After assessing a patient, a nurse develops a standard formal nursing diagnosis. What is the rationale for the nurse’s actions?
a. To form a language that can be encoded only by nurses
b. To determine the direction of nursing care
c. To develop clinical judgment based on other’s intuition
d. To help nurses focus on the scope of medical practice

b. To determine the direction of nursing care

Which diagnosis will the nurse document in a patient’s care plan that is NANDA-I approved?
a. Sore throat
b. Acute pain
c. Sleep apnea
d. Heart failure

b. Acute pain

A nurse develops a nursing diagnostic statement for a patient with a medical diagnosis of pneumonia with chest x-ray results of lower lobe infiltrates. Which nursing diagnosis did the nurse write?
a. Ineffective breathing pattern related to pneumonia
b. Risk for infection related to chest x-ray procedure
c. Risk for deficient fluid volume related to dehydration
d. Impaired gas exchange related to alveolar-capillary membrane changes

d. Impaired gas exchange related to alveolar-capillary membrane changes

The nurse is reviewing a patient’s plan of care, which includes the nursing diagnostic statement, Impaired physical mobility related to tibial fracture as evidenced by patient’s inability to ambulate. Which part of the diagnostic statement does the nurse need to revise?
a. Etiology
b. Nursing diagnosis
c. Collaborative problem
d. Defining characteristic

a. Etiology

A nurse is using assessment data gathered about a patient and combining critical thinking to develop a nursing diagnosis. What phrase is used to identify what the nurse is doing?
a. Assigning clinical cues
b. Defining characteristics
c. Diagnostic reasoning
d. Diagnostic labeling

c. Diagnostic reasoning

A patient presents to the emergency department following a motor vehicle crash that causes a right femur fracture. The leg is stabilized in a full leg cast. Otherwise, the patient has no other major injuries, is in good health, and reports only moderate discomfort. Which is the most pertinent nursing diagnosis the nurse will include in the plan of care?
a. Posttrauma syndrome
b. Constipation
c. Acute pain
d. Anxiety

c. Acute pain

The nurse is reviewing a patient’s database for significant changes and discovers that the patient has not voided in over 8 hours. The patient’s kidney function lab results are abnormal, and the patient’s oral intake has significantly decreased since previous shifts. Which step of the nursing process should the nurse proceed do after this review?
a. Diagnosis
b. Planning
c. Implementation
d. Evaluation

a. Diagnosis

A patient with a spinal cord injury is seeking to enhance urinary elimination abilities by learning self-catheterization versus assisted catheterization by home health nurses and family members. The nurse adds Readiness for enhanced urinary elimination in the care plan. Which type of diagnosis did the nurse write?
a. Risk
b. Problem focused
c. Health promotion
d. Collaborative problem

c. Health promotion

A nurse administers an antihypertensive medication to a patient at the scheduled time of 0900. The nursing assistive personnel (NAP) then reports to the nurse that the patient’s blood pressure was low when it was taken at 0830. The NAP states that was busy and had not had a chance to tell the nurse yet. The patient reports feeling dizzy and light-headed. The blood pressure is re-checked, and it has dropped even lower. In which phase of the nursing process did the nurse first make an error?
a. Assessment
b. Diagnosis
c. Implementation
d. Evaluation

a. Assessment

A nurse adds the following diagnosis to a patient’s care plan: Constipation related to decreased gastrointestinal motility secondary to pain medication administration as evidenced by the patient reporting no bowel movement in seven days, abdominal distention, and abdominal pain. Which element did the nurse write as the defining characteristic?
a. Decreased gastrointestinal motility
b. Pain medication
c. Abdominal distention
d. Constipation

c. Abdominal distention

The patient database reveals that a patient has decreased oral intake, decreased oxygen saturation when ambulating, reports of shortness of breath when getting out of bed, and a productive cough. Which elements will the nurse identify as defining characteristics for the diagnostic label of Activity intolerance?
a. Decreased oral intake and decreased oxygen saturation when ambulating
b. Decreased oxygen saturation when ambulating and reports of shortness of breath when getting out of bed
c. Reports of shortness of breath when getting out of bed and a productive cough
d. Productive cough and decreased oral intake

b. Decreased oxygen saturation when ambulating and reports of shortness of breath when getting out of bed

A nurse performs an assessment on a patient. Which assessment data will the nurse use as an etiology for Acute pain?
a. Discomfort while changing position
b. Reports pain as a 7 on a 0 to 10 scale
c. Disruption of tissue integrity
d. Dull headache

c. Disruption of tissue integrity

A new nurse writes the following nursing diagnoses on a patient’s care plan. Which nursing diagnosis will cause the nurse manager to intervene?
a. Wandering
b. Hemorrhage
c. Urinary retention
d. Impaired swallowing

b. Hemorrhage

A patient has a bacterial infection in left lower leg. Which nursing diagnosis will the nurse add to the patient’s care plan?
a. Infection
b. Risk for infection
c. Impaired skin integrity
d. Staphylococcal leg infection

c. Impaired skin integrity

A nurse adds a nursing diagnosis to a patient’s care plan. Which information did the nurse document?
a. Decreased cardiac output related to altered myocardial contractility.
b. Patient needs a low-fat diet related to inadequate heart perfusion.
c. Offer a low-fat diet because of heart problems.
d. Acute heart pain related to discomfort.

a. Decreased cardiac output related to altered myocardial contractility.

