Which of the following activities would be a part of the planning phase of the nursing process?
Question 1 Which of the following activities would be a part of the planning phase of the nursing process?
asking the patient about his past history in regard to medication use.
teaching the spouse how to use the glucometer which the patient will have at home.
prioritizing the needs of the patient and making a decision on what to teach first.
assisting the patient with insulin administration.
Question 2 What data would be considered subjective?
Apical heart rate 70 beats per minute
No heart murmurs noted
No current medications or treatments
Jugular venous pressure 2 cm
Subjective data is the data the patient can describe or explain based on how they feel or perceive something or upon their history–something you could not witness. Objective data can be measured or assessed empirically by the nurse.
Question 3 What should the nurse do immediately before beginning the physical exam?
Collect all equipment essential to the exam.
Establish the client’s reliability as historian.
Construct the client’s family genogram.
Practice interviewing skills.
Question 4 When initiating the collection of the client subjective database, what initial step is most important for the nurse to implement?
Establishing a trusting relationship
Making inferences
Identifying health problems
Determining client strengths
Question 5 A surgical client’s pain has become increasingly severe overnight, and she has received her maximum current doses of analgesics. The nurse has consequently phoned the surgeon to obtain a new order for analgesia. After the surgeon tells the nurse the new order, how should the nurse best validate this information?
Have another nurse read the order that the nurse has transcribed.
Compare the order with the standard timing and dosage of the analgesic.
Compare the order to the client’s existing medication administration record (MAR).
Read the order back to the surgeon for confirmation.
Question 6When documenting findings of an abdominal assessment, which of the methods below are best?
Good bowel sounds in all quadrants, fair amount of tenderness on deep palpation.
Abnormal B.S. in 3 of 4 quadrants.
Complains of tenderness in right lower quadrant with deep palpation. Denies pain/tenderness in other quadrants.
Signs of appendicitis present, with pain in right lower quadrant.
The correct answer uses no inappropriate terms, though in a clinical setting the nurse would use approved abbreviations. However, the incorrect answers use vague terms like good, fair, abnormal–with no description of what the abnormal findings were.
Question 7 In thinking critically, nurses need to have a sense of urgency, yet put all facts in the context of the evolving situation.
The daughter of a geriatric patient rushes to the nursing station and shouts, “I need someone to come now! I think mother has stopped breathing!” The charge nurse hurries to the room and sees the patient lying calmly in bed with respiratory rate of 28. Which response by the nurse shows evidence of critical thinking?
The nurse documents that the patient’s daughter seems paranoid about the mother’s condition.
The nurse states, “Looks like the problem has resolved!” and plans to monitor the situation closely over the next few hours.
The nurse thanks the daughter and asks what it was that made her feel that there was a problem with her mother’s breathing.
The nurse does a quick subjective assessment to determine if the patient agreed that she had stopped breathing at any point recently.
The patient seems to be in no immediate danger so it would be best to find out why the daughter felt there was a problem. As it turns out, the oximeter fell off the patient’s finger and the reading showed a 0, and that what the daughter based her panic upon.
Question 8Which route will yield the highest temperature reading? Select one answer.
Temporal artery
Tympanic membrane
Axillary
Oral (sublingual)
Question 9 A client is two weeks postoperative appendectomy and is still experiencing pain. The nurse realizes this client is most likely experiencing:
Deep somatic pain
cutaneous pain
Referred pain
Visceral pain
Question 10Based only on anthropometric measurements, which set of clients listed below are at the greatest risk for diabetes and cardiovascular disease?
Clients with a BMI of 23
Clients with a weight of 185 pounds or more
Females with 35 inches (88.9 cm) or greater waist circumference.
Males with 35 inches (88.9 cm) or greater waist circumference
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