NUR 115 Final Test Bank, Questions/answers/Rationales
Chapter 09: Nursing Process: Your Role
MULTIPLE CHOICE
1. A student nurse asks, If RNs use a five-step nursing process and LPN/LVNs use a four-step process, what phase is missing? The best response would be, The phase of the nursing process ...
NUR 115 Final Test Bank,
Questions/answers/Rationales Chapter 09: Nursing Process: Your Role
MULTIPLE CHOICE
1. A student nurse asks, If RNs use a five-step nursing process and LPN/LVNs use a four-step process, what phase is
missing? The best response would be, The phase of the nursing process that is the sole responsibility of the registered
nurse is
a.assessment.
b.nursing diagnosis.
c.planning.
d.implementation.
e.evaluation.
ANS: B
The LPN/LVN participates in all phases of the nursing process with the exception of establishing a nursing diagnosis.
2. The student nurse asks, How does knowing the nursing diagnosis assist the LPN/LVN? The best response is based on
understanding that
a.a nursing diagnosis identifies the patients problems.
b.it permits the practical nurse to go beyond the scope of practice.
c.this step makes the practical nurse equal to the medical doctor.
d.knowledge of the nursing diagnosis ensures a cure for the patient.
ANS: A
The LPN/LVN uses the nursing diagnosis to identify a patients problems.
3. Which of the following is the primary reason that LPN/LVNs are taught to use the nursing process?
a.To diagnose disease
b.To provide reimbursement
c.To resolve patient problems
d.To communicate with health team members
ANS: C
The nursing process provides a structure for nurses to identify and respond to patient needs within the scope of
nursing. Diagnosing disease is the domain of the physician. Reimbursement is not the primary purpose of the nursing
process. Communication facilitation is not the primary purpose of the nursing process.
4. During the assessment phase of the nursing process, the LPN/LVN is expected to
a.establish goals and outcome criteria.
b.collect data about the patient.
c.determine whether established goals have been met.
d.plan interventions to implement for the patient.
ANS: B
Data are collected as part of the assessment phase. This is the only option that relates to assessment.
5. The nursing care plan requires the nurse to ambulate the patient twice daily. The phase of the nursing process in
which the nurse is participating is
a.assessment.
b.planning.
c.implementation.
d.evaluation.
ANS: C
Carrying out the care plan is termed implementation. Assessment involves data collection. Planning involves creation
of the nursing care plan. Evaluation involves determining goal attainment.
6. An LPN/LVN demonstrates to a new mother how to safely bathe her infant. This is an example of the phase of the
nursing process called a.assessment.
b.nursing diagnosis.
c.planning.
d.implementation.
ANS: D
Initiating teaching that is within the role of the LPN/LVN and supporting teaching by the RN are examples of
implementation.
7. When the LPN/LVN participates in the evaluation phase of the nursing process, she or he compares the patients
responses with the
a.nursing orders.
b.outcome criteria.
c.nursing diagnosis.
d.database.
ANS: B
The process of determining outcome attainment involves comparing actual patient outcomes with desired patient
outcomes.
8. Which of the following are considered subjective data?
a.The patient tells the nurse that he has a headache.
b.The nursing assistant tells the nurse that the patient vomited.
c.The patients mother tells the nurse that the patient needs a ride to the clinic for follow-up.
d.The physician tells the nurse that the patient needs a chest x-ray.
ANS: A
Subjective data are based on the patients report or opinion. The only option representing a patients report or opinion
is the patient telling the nurse that he has a headache.
9. I feel like I cant catch my breath is an example of
a.effective data.
b.objective data.
c.subjective data.
d.evaluative data.
ANS: C
Subjective data are based on the patients report or opinion. Objective data are data the nurse can verify. Effective
data and evaluative data are not used as data classifications.
10. A blood pressure of 110/70 at 8 PM is most accurately described as an example of
a.planning data.
b.subjective data.
c.objective data.
d.reassessment data.
ANS: C
Objective data are sometimes called signs. Objective data can be verified. Subjective data are based on the patients
report. Planning data and reassessment data are not used as data classifications.
11. When a nurse uses Maslows hierarchy of needs to prioritize patient problems, which problem would be considered
the highest priority?
a.The patient is unsteady and may become injured.
b.The patient is experiencing marital difficulties.
c.The patient has deficient knowledge about the condition.
d.The patient is acutely short of breath.
ANS: D
The priority problem is one that is potentially life-threatening: shortness of breath. Physiologic or survival needs take
priority over higher level needs. The problems mentioned in the other options do not threaten survival. 12. Which of the following statements regarding short-term goals is accurate?
a.Short-term goals are broad rather than specific.
b.Short-term goals can be accomplished within days or hours.
c.Short-term goals must be accomplished while the patient is hospitalized.
d.Short-term goals are less realistic than long-term goals.
ANS: B
Short-term goals can usually be accomplished within hours or days, whereas long-term goals may take weeks.
13. The patients problem has been identified as insufficient intake of oral fluids. The best outcome statement is:
a.The patient will ingest 1500 ml of oral fluids during each 24-hour period.
b.The patient will request fluids when thirsty.
c.The nurse will encourage fluid intake by the patient.
d.The nurse will provide the patient with 100 ml of fluid hourly.
