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NR224 Exam 1- Critical Thinking, Nursing Process, Vital Signs, Infection Control Exam Questions and Answers
NR224 Exam 1- Critical Thinking, Nursing Process, Vital Signs, Infection Control Exam Questions and Answers
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NR224 EXAM 1|90 QUESTIONS AND ANSWERSWhile assessing a patient, the nurse observes the patient's IV line is not
infusing at the ordered rate. The nurse assesses the patient for pain at the IV
site, checks the flow regulator on the tubing, looks to see if the patient is
lying on the tubing, checks the point of connection between the tubing and
the IV catheter, and then checks the condition of the site where the IV
catheter enters the patient's skin. After the nurse readjusts the flow rate, the
infusion begins at the correct rate. This is an example of:
A. inference
B. Diagnostic reasoning
C. Competency
D. Problem solving - -D. Problem Solving
-The nurse sits down to talk with a patient who lost her sister 2 weeks ago.
The patient reports she is unable to sleep, feels very fatigued during the day,
and is having trouble at work. The nurse asks her to clarify the type of
trouble. The patient explains she can't concentrate or even solve simple
problems. The nurse records the results of the assessment, describing the
patient as having ineffective coping. This is an example of :
A. diagnostic reasoning
B. Competency
C. Inference
D. Problem Solving - -A. Diagnostic reasoning
-A patient on a surgical unit develops sudden shortness of breath and a drop
in BP. The staff respond, but the patient dies 30 minutes later. the manager
on the nursing unit calls the staff involved in the emergency response
together, The staff discusses what occurred over the 30 minute time frame,
the actions taken, and whether other steps should have been implemented.
The nurses in this situation are:
A. problem solving
B. showing humility
C. conducting reflective practice
D. Exercising responsibility - -C. Conducting reflective practice
-A nurse has worked on an oncology unit for 3 years. One patient has
become visibly weaker and states, "I feel funny". The nurse knows how
patients often have behavior changes before developing sepsis when they
have cancer. The nurse asks the patient questions to assess thinking skills
and notices the patient shivering. The nurse goes to the phone, calls the
physician, and begins the conversation by saying, "I believe that your patient
is developing sepsis. I want to report symptoms I'm seeing." What examples
of critical thinking concepts does the nurse show? (Select all that apply)
A. Experience
,B. Ethical
C. Analyticity
D. Self-confidence
E. Risk taking - -C. Analyticity
D. Self confidence
-A nurse who is working on a surgical unit is caring for four different
patients. Patient A will be discharged home and is in need of instruction
about wound care. Patients B and C have returned from the operating room
within an hour of each other, and both require vital signs and monitoring of
their intravenous (IV) lines.
Patient D is resting following a visit by physical therapy. Which of the
following activities by the nurse represent(s) use of clinical decision making
for groups of patients? (Select all that apply.)
A. consider how to involve patient A in deciding whether to involve the family
caregiver in wound care instruction
B. Think about past experience with patients who develop postoperative
complications
C. Decide which activities can be combined for patients B and C
D. Carefully gather any assessment info and identify patient problems - -A &
C
-The surgical unit has initiated the use of a pain-rating scale to assess
patients' pain severity during their postoperative recovery. The registered
nurse (RN) looks at the pain flow sheet to see the pain scores recorded for a
patient over the last 24 hours. Use of the pain scale is an example of which
intellectual standard?
A. deep
B. Relevant
C. Consistent
D. Significant - -C
-During a home health visit the nurse prepares to instruct a patient in how
to perform range-of-motion (ROM) exercises for an injured shoulder. The
nurse verifies that the patient took an analgesic 30 minutes before arrival at
the patient's home. After discussing the purpose for the exercises and
demonstrating each one, the nurse has the patient perform them. After two
attempts with only the second of three exercises, the patient stops and says,
"This hurts too much. I don't see why I have to do this so many times." The
nurse applies the critical thinking attitude of integrity in which of the
following actions?"
A. "I understand your reluctance, but the exercises are necessary for you to
regain function in your shoulder. Let's go a bit more slowly and try to relax"
, B. "I see that you're uncomfortable. I'll call your doctor to decide the next
step."
C. "Show me exactly where your pain is and rate it for me on a scale of 0 to
10."
D. "Is anything else bothering you? Other than the pain, is there any other
reason you might not want to do the exercises?" - -A
-The nurse cared for a 14-year-old with renal failure who died near the end
of the work shift. The health care team tried for 45 minutes to resuscitate the
child with no success. The family was devastated by the loss, and, when the
nurse tried to talk with them, the mother said, "You can't make me feel
better; you don't know what it's like to lose a child." Which of the following
examples of journal entries might best help the nurse reflect and think about
this clinical experience? (Select all that apply.)
A. Data entry of the time of day, who was present, and the condition or the
child
B. Description of the efforts to restore the child's BP, what was used, and
questions about the child's response
C. The meaning the experience had for the nurse with respect to her
understanding of dealing with the patient's death
D. A description of what the nurse said to the mother, the mother's response,
and how the nurse might approach the situation differently in the future - -B,
C, & D
-A nurse has been working on a surgical unit for 3 weeks. A patient requires
a Foley catheter to be inserted, so the nurse reads the procedure manual for
the institution to review how to insert it. The level of critical thinking the
nurse is using is:
A. Commitment
B. Scientific method
C. basic critical thinking
D. Complex critical thinking - -C
-A patient had hip surgery 16 hours ago. During the previous shift the
patient had 40 mL of drainage in the surgical drainage collection device for
an 8-hour period. The nurse refers to the written plan of care, noting that the
health care provider is to be notified when drainage in the device exceeds
100 mL for the day. On entering the room, the nurse looks at the device and
carefully notes the amount of drainage currently in it. This is an example of:
A. planning
B. evaluation
C. Intervention
D. Diagnosis - -B
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