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Nurs 101 Midterm
Nurs 101 Midterm
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1
Which intervention for a patient with poor wound healing should the nurse perform first?
Perform the ordered dressing change twice daily.
Observe wound appearance and edges.
Document wound characteristics.
2
A nurse has already set the agenda during a patient-centered interview. What will the nurse do next?
Carefully review lab results
Prolong the termination phase of the interview
Ask about the chief concerns or problems
Conduct the physical assessment.
3
If a patient is reporting a 7/10 after receiving IV morphine, what would the nurses next action be?
Tell the patient they cannont have more pain medication for 30 min
Investigate other pain relief options
Explain that pain comes with surgery
4
Nurse's specific knowledge base, is the first component of the critical thinking model?
False
True
5
A nurse sees a patient crying in their room, the nurse uses critical thinking by asking why they are crying. T or F?
True
False
6
Dynamic thinking process that is hypothesis driven and leads to a dx that best explains the symptoms & clinical evidence
Clinical Reasoning
Diagnostic process
Diagnostic reasoning
Critical thinking
7
An expected outcome for a pt that states HR will be less than 80 beats/min by 12/3. Which finding shows the goal met?
Heart rate 80 beats/min on 12/4
Heart rate 78 beats/min on 12/4
Heart rate 80 beats/min on 12/3
Heart rate 78 beats/min on 12/3
8
Which goal statement is realistic for the nurse to assign to this patient with a hip fx?
Patient will use a sliding board correctly to transfer to the commode
Patient will use the walker correctly to ambulate to the bathroom as needed
Patient will turn side to back to side with assistance every 2 hours.
Patient will increase activity level this shift
9
A new nurse is working in a unit that uses interdisciplinary collaboration. Which should she take?
Develop good communication skills.
Avoid conflict.
Work solely with nurses
Act as a leader of the health care team
10
A new nurse writes a nursing diagnoses for a care plan. Which nursing diagnosis will cause the the charge RN alarm?
Hemorrhage
Impaired swallowing
A. Wandering
11
A nurse notes her patient has a low HR, she does a cardiac assessment and checks the history, which skill is being used?
Interpretation
Evaluation
Explanation
A. Self-regulation
12
When completing a thorough health history, which component will the nurse specifically address?
The nurses specific concerns
The physician orders
Patient expectations
Care plan treatment goals
13
Tachycardia, increased thirst, headache, low urine output, and high body temperature most likely indicate what condition
Hypothermia
Hypervolemia
Hypovolemia
14
Which action should the nurse take first during the initial phase of implementation?
Reassess the patient
Prioritize patient’s nursing diagnoses.
Evaluate interventions.
Determine patient outcomes and goals
15
Which component of the critical thinking model is first in helping a nurse make a critical decision?
Nursing process
Specific knowledge base
Attitude
Experience
16
Which direct care intervention is best for a patient at risk for a UTI?
Properly cleans the patient’s toilet
Teaches proper handwashing technique
A. Informs the oncoming nurse during hand-off
Transports urine specimen to the lab
17
When a patient states they are allergic to a medication, what is the next most important question to ask?
What type of reaction do you have
Consult an allergist
Terminate the interview
Document the finding
18
In the nursing process what will nurse do after the interview?
A. See what the patient's expectations are
A. Have a casual conversation
A. Quick assessment
Collect full history
19
Which of the following is a PROBLEM-FOCUSED DIAGNOSIS?
A. Risk for falls as evidenced by poor gait
Risk for infection AEB inadequate vaccination and immunosuppression
Anxiety r/t to situational crises and stress AEB restlessness & insomnia
Readiness for enhanced self-care AEB expressed desire to enhance self-care
20
If a nurse performs an intervention for a collaborative problem. Which type of intervention was done?
Dependent
Independent
Interdependent
21
All options for pain relief should be explored first by the critically thinking nurse?
False
True
22
What will the nurse do nurse after the plan of care for a patient is developed?
File the plan of care in the administration office for legal examination.
Place the original copy in the chart, so it cannot be changed
Communicate the plan to all clinicianss involved in the client's care
A. Send the plan of care to quality assurance for review.
23
A nurse develops a plan of care what is the next step she will use in the nursing process
Select a nursing Diagnosis
Prioritize interventions
Reassess plan of care
Implementation
24
When gathering information on lifestyle and habits, which method of data collection is best?
