NUR 209/NUR 209 Exam
Questions with 100% Verified
Solutions 2024/2025
A nurse is engaged in diagnostic reasoning to propose appropriate
nursing diagnosis for a client. Place the steps in the order that they
would occur from first to last during this process. Correct response:
Organizing the existence of cues, Generating possible diagnoses, Comparing
cues to possible diagnoses, Conducting a focused data collection, Validating
diagnoses
Which activity is the clearest example of the evaluation step in the
nursing process? Correct response: checking the client's blood
pressure 30 minutes after administering captopril.
A nurse arrives at the home of an older adult client. The agency was
called because a neighbours noticed that the client was home alone.
The nurse finds the client alone in the living room. When asked about
the client's daughter who lives there and has been caring for her, the
client says, "She went on vacation for about a month. She'll be back
soon." Further assessment reveals that there are no other family
members or services currently involved. The nurse would identify
this situation as: abandonment
During a home health care visit, the nurse identifies a nursing
diagnosis of Caregiver Role Strain for a parent who is caring for a
child dependent on a ventilator. What subjective assessment data
would support the nurse's diagnosis? The parent states, "I cannot
allow anyone else to help because they won't do it right."
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The night shift RN is caring for a hospitalized adult client who reports
being unable to sleep. The client states, "I just can't sleep here. I miss
my home. There are too many lights and it is too hot." Which would be
the best nursing diagnosis for this client? Disturbed sleep pattern
The nurse is performing an admission assessment on a young client
admitted to the unit. Which of the following are considered objective
data? Select all that apply. 38-year-old man
height 6' (1.82m)
weight 195 lb (89kg)
A client has had major abdominal surgery and just returned to the
unit from the operating room. The nursing priority is to:
complete postoperative assessment.
During morning report, the night nurse tells the day nurse that the
client refused to allow the technician to draw blood for laboratory
testing. What step would be essential for the day nurse to complete
before selecting a nursing diagnosis to address this issue? The
nurse should determine the reason for the client's refusal.
When the nurse inspects a postoperative incision site for infection,
which one of the following types of assessments is being performed?
Focused
A nurse designs a care plan to improve walking mobility in an older
adult client. When encouraged to implement the new strategies for
ambulation the client refuses to try and tells the nurse, "I find it easier
to use a wheelchair." What action by the nurse may have led to failure
to meet the outcome? developing the plan without client input
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Which statement appropriately identifies an at-risk nursing diagnosis
for a woman 78 years of age who is confined to bed? Risk for
impaired skin integrity related to bed rest
A student takes an adult client's pulse and counts 20 beats/min.
Knowing this is not the normal range for an adult pulse, what should
the student do next? Ask the instructor or a staff nurse to take the
pulse.
A nurse takes the vital signs of a new hospital client admitted for
severe abdominal pain. Which initial step of the nursing process is
this nurse performing? Assessment
The RN is admitting a client to a medical unit. The nurse delegates the
measurement of the vital signs to unlicensed assistive personnel
(UAP) while she collects data. After completing the admission process
the client reports a severe headache, so the nurse reassesses the vital
signs to find the client's blood pressure extremely elevated. Whose
responsibility is the accuracy of the blood pressure measurement?
the nurse
Nurses collect objective and subjective data when performing client
assessments. What is an example of objective data? The skin of a
client who has liver failure has a yellowish tint.
The nurse writes the following on the client's chart: The client will
have complete healing of the surgical incision on the right lower
quadrant of the abdomen in 3 weeks. This is a(an): outcome
identification
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The nurse is caring for a client who is suspected of having a kidney
infection. Which scenario involves the use of subjective data from the
primary source? The client tells the nurse that there is a burning
sensation when voiding.
A nurse is documenting assessment findings. Which finding would the
nurse include as objective data? Select all that apply. Blood
pressure 128/68 mm Hg
Weight 175 lb (80 kg)
Bowel sounds active in all 4 quadrants
A nurse is reviewing the health history and physical assessment
findings for a client who is having respiratory problems. Of the
following data collected, what data from the health history would be a
cue to a nursing diagnosis for this problem? "I get out of breath when
I walk a few steps."
After completing an assessment of a client, which data would the
nurse determine is the priority for care?
Severe bleeding from a wound
The nurse is reviewing information about a client and notes the
following assessment data. Which data cue does the nurse recognize
as subjective data?
Pain rating is 7
The nurse is completing rounds and notices the client has slumped
down in bed. The nurse assists the client to settle more comfortably,
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