NURS 224 Test #1 Questions With Complete Solutions
A cardiac specialty hospital has several written plans in place for
clients who are admitted, according to specific medical
diagnoses and nursing interventions. Typical nursing diagnoses
as well as standard nursing interventions are included in these
plans. Which type of form is this hospital utilizing?
a. Standardized care plans
b. Traditional care plans
c. Critical pathways
d. Kardex Correct Answer Standardized care plans
A client comes to the clinic seeking information and education
regarding healthy lifestyles and eating habits. Which type of
diagnosis should the nurse select for this client?
a. Risk nursing diagnosis
b. Syndrome diagnosis
c. Wellness diagnosis
d. Actual diagnosis Correct Answer Wellness diagnosis
A client grimaces and responds "I'm fine" when asked by the
nurse to describe a level of pain. Which communication factor is
the client struggling with?
a. Territoriality
b. Environment
c. Congruence
d. Attitude Correct Answer Congruence
A client has been having pain without any clear pathology for
cause. Which nursing diagnosis should the nurse identify as
being the most appropriate for this client?
,a. Pain due to unknown factors
b. Pain related to unknown etiology
c. Pain caused by psychosomatic condition
d. Pain manifested by client's report Correct Answer Pain
related to unknown etiology
A client has the goal statement "Client will have clear lung
sounds bilaterally within 3 days." One intervention to meet this
goal is for the nurse to teach the client to cough and deep-
breathe and have the client do this several times every 2 hours.
At the end of the third day, the client's lungs are indeed clear.
What should the nurse do to relate the intervention to the
outcome?
a. Ask how many times per day the client practiced the coughing
and deep-breathing exercises.
b. Tell the client that the lungs are clear.
c. Document the assessment findings to show the effectiveness
of the intervention.
d. Write this evaluation statement: Goal met, lung sounds clear
by third day. Correct Answer Ask how many times per day the
client practiced the coughing and deep-breathing exercises
A client is admitted to a comprehensive rehabilitation center for
continuing care following a motor vehicle crash. The admitting
nurse will develop the initial plan of care, but who will be
involved with the ongoing planning of this client's care?
a. The admitting nurse
b. All nurses who work with the client
c. Everybody involved in this client's care
d. The client and the client's support system Correct Answer
Everybody involved in this client's care
, A client is experiencing a productive cough, audible coarse
crackles, elevated temperature of 102.3°F, chills, and body
aches. What did the nurse use to determine that this patient is
experiencing respiratory compromise?
a. Deductive reasoning
b. Inductive reasoning
c. Socratic questioning
d. Critical analysis Correct Answer Deductive reasoning
A client is prescribed a medication that the nurse has never
administered and information about the medication is not in the
drug reference manual. What should the nurse do?
a. Follow the physician's orders as written and give the
medication.
b. Call the pharmacy and do further investigating before
administering the medication.
c. Ask the client about this medication.
d. Call the physician and ask what the medication is and what it
is for. Correct Answer Call the pharmacy and do further
investigating before administering the medication
A client is prescribed to be out of bed three times a day. In
which way should the nurse document this activity level?
a. OOB tid
b. OOB 3 x /day
c. Out of bed T.I.D.
d. OOB three times a day Correct Answer OOB tid
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