Nursing Fundamentals CCHS Test 1 questions and Answers Latest Update Fully Solved 100%
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Course
Nursing Fundamentals CCHS
Institution
Nursing Fundamentals CCHS
Which word is most closely related with scientific principles? - Rationale (justification based on
reasoning)
When 2 nursing diagnoses that appear closely related, which should the nurse do first? - Compare
major and minor data to defining characteristics?
A nurse concludes that a pt's elevated...
Nursing Fundamentals CCHS Test 1
Which word is most closely related with scientific principles? - Rationale (justification based on
reasoning)
When 2 nursing diagnoses that appear closely related, which should the nurse do first? - Compare
major and minor data to defining characteristics?
A nurse concludes that a pt's elevated pulse and temp, and RR are significant. Which step of the nursing
process is being used when she comes to this conclusion? - Analysis
A nurse evaluates a pt's response to a nursing intervention. To which aspect of the nursing process is this
evaluation most directly related? - Goal (compare pt outcome with expected pt outcome)
A nurse in the ED is engaging in an initial assessment of pt. - Airway clearance, breathing pattern,
circulatory status?
Airway clearance<-
A nurse is assessing a pt's HR by assessing the carotid. - Press gently (light palpation)
A nurse is caring for a pt who is experiencing an increase in S/S associated with MS. Which term
describes a recurrence with the disease? - Exacercerbate
A nurse is caring for a pt with a urinary incontinence problem. Which are accurately stated goals?
Select all that apply. - -The pt will transfer independently and safely before DC.
-Pt will experience 1 or less events of urinary incontinence daily within 6 weeks.
(both apply) ***look for timeframe, and something measurable. Safely, Independently...etc.
A nurse is identifying a pt. Which statements are objective? - Ate half my lunch
, Rash on my arm
Vomit every time I eat
---pt stating they have the urge to urinate is subjective. However, a pain rating is OBJECTIVE.
A nurse is monitoring the status of a post op pt. Which vital sign will change first when a pt has internal
bleeding? - HR (aortic arch will detect a drop in MAP)
A nurse is performing a psychological exam. Which assessment should be identified as a subtle cue for
depression? - unkempt appearance
A nurse is planning care for a pt who has an intolerance to an activity. - pattern of vital signs
(related to inability to maintain adequate O2 to cells)
A nurse is unable to palpate a pt's brachial pulse. Which pulse should the nurse palpate to ensure
adequate brachial blood flow? - Radial
A nurse must assess for the presence of bowel sounds in a post-op pt? Which technique should the
nurse employ to obtain accurate results when auscultating each quadrant? - Bowel sounds are
auscultated before percussion and palpation
A nurse must take a rectal temp. What should the nurse do? - Wear gloves throughout the
procedure
A nurse obtains the BP of several adults. Which BP result should cause the most concern? -
140/90
A nurse teaches a pt to use visualization to cope with chronic pain. Which step of the nursing process is
associated with this nursing intervention? - Implementation
A pt has had a fever of 101 for the last 24 hours, how often should the nurse monitor this pt? - 4
hours
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