2024 NUR 155 FOUNDATIONS TO
NURSING EXAM WITH CORRECT
ANSWERS
What is the nursing process? - CORRECT-ANSWERSSystematic, rational
method of planning and proving individualized care.
What do you do in the nursing process? - CORRECT-ANSWERS1. Assessing
2. Nursing Diagnosing
3. Planning
4. Implementing
5. Evaluating
What is the Decision-Making Process? - CORRECT-ANSWERS-Choosing the
best actions to meet a desired goal
-Make value decisions
-Time management decisions
-Scheduling decisions
-Priority decisions
Differentiating Nursing Diagnosis from Medical Diagnosis - CORRECT-
ANSWERS-Nursing Diagnosis
Nursing judgment
Describes human response
Changes as client responds
-Medical Diagnosis
Made by physician
Disease process
Stays the same
Steps in Diagnostic Process - CORRECT-ANSWERS1. Analyzing Data
-Compare data against standards
-Cluster cues
-Identify gaps and inconsistencies
2.Identifying health problems, risks, and strengths
-Basic Three-Part Statement (actual)
Problem (P)
Etiology (E)
Signs and symptoms (S)
PRACTICE: nursing diagnoses:
A client who experienced a stroke last week is unable to swallow. You
witness him choke during a feeding session. - CORRECT-ANSWERS-impaired
swallowing
-R/T facial paralysis
-AEB observed choking (Observed evidente of difficulty in swallowing
PRACTICE: nursing diagnoses:
A newborn has a temp of 97.1 Ax. - CORRECT-ANSWERS-Hypothermia
-R/T immature body system
-AEB Ax temp of 97.1
PRACTICE: nursing diagnoses:
A client comes to the clinic and states he can't handle the stress anymore. -
CORRECT-ANSWERS-Ineffective coping
-R/T inadequate coping
-AEB verbalization of the inability to cope
PRACTICE: nursing diagnoses:
An assessment on a post-operative client reveals rhonchi. The client refuses
to cough due to pain. - CORRECT-ANSWERS-ineffective airway clearance
-R/T ineffective cough
-AEB abnormal breath sounds
PRACTICE: nursing diagnoses:The nurse is caring for a post-operative
surgical client. The nurse identifies the client is at risk for developing
infection. The client does not have symptoms of an infection at this time. -
CORRECT-ANSWERS-Risk for infection
-R/T surgical incision
The nursing process: Planning - CORRECT-ANSWERSNurse and the client in
collaboration
Set priorities
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