NursingProcess:EvaluationMSC: NCLEX: Safe and Effective Care Environment
b z z
b z
b io bz bz b z bz bz bz bz bz
4. A patient admitted to the hospital for surgery tells the nurse, ―I do not feel
bz bz bz bz bz bz bz bz bz bz bz bz bz bz
comfortableleaving my children with my parents.‖ Which action would the nursetake
bz bz bz bz bz bz bz bz bz bz bz bz
next?
bz
a. Reassurethepatient that thesefeelings arecommon forparents. z
b bz bz bz bz bz bz bz
b. Havethe patient call the children to ensure that theyaredoingwell.
z
b bz bz bz bz bz bz bz bz bz bz
c. Gatherinformation onthepatient‗s concerns about thechildcarearrangements. bz bz z
b bz bz bz bz
d. Callthepatient‗s parents todeterminewhetheradequatechild
z
b z
b bz bz z
b bz bz bz
careisbeingprovided.
bz z
b io
ANS: C b z
Because a complete assessment is necessary in order to identify a problem and choose an
bz bz bz bz bz bz bz bz bz bz bz bz bz bz
appropriate intervention, the nurse‗s first action should be to obtain more information.
bz bz bz bz bz bz bz bz bz bz bz bz
Theother actions maybe appropriate, but more assessment is needed before the best
bz bz bz bz bz bz bz bz bz bz bz bz bz
interventioncan be chosen.
bz io bz bz
DIF: CognitiveLevel:Analyze(Analysis) z
b z
b z
b
TOP: NursingProcess: Assessment z
b bz MSC: NCLEX:PsychosocialIntegrity b z bz bz
5. Apatient withabacterial infectionishypovolemic duetoafever and
bz bz z
b bz bz bz bz bz bz bz bz bz
excessivediaphoresis.Which expected outcome would the nurse select for this
bz z
b bz bz bz bz bz bz bz bz
patient?
bz
a. Patienthasabalanced intakeand output. z
b bz bz z
b bz
b. Patient‗sbeddingiskeptclean andfreeofmoisture. bz bz z
b bz bz bz
c. Patient understands theneed forincreased fluidintake. bz bz z
b bz bz bz
d. Patient‗s skin remains cool and dry throughout hospitalization. bz b z b z b z b z bz b z
ANS: A b z
Balanced intake and output gives measurable data showingresolution of the problem
bz bz bz bz bz bz bz bz bz bz
ofdeficient fluid volume. The other statements would not indicate that the problem
bz bz bz bz bz bz bz bz bz bz bz bz
ofhypovolemia was resolved.
bz bz bz bz
DIF: Cognitive Level: Apply(Application) bz bz z
b TOP: Nursing Process: bz bzbz io
PlanningMSC: NCLEX: Physiological Integrity
bz io bz bz b z bz bz
6. Whichstatement describes the purposeoftheevaluation phase ofthe nursingprocess?
z
b bz bz bz bz bz bz bz bz bz bz bz
a. Todocument the nursing careplan in theprogress notes of thehealth record
z
b bz bz bz bz bz bz bz bz bz bz bz bz
b. Todetermineifinterventions havebeen effective in meetingpatient outcomes
z
b bz z
b bz bz bz bz bz bz
c. Todecidewhetherthepatient‗s healthproblems havebeen completelyresolved
z
b z
b z
b bz bz bz bz bz bz
d. Toestablish if thepatient agrees that thenursingcareprovided was satisfactory
z
b bz bz z
b bz bz bz bz bz bz bz bz
ANS: B b z
?
, Evaluation consists of determining whether the desired patient outcomes haveb z b z b z b z b z b z b z b z b z
been met and whether the nursing interventions were appropriate. The other responses do
b z b z z
b bz bz bz bz bz bz bz bz bz bz
not describe theevaluation phase.
b z bz bz bz
DIF: Cognitive Level: Understand (Comprehension)
bz bz bz bz b z TOP: bz bz bz Nursing
Process:EvaluationMSC: NCLEX: Safe and Effective Care Environment
bz z
b b z bz bz bz bz bz
7. Whichstatement describes the purposeoftheassessment phaseofthenursingprocess?
z
b bz bz bz bz bz bz bz bz bz bz bz
a. Toteachinterventionsthatrelievehealthproblems
z
b bz bz z
b bz bz
b. To usepatient data to evaluatepatient careoutcomes
bz z
b bz bz bz bz bz bz
c. Toobtaindatatodiagnosepatient strengths and problems
z
b z
b z
b z
b z
b bz bz bz
d. Tohelp thepatient identifyrealisticoutcomes for healthproblems
z
b bz z
b bz bz bz bz bz
ANS: C b z
During theassessment phase,the nurse gathers information about thepatient to diagnosepatient
io z
b bz bz bz bz bz bz bz bz bz bz
strengths and problems. The other responses are examples of the planning,intervention, and
bz bz bz bz bz bz bz bz bz bz bz bz bz
evaluation phases of the nursing process.
bz bz bz bz bz bz
DIF: CognitiveLevel:Understand(Comprehension) z
b bz bz
TOP: NursingProcess: Assessment MSC: NCLEX:SafeandEffective CareEnvironment z
b bz b z bz bz bz bz bz
8. Whendevelopingthe plan ofcare, which components would thenurseincludein
z
b z
b bz bz bz bz bz bz bz bz bz bz
theclinicalproblem statement?
bz bz bz
a. Theproblem and thesuggested patient goals oroutcomes bz bz z
b bz bz bz bz
b. Theproblem,its causes, andthesigns and symptoms oftheproblem
z
b bz bz bz z
b bz bz bz bz bz bz
c. Theproblem with thepossible etiologyand theplanned interventions
z
b bz bz bz bz bz bz bz
d. Theproblem, itspathophysiology, and theexpected outcome bz bz bz bz bz bz
ANS: B b z
When writing clinical problems or nursing diagnoses, the subjective as well as objective data to
bz bz bz bz bz bz bz bz bz bz bz bz bz bz
support the problem‗s existence should be included. Goals, outcomes, and interventions
bz bz bz bz bz bz bz bz bz bz bz
arenot included in the problem statement.
bz bz bz bz bz bz
DIF: Cognitive Level: Understand (Comprehension) TOP: Nursing Process: bz bz bz bz b z io
DiagnosisMSC: NCLEX: Safe and Effective Care Environment
bz io bz bz b z bz bz bz bz bz
9. Whichpatient caretask would the nursedelegate to experienced assistive personnel (AP)?
z
b bz z
b bz bz bz bz bz bz bz bz bz
a. Instruct the patient about the need to alternate activityand rest. bz bz bz bz bz bz bz bz bz
b. Monitorlevel ofshortness ofbreath orfatigue after ambulation. z
b bz bz bz z
b bz bz bz bz
c. Obtainthepatient‗sbloodpressureandpulserate afterambulation. z
b z
b bz bz bz bz bz
d. Determinewhetherthe patient is readyto increase the activitylevel. z
b bz bz bz bz bz bz bz
ANS: C b z
AP education includes accurate vital sign measurement. Assessment and patient
bz bz bz bz bz bz bz bz bz
teachingrequire registered nurse education and scopeof practice and cannot be delegated.
bz bz bz bz bz bz bz bz bz bz bz bz
DIF: Cognitive Level: Apply(Application) TOP: Nursing Process: bz bz z
b bz bzbz io
PlanningMSC: NCLEX: Safe and Effective Care Environment
bz io bz bz b z bz bz bz bz bz
?
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