PNC EXAM 2
The nursing process is based upon the process of problem solving. The nurse attempts
to obtain a blood pressure on the client's right arm, then on the left arm, then on the left
leg, and finally on the right leg, where the blood pressure is obtained. What type of
problem solving did the nurse use? - answer Trial-and-error problem solving
A hospital client has an aggressive fungal infection in the right eye that necessitates
evisceration (removal of the eye). Consequently, the client requires twice-daily packing
and dressing changes to the orbit. Which of the nurse's actions in the care of this client
most clearly demonstrates interpersonal skills? - answer Ensuring the client's privacy
during dressing changes and providing an explanation during the procedure
The plan of care for a client with diabetes mellitus includes daily assessment of lab
values. When assessed, these lab values are outside of the recommended range. The
nurse collaborates with the health care provider and the client to change medications
included in the plan of care. What characteristic of the nursing process does this
illustrate? - answerSystematic
The nurse is caring for a client who presents with polydipsia, polyphagia, and polyuria.
The client's laboratory test results reveal an increased HgbA1C level, which could
indicate increased blood glucose levels. What is the next step for the nurse to take
based on the nursing process? - answerAnalyze the data and create an individualized
nursing diagnosis.
A nurse has developed a plan of care for an adult client. What nursing function is
important when using nursing diagnoses to guide the care of this client? -
answerPrioritize the nursing diagnoses.
The nurse is developing a plan of care for a client with a fractured femur who is in
traction and will be restricted to bed for some time. Which domain should the nurse
consider when developing a nursing diagnosis based on this client's musculoskeletal
health problems? - answerActivity and rest
Which statements are true about the implementation phase of the nursing process?
Select all that apply. - answerCare provided during implementation should be
documented in the client's chart.
Implementation is the process of carrying out the plan of care.
This phase promotes wellness and restores health.
A client is newly diagnosed with diabetes and prescribed insulin injections. The nurse
identifies the client's knowledge deficiency regarding insulin injection. Which
, intervention is appropriate to address this deficiency? - answerTeach the client how to
administer insulin.
Research has demonstrated that a common source of hospital-acquired infections in
clients with intravenous (IV) infusions is the hub on the IV tubing. Which nursing
practice competency is displayed when health care institutions recommend that health
care providers always wash hands and wear gloves when accessing the hubs of IV
tubing? - answerEvidence-based practice
The ability to communicate clearly through documentation is a critical nursing skill.
Which statements accurately describe the role of documenting in the nursing process?
Select all that apply. - answerIt is helpful to practice documentation while learning any
given nursing activity.
A nursing action not documented is a nursing action not performed.
The content of the client report and nursing documentation helps to establish nursing
priorities in practice.
The client record is the chief means of communication among members of the
interdisciplinary team.
A nurse is reading a journal article about providing individualized care. Which aspect
would the nurse most likely read about as the almost universally accepted method for
providing nursing care? - answerNursing Process
A nurse has completed a client assessment and is preparing to identify appropriate
nursing diagnoses. Which areas would the nurse likely address in the diagnosis? Select
all that apply. - answerImpaired mobility
Imbalanced nutrition
Ineffective coping
Put the phases of the nursing process in the correct order. Use all options. -
answerassessment
diagnosis
planning
implementation
evaluation
A client, who has limited finances and limited capacity for education, requires home
health care for a chronic illness. For the nurse to provide a high level of care to this
client, the nurse must first: - answerimplement critical thinking skills.
Which term refers to a purposeful activity that leads to action, improvement of practice,
and better client outcomes? - answerReflection
A nurse administers intravenous fluids to a client diagnosed with dehydration. After the
fluids are completed, the client's blood pressure is increased and pulse is decreased.
The nursing process is based upon the process of problem solving. The nurse attempts
to obtain a blood pressure on the client's right arm, then on the left arm, then on the left
leg, and finally on the right leg, where the blood pressure is obtained. What type of
problem solving did the nurse use? - answer Trial-and-error problem solving
A hospital client has an aggressive fungal infection in the right eye that necessitates
evisceration (removal of the eye). Consequently, the client requires twice-daily packing
and dressing changes to the orbit. Which of the nurse's actions in the care of this client
most clearly demonstrates interpersonal skills? - answer Ensuring the client's privacy
during dressing changes and providing an explanation during the procedure
The plan of care for a client with diabetes mellitus includes daily assessment of lab
values. When assessed, these lab values are outside of the recommended range. The
nurse collaborates with the health care provider and the client to change medications
included in the plan of care. What characteristic of the nursing process does this
illustrate? - answerSystematic
The nurse is caring for a client who presents with polydipsia, polyphagia, and polyuria.
The client's laboratory test results reveal an increased HgbA1C level, which could
indicate increased blood glucose levels. What is the next step for the nurse to take
based on the nursing process? - answerAnalyze the data and create an individualized
nursing diagnosis.
A nurse has developed a plan of care for an adult client. What nursing function is
important when using nursing diagnoses to guide the care of this client? -
answerPrioritize the nursing diagnoses.
The nurse is developing a plan of care for a client with a fractured femur who is in
traction and will be restricted to bed for some time. Which domain should the nurse
consider when developing a nursing diagnosis based on this client's musculoskeletal
health problems? - answerActivity and rest
Which statements are true about the implementation phase of the nursing process?
Select all that apply. - answerCare provided during implementation should be
documented in the client's chart.
Implementation is the process of carrying out the plan of care.
This phase promotes wellness and restores health.
A client is newly diagnosed with diabetes and prescribed insulin injections. The nurse
identifies the client's knowledge deficiency regarding insulin injection. Which
, intervention is appropriate to address this deficiency? - answerTeach the client how to
administer insulin.
Research has demonstrated that a common source of hospital-acquired infections in
clients with intravenous (IV) infusions is the hub on the IV tubing. Which nursing
practice competency is displayed when health care institutions recommend that health
care providers always wash hands and wear gloves when accessing the hubs of IV
tubing? - answerEvidence-based practice
The ability to communicate clearly through documentation is a critical nursing skill.
Which statements accurately describe the role of documenting in the nursing process?
Select all that apply. - answerIt is helpful to practice documentation while learning any
given nursing activity.
A nursing action not documented is a nursing action not performed.
The content of the client report and nursing documentation helps to establish nursing
priorities in practice.
The client record is the chief means of communication among members of the
interdisciplinary team.
A nurse is reading a journal article about providing individualized care. Which aspect
would the nurse most likely read about as the almost universally accepted method for
providing nursing care? - answerNursing Process
A nurse has completed a client assessment and is preparing to identify appropriate
nursing diagnoses. Which areas would the nurse likely address in the diagnosis? Select
all that apply. - answerImpaired mobility
Imbalanced nutrition
Ineffective coping
Put the phases of the nursing process in the correct order. Use all options. -
answerassessment
diagnosis
planning
implementation
evaluation
A client, who has limited finances and limited capacity for education, requires home
health care for a chronic illness. For the nurse to provide a high level of care to this
client, the nurse must first: - answerimplement critical thinking skills.
Which term refers to a purposeful activity that leads to action, improvement of practice,
and better client outcomes? - answerReflection
A nurse administers intravenous fluids to a client diagnosed with dehydration. After the
fluids are completed, the client's blood pressure is increased and pulse is decreased.
