Nursing 110 Study Guide Exam Questions And All Actual Answers.
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Course
NURS 110
Institution
NURS 110
A nurse determines that the patient's condition has improved and has met expected outcomes. Which step of the nursing process is the nurse exhibiting?
a. Assessment
b. Planning
c. Implementation
d. Evaluation - Answer ANS: D. Evaluation
Evaluation, the final step of the nursing proces...
Nursing 110 Study Guide
Exam Questions And All Actual
Answers.
A nurse determines that the patient's condition has improved and has met expected outcomes. Which
step of the nursing process is the nurse exhibiting?
a. Assessment
b. Planning
c. Implementation
d. Evaluation - Answer ANS: D. Evaluation
Evaluation, the final step of the nursing process, is crucial to determine whether, after application of the
first four steps of the nursing process, a patient's condition or well-being improves and if goals have been
met. Assessment, the first step of the process, includes data collection. Planning, the third step of the
process, involves setting priorities, identifying patient goals and outcomes, and selecting nursing
interventions. During implementation, nurses carry out nursing care, which is necessary to help patients
achieve their goals
A nurse completes a thorough database and carries out nursing interventions based on priority
diagnoses. Which action will the nurse take next?
a. Assessment
b. Planning
c. Implementation
d. Evaluation - Answer ANS: D. Evaluation
,Evaluation, the final step of the nursing process, is crucial to determine whether, after application of the
first four steps of the nursing process, a patient's condition or well-being improves. Assessment involves
gathering information about the patient. During the planning phase, patient outcomes are determined.
Implementation involves carrying out appropriate nursing interventions
A new nurse asks the preceptor to describe the primary purpose of evaluation. Which statement made
by the nursing preceptor is most accurate?
a. "An evaluation helps you determine whether all nursing interventions were completed."
b. "During evaluation, you determine when to downsize staffing on nursing units."
c. "Nurses use evaluation to determine the effectiveness of nursing care."
d. "Evaluation eliminates unnecessary paperwork and care planning." - Answer ANS: C "Nurses use
evaluation to determine the effectiveness of nursing care."
Evaluation is a methodical approach for determining if nursing implementation was effective in
influencing a patient's progress or condition in a favorable way. During evaluation, you do not simply
determine whether nursing interventions were completed. The evaluation process is not used to
determine when to downsize staffing or how to eliminate paperwork and care planning.
After assessing the patient and identifying the need for headache relief, the nurse administers
acetaminophen for the patient's headache. Which action by the nurse is priority for this patient?
a. Eliminate headache from the nursing care plan.
b. Direct the nursing assistive personnel to ask if the headache is relieved.
c. Reassess the patient's pain level in 30 minutes.
d. Revise the plan of care. - Answer ANS: C. "Reassess the patient's pain level in 30 minutes."
,The nurse's priority action for this patient is to evaluate whether the nursing intervention of
administering acetaminophen was effective. The nurse does not have enough evaluative data at this
point to determine whether headache needs to be discontinued. Assessment is the nurse's responsibility
and is not to be delegated to nursing assistive personnel. The nurse does not have enough evaluative
data to determine whether the patient's plan of care needs to be revised.
A nurse is getting ready to discharge a patient who has a problem with physical mobility. What does the
nurse need to do before discontinuing the patient's plan of care?
a. Determine whether the patient has transportation to get home.
b. Evaluate whether patient goals and outcomes have been met.
c. Establish whether the patient has a follow-up appointment scheduled.
d. Ensure that the patient's prescriptions have been filled to take home. - Answer ANS: B "Evaluate
whether patient goals and outcomes have been met."
You evaluate whether the results of care match the expected outcomes and goals set for a patient before
discontinuing a patient's plan of care. The patient needs transportation, but that does not address the
patient's mobility status. Whether the patient has a follow-up appointment and ensuring that
prescriptions are filled do not evaluate the problem of mobility.
The nurse is evaluating whether patient goals and outcomes have been met for a patient with physical
mobility problems due to a fractured leg. Which finding indicates the patient has met an expected
outcome?
a. The nurse provides assistance while the patient is walking in the hallways.
b. The patient is able to ambulate in the hallway with crutches.
c. The patient will deny pain while walking in the hallway.
d. The patient's level of mobility will improve. - Answer ANS: B "The patient is able to ambulate in the
hallway with crutches."
The patient's being able to ambulate in the hallway with crutches is an expected outcome of nursing
care. The outcomes of nursing practice are the measurable conditions of patient, family or community
status, behavior, or perception. These outcomes are the criteria used to judge success in delivering
, nursing care. The option stating, "The patient's level of mobility will improve" is a broader goal
statement. The nurse's assisting a patient to ambulate is an intervention. The patient's denying pain is an
expected outcome for pain, not for physical mobility problems.
The nurse is evaluating whether a patient's turning schedule was effective in preventing the formation of
pressure ulcers. Which finding indicates success of the turning schedule?
a. Staff documentation of turning the patient every 2 hours
b. Presence of redness only on the heels of the patient
c. Patient's eating 100% of all meals
d. Absence of skin breakdown - Answer ANS: D "Absence of skin breakdown"
To determine whether a turning schedule is successful, the nurse needs to assess for the presence of
skin breakdown. Redness on any part of the body, including only the patient's heels, indicates that the
turning schedule was not successful. Documentation of interventions does not evaluate whether patient
outcomes were met. Eating 100% of meals does not evaluate the effectiveness of a turning schedule.
A nurse has instituted a turn schedule for a patient to prevent skin breakdown. Upon evaluation, the
nurse finds that the patient has a stage II pressure ulcer on the buttocks. Which action will the nurse take
next?
a. Reassess the patient and situation.
b. Revise the turning schedule to increase the frequency.
c. Delegate turning to the nursing assistive personnel.
d. Apply medication to the area of skin that is broken down - Answer ANS: A "Reassess the patient and
situation."
If a nursing diagnosis is unresolved or if you determine that a new problem has perhaps developed,
reassessment is necessary. A complete reassessment of patient factors relating to an existing nursing
diagnosis and etiology is necessary when modifying a plan. The nurse must assess before revising,
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