ANS: A
An outcome may be attained by stating the problem in positive terms. It is always a statement of what the patient will
do. Stating that the patient will request fluids when thirsty may not result in the desired intake. The remaining options
are nurse centered.
14. A student nurse asks, Whats the primary purpose of the evaluation phase of the nursing process? The best
response is to
a.establish a time frame for completion of goals.
b.determine whether the nurse completed all nursing interventions.
c.determine which nurses are eligible for raises or promotion.
d.compare actual patient outcomes with desired outcomes.
ANS: D
Data collection, with comparison of actual and desired patient outcomes, is the focus of the evaluation phase of the
nursing process. The response to establish a time frame for completion of goals is initially part of the planning phase.
Time frames for goal attainment may be revised during the evaluation phase, but this is not the primary purpose of
evaluation. In the remaining options, evaluation is patient centered.
15. How does the LPN/LVN use nursing diagnosis in patient care?
a.To set patient-centered goals
b.To convert nursing diagnoses to patient problems
c.To implement independent nursing interventions
d.To justify participation in data collection
ANS: B
The LPN/LVN uses the nursing diagnosis as the reference point for identifying patient problems that require
intervention. The nursing diagnosis is not required by the LPN/LVN to set goals and outcomes, implement nursing
interventions, or participate in data collection.
16. The phases of the nursing process in which the LPN/LVN participates with the greatest degree of independence are
a.goal setting and evaluation.
b.planning and implementation.
c.data collection and implementation.
d.evaluation and data collection.
ANS: C
The LPN/LVN curriculum trains graduates to collect data and implement a variety of nursing interventions, making a
high degree of independence possible in these areas. Goal setting, evaluation, and planning all require a greater
degree of interdependence with the RN.
17. The RN head nurse is having a busy day. When the LPN/LVN reports data she has collected, the RN states,
Incorporate that into the nursing care plan and write down the intervention youd use. Ill co-sign the entry. The
LPN/LVN should
a.do as requested.
b.ask the advice of the shift supervisor later in the shift.
c.tell the RN that this action is not within the LPN/LVN scope of practice. d.write a letter to the state board of nursing to report the RNs unprofessional conduct.
ANS: C
The RN is responsible for determining the nursing care plan. The LPN/LVN collects data that the RN may use to modify
the plan, but the LPN/LVN may not independently modify the plan. If the LPN/LVN functions outside the identified
scope of practice, he or she would be breaking the law. The remaining options do not directly address the problem at
the time it occurs.
18. The LPN/LVN learns at report that a patients priority problems are pain and inability to ambulate associated with
arthritis. During the patients bath, he becomes short of breath. The LPN/LVN should implement interventions based on
a.the priorities given at the report.
b.the patients identified strengths.
c.the patients changing status.
d.information obtained from the Nursing Outcomes Classification (NOC) project.
ANS: C
Status changes are a priority. Priorities may change rapidly, depending on the patients condition. This change
challenges survival and assumes priority over the other identified problems.
19. Identify the outcome that would be appropriate to include in the nursing care plan of a patient who has undergone
total knee replacement.
a.The patient will be stronger by (date).
b.The patient will transfer from the bed to a chair with the assistance of a walker and one staff
member by the third postoperative day.
c.The nurse will help the patient ambulate the length of the hall twice daily.
d.The nurse will evaluate the patients strength based on his ability to ambulate in the hall on the
first postoperative day.
ANS: B
The patient will transfer from the bed to a chair with the assistance of a walker and one staff member by the third
postoperative day contains the elements necessary for a well-written outcome. It is patient centered, realistic,
measurable, and time referenced. The patient will be stronger by (date) is not measurable. The remaining options are
nurse centered.
20. A nurse expresses difficulty deciding which nursing interventions to suggest for a patient with arthritic pain during
an upcoming patient-centered conference. A peer suggests referring to the Nursing Interventions Classification (NIC)
taxonomy. This would provide the nurse with information on
a.how to provide basic care to patients.
b.identification of nursing measures to help patients progress toward goals.
c.a language for measuring patients response to nursing interventions.
d.how to translate nursing diagnoses into nursing problems.
ANS: B
NIC standardizes, defines, and assists nurses in choosing the appropriate nursing interventions. It includes physical
and psychosocial interventions, health promotion, illness treatment, and independent and collaborative interventions.
NIC is not a basic text. NIC does not provide a measurement language. NIC does not give information about translating
nursing diagnoses into nursing problems.
21. The patients nursing diagnosis is pain associated with walking related to knee injury. The LPN/LVN should
accurately identify the patient problem as
a.arthritis.
b.unwillingness to exercise.
c.need for knee brace.
d.knee pain.
ANS: D
Knee pain is the best translation given for the nursing diagnosis. Arthritis is a medical diagnosis. Unwillingness to
exercise assumes information not given in the scenario. Need for a knee brace prescribes a treatment.
22. A beginning nurse asks an experienced nurse, When should I focus on data collection? Which statement provides
the best description for when a nurse should collect patient-centered data?
a.After report when coming on duty
b.Within 1 hour of reporting off duty
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