Exam 1: Foundations
1. A nurse is caring for a client who has hyperglycemia, diagnosed w/ diabetes mellitus, which of
these should the nurse include in the education plan for this client?
Prioritize realistic goals that are essential for the clients welfare.
2. When assessing a client readiness for education, which of these should a nurse do first?
What info. has been provided about the clients health problem.
3. A nurse is developing a teaching plan for clients. The following teaching goal is developed.
The client will select a 2000 mg Na diet from the hospital menu daily for 3 days w/ 90%
accuracy. Which of these actions should the nurse use to evaluate if this goal has been met?
A nurse notes the foods selected on 3 daily menus and determines whether the
daily Na content was within 1800 - 2200 mg.
4. A nurse is evaluating a clients' readiness to learn which of these clients statements indicates the
need for the nurse to postpone teaching?
"There's no sense in showing me, I'm too sick right now."
5. A nurse is evaluating the responses of client to teaching sessions. Which of these is an example
of an evaluation of a psychomotor skill?
The client would use the cane correctly.
6. A nurse is evaluating the responses to clients teaching sessions, which of these is an example of
an evaluation of a client of a cognitive skill?
Explain that medication should be taken w/ meals.
7. A health provider calls the leading nurse for a client assigned to a nursing student. The best
response by the nursing student at this time would be:
Let me get the RN to care for the client.
8. A nurse is collaborating with a physical therapist in developing plan of care for a client w/ a
fractured hip. While explaining the nursing process to the therapist, the nurse realizes that it
would be better understood if each step were listed. Which of these identify each step in
sequential order.
Assessment, Nursing diagnosis, outcome identification, Planning,
implementation and evaluation.
9. A nurse understands that the nursing process is used on a pair of clients primarily as:
A tool to organize nurses thinking and clinical decision making about the client
health care needs.
10. A nurse begins to ascultate the clients' lungs and notices fresh blood drainage oozing from the
abdominal dressing. The nurse stops ascultating and applies direct pressure to the wound. This
action is an example of:
Critically analyzing the data and implementing the safest nursing action.
11. When assessing a client, a nurse obtains important info. for planning the nursing care. Which
of these client needs should take priority?
Difficulty breathing.
12. Which of these nursing interventions is an example of a nurse-initiated intervention?
Providing client teaching
13. A nurse is caring for a mobile client w/ a urinary elimination problem. Which of the following
is the most appropriate outcome for this client?
The client will independently transfer to the commode prior to discharge.
14. The clients status has changed significantly over the past few days and a nurse recognizes the
need to update the plan of care. When modifying a care plan to meet the clients changing needs,
the nurse should:
Perform a complete reassessment of all client factors.
15. Which of these is the most appropriate for nonjudgmental nursing documentation for a client
admitted to the hospital.
, The client does not recognize family members.
16. A nurse is documenting objective client assessment data. Which of these demonstrates that the
nurse understands objective client nursing data?
The client expresses pain of an 8 out of a 10 with diaphoretic, guarding the
abdomen and clenching fists.
17. Which of these nurse statements regarding the release of a clients medical records to an
institution requires immediate follow-up by the nurse manager?
"Are you sure of the exact policy, do you know what I should do?"
18. A clinical manager is reviewing the charting of a nurse orientee, the clinical manger
determines that the documentation is appropiate when the orientee:
Dates and signs all the entries in the record
19. Which of this statements, if made by a nurse most reflects the need for additional instruction
regarding proper nursing documentation?
I provided a detail description of the steps of the dressing change on the clients
chart in order to show that it was done as prescribed.
20. A nurse has documented an entry regarding client care in the client medical record. While
checking the entry the nurse realizes that the incorrect info. was documented, which action should
the nurse take at this time?
Draw a second line, cross out the incorrect entry and initial the change.
21. A nursing manager is reviewing nursing documentation on the unit. Which of these statements
written in the client record show the nurse manager evaluation as a illegally appropriate notation?
Verbalized shock stabbing pain along the left side of the chest.
22. A nurse discharges 5 clients that have been scored during a 12 hour shift. A nurse decides to
complete the documentation on the last admission when he/she returns to work tomorrow. The
nurses’ decision to postpone the documentation on the last admission has:
Legal implications
23. When caring for a client which of these actions should a nurse take to establish a therapeutic
relationship?
Knock before entering the clients' room.
24. When interviewing a client the best way for a nurse to demonstrate active listening is?
To sit facing the client.
25. When caring for a client which of these statements made by a nurse best invades empathy?
"I can imagine your concern about learning how to inject yourself."
26. A nurse walks into a male clients room, & sees the client holding his abdomen and grimacing.
The nurse states “YOU LOOK LIKE YOU ARE IN PAIN” the nurses statement is?
Appropriate because it states what the nurse is observing.
27. A client with liver cirrhosis secondary to alcohol abuse, states " I really don't believe that
drinking a couple of beers a day has anything to do with my liver problem." The best response
would be:
"You find it hard to believe that beer can damage your liver?"
28. When caring for a client with chronic pain, a nurse uses active listening. The nurse
understands that active listening:
Means the nurse focuses primarily on the words of the speaker.
29. A client tells the nurse "I do not read well." In developing a teaching plan for the client. This
information guides the nurse in determining:
∙ What instructional strategy should be used when teaching this client.
30. A nurse has completed an assessment of a client and identifies these nursing diagnoses. Which
of these nursing diagnoses, indicates a need to postpone the teaching that was planned?
Activity intolerance r/t pain.
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