Completing a health history
Reviewing the lab results
Doubling the time of the termination phase
Physical assessment
25
Which learning assignement helps students to synthesize data and identify relationships between nursing diagnoses?
Research papers
Reflective journaling
Concept map
Care plans
26
The critical thinking skill of evaluation helps with??
A. Support findings and conclusions.
Examine the meaning of data
Review the effectiveness of nursing actions
Search for links between the data and the nurse’s assumptions
27
A patient has a bacterial infection their lower leg, what would an appropriate nursing dx be?
Impaired skin integrity
Risk for infection
Impaired mobility
28
A patient states their pain is 3/10 but is grimacing and wincing when attmepting to move, what should the nurse do next
Document the findings
Ask the patient why they are making these specific expressions
Give more pain medication
29
Providing nursing care to patients occurs in what step of the nursing process?
Assessment
Evaluation
Implementation
Planning
30
Impaired physical mobility related to a fracture as evidenced by patient’s inability to ambulate-
what should be fixed?
Nursing Diagnosis
Etiology
Collaborative problem
Defining characteristics
31
Which information indicates a nurse has a good understanding of a goal?
It is a measurable change in a patient’s physical state.
A statement describing the patient’s accomplishments with no time contraint
It is a broad statement describing a desired change in a patient’s behavior
It is a realistic statement predicting any negative responses to treatments
32
Which outcome reflects the SMART approach?
administer pain meds every 4 hours to keep the patient free from discomfort
The nurse will monitor the patient’s heart rhythm continuously this shift
The patient will ambulate in hallways.
The patient will feed self at all mealtimes today without reports of SOB
33
The client’s condition has improved and has met expected outcomes. Which step of the nursing process is the nurse using?
Implementation
Assessment
Planning
Evaluation
34
Which question would be
best
for a nurse to ask a pt to assist in making a nursing dx of diarrhea
What are your current medications
How many bowel movements a day have you had?
Does any particular food upset your stomach
35
Taking immediate action when a patient's condition worsens is an example of an RN making a responsible decision
True
False
36
If you saw "Readiness for enhanced urinary elimination"
in the care plan, What type of nursing dx would be appropriate?
Health promotion
Risk
Problem focused
37
Which of the following is an approved NANDA-I dx?
Hypertension
Acute pain
COPD
Strep throat
38
What is the first step of a problem oriented approach?
Complete the questions in chronological order
Focus on the patient’s presenting situation.
A. Make accurate interpretations of the data.
39
A pt is afraid of going home and being alone. VS are stable and the incision is intact, what does subjective data show?
The patient can now perform the dressing changes without help.
The patient’s surgery was not successful
The patient is apprehensive about discha
40
Patient expectations is done by which part of clinical decision making?
Nursing assessment
Interview
Nursing diagnosis
Data validation
41
You are using assessment data obtained about a pt & combining critical thinking to develop a nursing dx, Whats happening
Diagnostic labeling
Defining characteristics
Diagnostic reasoning
42
How can a nurse best develop critical thinking skills?
Going to inservice classes
Actively participating in clinical experiences
Studying evidenced based practice
43
The nurse completes a thorough assessment of a patient and analyzes the data to identify nursing diagnoses. What's next?
Assessment
Planning
Implementation
Diagnosis
44
What involves determining the effectiveness of interventions?
Evaluation
Explanation
Interpretation
45
The nursing dx deals with human response to actual or potiential health problems and life processes. T or F
False
True
46
Out of these choices, which is most appropriate for the nursing dx statement
Impaired skin integrity related to sheering
Turn the patient every 2 hours, even hours.
Monitor vital signs, especially rhythm.
Keep the bed side rails up at all times.
Administer pain medication every 4 hours as needed
47
Which initial intervention is most appropriate for a patient who has a new onset of chest pain
Prioritize patient’s nursing diagnoses
Reassess the patient
Evaluate interventions
Administer a prn medication for pain
48
The nurse is intervening for a family member with role strain
.
Which direct care intervention is best?
Counseling about respite care options
Consulting with a social worker
Teaching range-of-motion exercises
Assisting with activities of daily living
49
If a patient is hard of hearing, what should the nurse do in order to conduct an appropriate interview?
Close the door to the patient's room
Yell loudly
Use hand gestures while speaking
50
A nurse checks a med order and gives the med using the patient rights. She is using the SMART approach during care
False
True
51
A nurse needs to give a patient morphine for pain she is using which type of nursing intervention?
Interdependant
Dependant
Intervention with a standing order
Independent
