Nursing 251 - Nursing Process exam with complete solutions 2024_2025
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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 ...
Nursing 251 - Nursing Process exam with
complete solutions 2024/2025
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 - ANSWER- 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 - ANSWER- 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 - ANSWER- 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 - ANSWER- 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." - ANSWER- 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 - ANSWER- 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 - ANSWER- 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 - ANSWER- 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 - ANSWER- 2. Working Phase
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