Nursing 251 - Nursing Process Review Questions and Correct Answers
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Course
Nurs 251
Institution
Nurs 251
What occurs in the planning phase of the nursing process?
A. Perform actions to meet goals B. Determine if goals are met C. Gather information D. Set goals of care and identify nursing actions D. Set goals of care and identify nursing actions
By the second postoperative day, a client has not achi...
Nursing 251 - Nursing Process Review
Questions and Correct Answers
What occurs in the planning phase of the nursing process?
A. Perform actions to meet goals
B. Determine if goals are met
C. Gather information
D. Set goals of care and identify nursing actions ✅D. Set goals of care and identify
nursing actions
By the second postoperative day, a client has not achieved satisfactory pain relief.
Based on this evaluation, which of the following actions should the nurse take,
according to the nursing process?
A. Reassess the client to determine the reasons for inadequate pain relief.
B. Wait to see whether the pain lessens during the next 24 hours.
C. Change the plan of care to provide different pain relief intervention
D. Teach the client about the plan of care for managing his pain ✅A. Reassess the
client to determine the reasons for inadequate pain relief.
A newly licensed nurse is reporting to the charge nurse about the care she gave to a
client. She states, "The client said his leg pain was back, so I checked his medical
record, and he last received his pain medication 6 hours ago. The prescription reads
every 4 hours PRN for pain, so I decided he needs it. I asked the unit nurse to observe
me preparing and administering it. I checked with the client 40 minutes later, and he
said his pain is going away" The charge nurse should inform the newly licensed nurse
that she left out which of the following steps of the nursing process?
A. Assessment
B. Planning
C. Intervention
D. Evaluation ✅A. Assessment
A charge nurse is reviewing the steps of the nursing process with a group of nurses.
Which of the following data should the charge nurse identify as objective data? (select
all that apply)
A. Respiratory rate is 22/min with eve, unlabored respirations
B. The client's partner states, "He said he hurts after about 10 minutes."
C. Pain rating is 3 on a scale of 0 to 10
D. Skin is warm, pink, and dry
E. The assistive personnel reports the client walked with a limp ✅A. Respiratory rate is
22/min with eve, unlabored respirations
D. Skin is warm, pink, and dry
E. The assistive personnel reports the client walked with a limp
,A nurse is discussing the nursing process with a newly hired nurse. Which of the
following statements by the newly hired nurse should the nurse identify as appropriate
for the planning step of the nursing process?
A. "I will determine the most important client problems that we should address."
B. "I will review the past medical history on the client's record to get more information."
C. "I will go carry out the new prescriptions from the provider."
D. "I will ask the client if his nausea has resolved." ✅A. "I will determine the most
important client problems that we should address."
A nurse completes the following steps during her shift of care, which are the steps of
nursing assessments? (select all that apply)
A. The review of patient data in the medical record
B. Confirming a patient's self-reported abdominal pain by inspecting the abdomen
C. Reporting results of an ongoing assessment to a nurse working the next scheduled
shift
D. Analyzing a set of signs revealing lower leg weakness and unsteady gait with a
pattern of mobility alteration
E. Conducting an interview of a family caregiver ✅A. The review of patient data in the
medical record
B. Confirming a patient's self-reported abdominal pain by inspecting the abdomen
D. Analyzing a set of signs revealing lower leg weakness and unsteady gait with a
pattern of mobility alteration
E. Conducting an interview of a family caregiver
Match the assessment activity on the left with the type of assessment on the right. A.
Problem focused OR B. Comprehensive
1. Assessment conducted at beginning of a nurse's shift
2. Review of a patient's chief complaint
3. Completion of admitting history at time of patient admission to a hospital
4. Completion of the Long Term Care Minimum Data Set during an elderly patient
admission to a nursing home ✅A. Problem Focused
1. Assessment conducted at beginning of a nurse's shift
2. Review of a patient's chief complaint
B. Comprehensive
3. Completion of admitting history at time of patient admission to a hospital
4. Completion of the Long Term Care Minimum Data Set during an elderly patient
admission to a nursing home
A nurse initiates a brief interview with a patient who has come to the medical clinic
because of self-reported hoarseness, sore throat, and chest congestion. The nurse
observes that the patient has a slumped posture and is using intercostal muscles to
breathe. The nurse auscultates the patient's lungs and hears crackles in the left lower
lobe. The patient's respiratory rate is 20 per minute compared with an average of 16 per
minute during previous clinic visits. The patient tells the nurse, "It is hard for me to get a
, breath." Which of the following data sets are examples of subjective data? (Select all
that apply.)
1. Heart rate of 20 per minute and chest congestion
2. Lung sounds revealing crackles and use of intercostal muscles to breathe
3. Patient statement, "It's hard for me to get a breath"
4. Slumped posture and previous respiratory rate of 16 per minute
5. Patient report of sore throat and hoarseness ✅3. Patient statement, "It's hard for me
to get a breath"
5. Patient report of sore throat and hoarseness
The nurse asks a patient the following series of questions: "Describe for me how much
you exercise each day." "How do you tolerate the exercise?" "Is the amount of exercise
you get each day the same, less, or more than what you did a year ago?" This series of
questions would likely occur during which phase of a patient-centered interview?
1. Orientation
2. Working phase
3. Data interpretation
4. Termination ✅2. Working Phase
A young male patient enters the emergency department with fever and signs of a
possible sexually transmitted infection. The nurse enters the patient's cubicle and
begins to enter a history on the computer screen. Before beginning the nurse introduces
himself and tells the patient all information will be held confidentially. The nurse starts
data collection by establishing eye contact with the patient and then looks at the
computer prompts to select a series of questions. As the nurse fills out questions on the
computer, the patient asks a question about his treatment. The nurse states, "Let me
get through these questions first." Which action interferes with the nurse's ability to use
connection as a communication skill.
1. Introducing self to patient
2. Using the computer as a prompt for questions
3. Making the nurse's questions a priority
4. Assuring the patient all information is confidential ✅3. Making the nurse's questions
a priority
A nurse observes a patient walking down the hall with a shuffling gait. When the patient
returns to bed, the nurse checks the strength in both of the patient's legs. The nurse
applies the information gained to suspect that the patient has a mobility problem. This
conclusion is an example of:
1. Reflection.
2. Clinical inference.
3. Cue.
4. Validation. ✅2. Clinical inference.
Place the following steps of the assessment process in the correct order.
1. Compare data with another source to determine data accuracy.
2. As a pattern forms, probe and frame further questions.
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