning.
D) implementation.

Question 17

Identify the outcome that would be appropriate to include in the nursing care plan of a patient who has undergone total knee replacement.

A) The patient will be stronger by (date).
B) The patient will transfer from the bed to a chair with the assistance of a walker and one staff member by the third postoperative day.
C) The nurse will help the patient ambulate the length of the hall twice daily.
D) The nurse will evaluate the patient's strength based on his ability to ambulate in the hall on the first postoperative day.

Question 18

When the LPN/LVN participates in the evaluation phase of the nursing process, she or he compares the patient's responses with the

A) nursing orders.
B) outcome criteria.
C) nursing diagnosis.
D) data collection.

Question 19

The LPN/LVN learns at report that a patient's priority problems are pain and inability to ambulate associated with arthritis. During the patient's bath, he becomes short of breath. The LPN/LVN should implement interventions based on

A) the priorities given at the report.
B) the patient's identified strengths.
C) the patient's changing status.
D) information obtained from the Nursing Outcomes Classification (NOC) project.

Question 20

A student nurse asks, "If RNs use a five-step nursing process and LPN/LVNs use a four-step process, what phase is missing?" The best response would be, "The phase of the nursing process that is the sole responsibility of the registered nurse is

A) assessment.
B) nursing diagnosis.
C) planning.
D) implementation.
E) evaluation.

Question 21

Which of the following are reasons the nursing process and critical thinking are included in the LPN/LVN curriculum? (Select all that apply.)

A) Both are needed to identify patient problems, issues, and risks.
B) They foster making evidence-based judgments.
C) Clearer communication between RN and LPN can take place.
D) Job stress and burnout are diminished.
E) Patient safety is adversely affected.

Question 22

A nurse reviews a patient's care plan and finds a goal for the patient to ambulate at least three times a day. The nurse assists the patient to accomplish this goal. The nurse is participating in which step of the nursing process?

A) Planning
B) Evaluation
C) Data collection
D) Implementation

Question 23

The nursing process consists of collecting data (assessment), nursing diagnosis, planning, implementation, and evaluating nursing care. Which step of the nursing process is the sole responsibility of the registered nurse?

A) Planning
B) Assessment
C) Implementation
D) Nursing diagnosis

Question 24

A nurse is comparing a patient's outcomes of nursing care to the expected outcomes. The nurse then communicates these findings to members of the health care team. The nurse is participating in which step of the nursing process?

A) Planning
B) Evaluation
C) Data collection
D) Implementation

Question 25

An LPN/LVN is assisting the RN in the development of goals and interventions for a patient's plan of care. The LPN/LVN is participating in which step of the nursing process?

A) Planning
B) Evaluation
C) Data collection
D) Implementation

Question 26

A nurse is gathering and reviewing information about a patient. The nurse is participating in which step of the nursing process?

A) Planning
B) Evaluation
C) Data collection
D) Implementation

Question 27

Which of the following are examples of subjective data? (Select all that apply.)

A) A patient has an offensive body odor.
B) A patient complains of feeling stressed.
C) A patient complains of feeling anxious.
D) A patient complains of substernal chest pain.
E) A patient falls when ambulating to the bathroom.
F) A patient states, "I feel a sense of impending doom."

Question 28

Which statements accurately describe the role of the LPN/LVN in relation to use of the nursing process? (Select all that apply.)

A) LPN/LVNs have an interdependent relationship with other health team members.
B) LPN/LVNs act in a more dependent role when participating in the planning and evaluation phases.
C) LPN/LVNs act more independently when participating in data collection and implementation phases than in any other phases of the nursing process.
D) LPN/LVNs are able to use the NANDA list to make nursing diagnoses.
E) LPN/LVN basic education enables them to perform patient interviews and assessment of body systems.

Question 29

A nurse notes that a patient is experiencing increased peripheral edema and has urinated 20 cc of urine in the past hour. This is an example of ________________ data.

Question 30

Which of the following are examples of objective data? (Select all that apply.)

A) A patient has an offensive body odor.
B) A patient complains of feeling stressed.
C) A patient complains of feeling anxious.
D) A patient complains of substernal chest pain.
E) A patient falls when ambulating to the bathroom.
F) A patient states, "I feel a sense of impending doom."

Question 31

A nurse is gathering data about a patient. The nurse determines that which of the following is subjective data?

A) The patient complains of excruciating, crushing chest pain.
B) The patient is short of breath and coughs up green sputum.
C) The patient has gained 1 lb within the past 24 hours.
D) The patient is experiencing sinus tachycardia and peripheral edema.

Question 32

A beginning nurse asks an experienced nurse, "When should I focus on data collection?" Which statement provides the best description for when a nurse should collect patient-centered data?

A) After report when coming on duty
B) Within 1 hour of reporting off duty
C) While assisting a patient with hygiene
D) During each patient contact

Question 33

A nurse is gathering data about a patient. The nurse determines that which of the following is subjective data?

A) The patient complains of feeling anxious about her upcoming surgery.
B) The patient is short of breath and has an oxygen saturation level of 86%.
C) The patient has a heart rate of 85 beats per minute and has a sinus rhythm.
D) The patient has consumed 60% of breakfast, 45% of lunch, and 50% of dinner.

Question 34

A patient states, "I'm feeling left-sided chest pain that radiates to my left arm." This is an example of _______________ data.

Question 35

Which strategies would facilitate patient data collection? (Select all that apply.)

A) Ensure that the patient knows who you are and what you are going to do.
B) Address the patient with familiarity, using terms of endearment.
C) Repeat questions the patient has previously answered.
D) Clarify what you do not understand with the patient.
E) Judge the patient's behaviors and attitudes.

Question 36

The LPN/LVN should be alert to possible barriers to data collection, such as which of the following? (Select all that apply.)

A) Inadequate assessment skills
B) Presence of distractions
C) Respectful distancing
D) Insufficient time
E) Inability to speak the language
F) Patient labeling

Question 37

A nurse is gathering data about a patient. The nurse determines that which of the following is objective data?

A) The patient complains of phantom pain after receiving a left below-the-knee amputation.
B) The patient complains of crushing chest pain and states, "I feel like there is an elephant sitting on my chest."
C) The patient complains of feeling anxious about being hospitalized and states, "I feel like I'm going to die."
D) The patient has a heart rate of 99 beats per minute, respirations of 20 per minute, and a temperature of 99.2° F.

Question 38

The patient's nursing diagnosis is pain associated with walking related to knee injury. The LPN/LVN should accurately identify the patient problem as

A) arthritis.
B) unwillingness to exercise.
C) need for knee brace.
D) knee pain.