Question 1

What activity is carried out during the implementing step of the nursing process?

Accepted Answer

A)  Assessments are made to identify human responses to health problems. 
B)  Mutual goals are established and desired client outcomes are determined. 
C)  Planned nursing actions (interventions) are carried out. 
D)  Desired outcomes are evaluated and, if necessary, the plan is modified.

Question 2

Educating clients on their diabetic regimen of administering insulin is the implementation of which skill?

Accepted Answer

A)  Intrinsic 
B)  Technical 
C)  Interpersonal 
D)  Visual

Question 3

A registered nurse who provides care in a subacute setting is responsible for overseeing and delegating to unlicensed assistive personnel (UAP). Which of the following principles should the nurse follow when delegating to UAP? Select all that apply.

Accepted Answer

A)  Ensure that UAPs closely follow the nursing process when providing care. 
B)  Audit the client documentation that UAPs record after they perform interventions. 
C)  Take frequent mini-reports from UAPs to ensure changes in client status are identified. 
D)  Know what clinical cues the UAP should be alert for and why. 
E)  Make frequent walking rounds to assess clients.

Question 4

The researchers developing classifications for interventions are also committed to developing a classification of which of the following?

Accepted Answer

A)  Diagnoses 
B)  Outcomes 
C)  Goals 
D)  Data clusters

Question 5

The nurse is delegating to the unlicensed assistive personnel (UAP). What is the best instruction by the nurse?

Accepted Answer

A)  Notify me right away if the client's systolic blood pressure is 170 or greater. 
B)  Let me know if the client's blood pressure becomes elevated. 
C)  If the client's blood pressure falls outside normal limits, come get me. 
D)  I need to know if the client's blood pressure changes from his normal baseline.

Question 6

A nurse is preparing to insert an intravenous line and begin administering intravenous fluids. The client has visitors in the room. What should the nurse do?

Accepted Answer

A)  Ask the visitors to leave the room. 
B)  Ask the client if visitors should remain in the room. 
C)  Tell the client to ask the visitors to leave the room. 
D)  Wait until the visitors leave to begin the procedure.

Question 7

A nurse administers a medication for pain but forgets to document it in the client's medical record. Legally, what does this mean?

Accepted Answer

A)  Nothing, the nurse's honesty will not be questioned. 
B)  The nurse can add the documentation after the client goes home. 
C)  The physician will verify that the nurse carried out the order. 
D)  In the eyes of the law, if it is not documented, it was not done.

Question 8

A nurse on duty finds that a client is anxious about the results of laboratory testing. Which intervention by the nurse reflects a supportive intervention?

Accepted Answer

A)  Sitting with the client to encourage her to talk 
B)  Telling the laboratory technician to speed up the results 
C)  Calling the physician for an order for an anxiolytic 
D)  Educating the client about reducing risk factors

Question 9

What role of the nurse is crucial to the prevention of fragmentation of care?

Accepted Answer

A)  Advocate 
B)  Educator 
C)  Counselor 
D)  Coordinator

Question 10

A student is ambulating a client for the first time after surgery. What would the student do to anticipate and plan for an unexpected outcome?

Accepted Answer

A)  Take the client's vital signs after ambulation. 
B)  Ask the client's wife to assist with ambulation. 
C)  Delay ambulation until the following shift. 
D)  Ask another student to help with ambulation.

Question 11

The staff in a long-term care facility often plays loud rock music on the radio and designs children's games as exercise. What is the staff doing in this situation?

Accepted Answer

A)  Considering the hearing level of older adults 
B)  Failing to consider visual deficits that occur with aging 
C)  Ignoring the developmental needs of older adults 
D)  Meeting needs for sensory input and exercise

Question 12

The nursing student is caring for a Native American client who is admitted for deep vein thrombosis. The nursing student speaks with a nurse regarding the client's lack of eye contact with the student. The nurse responds that Native Americans view eye contact as an invasion of privacy. Which error did the nursing student make?

Accepted Answer

A)  Failure to act in partnership with the client. 
B)  Failure to approach the client caringly. 
C)  Failure to seek the client's input in the plan of care. 
D)  Failure to provide culturally sensitive care.

Question 13

What characteristic of a competent nurse practitioner enables nurses to be role models for clients?

Accepted Answer

A)  Sense of humor 
B)  Writing ability 
C)  Organizational skills 
D)  Good personal health

Question 14

The nurse is preparing to implement plans of care with several clients. Which action would be inappropriate for the nurse to perform?

Accepted Answer

A)  Ask the English-as-a-Second-Language (ESOL) client to state in his or her own words what it means to be NPO. 
B)  Seek input from the family of how the client with aphasia normally communicates at home. 
C)  Respond to the postoperative client's question that baths are given only in the morning. 
D)  Request that family members provide ethnic/cultural foods of the African client's liking.

Question 15

Which is a responsibility of the nurse in the nurse-client-family team relationship?

Accepted Answer

A)  Provide creative leadership to make the nursing unit a satisfying and challenging place to work. 
B)  Support the nursing care given by other nursing and non-nursing personnel. 
C)  Educate the family to be informed and assertive consumers of health care. 
D)  Coordinate the inputs of the multidisciplinary team into a comprehensive plan of care.

Exam 14: Implementing