A charge nurse is evaluating a new nurse’s plan of care. Which finding will cause the charge nurse to follow up?
a. Assigning a documented nursing diagnosis of Risk for infection for a patient on intravenous (IV) antibiotics
b. Completing an interview and physical examination before adding a nursing diagnosis
c. Developing nursing diagnoses before completing the database
d. Including cultural and religious preferences in the database

c. Developing nursing diagnoses before completing the database

A patient exhibits the following symptoms: tachycardia, increased thirst, headache, decreased urine output, and increased body temperature. The nurse analyzes the data. Which nursing diagnosis will the nurse assign to the patient?
a. Adult failure to thrive
b. Hypothermia
c. Deficient fluid volume
d. Nausea

c. Deficient fluid volume

Which question would be most appropriate for a nurse to ask a patient to assist in establishing a nursing diagnosis of Diarrhea?
a. ―What types of foods do you think caused your upset stomach?
b. ―How many bowel movements a day have you had?
c. ―Are you able to get to the bathroom in time?
d. ―What medications are you currently taking?

b. ―How many bowel movements a day have you had?

A nurse assesses that a patient has not voided in 6 hours. Which question should the nurse ask to assist in establishing a nursing diagnosis of Urinary retention?
a. ―Do you feel like you need to go to the bathroom?
b. ―Are you able to walk to the bathroom by yourself?
c. ―When was the last time you took your medicine?
d. ―Do you have a safety rail in your bathroom at home?

a. ―Do you feel like you need to go to the bathroom?

A nurse is developing nursing diagnoses for a patient. Beginning with the first step, place in order the steps the nurse will use.
1. Observes the patient having dyspnea (shortness of breath) and a diagnosis of asthma.
2. Writes a diagnostic label of impaired gas exchange.
3. Organizes data into meaningful clusters.
4. Interprets information from patient.
5. Writes an etiology.
a. 1, 3, 4, 2, 5
b. 1, 3, 4, 5, 2
c. 1, 4, 3, 5, 2
d. 1, 4, 3, 2, 5

a. 1, 3, 4, 2, 5

A nurse is developing nursing diagnoses for a group of patients. Which nursing diagnoses will the nurse use? (Select all that apply.)
a. Anxiety related to barium enema
b. Impaired gas exchange related to asthma
c. Impaired physical mobility related to incisional pain
d. Nausea related to adverse effect of cancer medication
e. Risk for falls related to nursing assistive personnel leaving bedrail down

c. Impaired physical mobility related to incisional pain
d. Nausea related to adverse effect of cancer medication

The nurse completes a thorough assessment of a patient and analyzes the data to identify nursing diagnoses. Which step will the nurse take next in the nursing process?
a. Assessment
b. Diagnosis
c. Planning
d. Implementation

c. Planning

A patient’s plan of care includes the goal of increasing mobility this shift. As the patient is ambulating to the bathroom at the beginning of the shift, the patient falls. Which initial action will the nurse take next to most effectively revise the plan of care?
a. Consult physical therapy.
b. Establish a new plan of care.
c. Set new priorities for the patient.
d. Assess the patient.

d. Assess the patient.

Which information concerning a goal indicates a nurse has a good understanding of its purpose?
a. It is a statement describing the patient’s accomplishments without a time restriction.
b. It is a realistic statement predicting any negative responses to treatments.
c. It is a broad statement describing a desired change in a patient’s behavior.
d. It is a measurable change in a patient’s physical state.

c. It is a broad statement describing a desired change in a patient’s behavior.

A nurse is developing a care plan for a patient prescribed bed rest as a result of a pelvic fracture. Which goal statement is realistic for the nurse to assign to this patient?
a. Patient will increase activity level this shift.
b. Patient will turn side to back to side with assistance every 2 hours.
c. Patient will use the walker correctly to ambulate to the bathroom as needed.
d. Patient will use a sliding board correctly to transfer to the bedside commode as needed.

a. Patient will increase activity level this shift.

The following statements are on a patient’s nursing care plan. When creating a nursing care plan, which statement should the nurse use as an outcome for a goal of care?
a. The patient will verbalize a decreased pain level less than 3 on a 0 to 10 scale by the end of this shift.
b. The patient will demonstrate increased tolerance to activity over the next month.
c. The patient will understand needed dietary changes by discharge.
d. The patient will demonstrate increased mobility in 2 days.

a. The patient will verbalize a decreased pain level less than 3 on a 0 to 10 scale by the end of this shift.

A charge nurse is reviewing outcome statements written by a novice nurse. The nurse is using the SMART approach. Which patient outcome statement will the charge nurse identify as appropriate to the new nurse?
a. The patient will ambulate in hallways.
b. The nurse will monitor the patient’s heart rhythm continuously this shift.
c. The patient will feed self at all mealtimes today without reports of shortness of breath.
d. The nurse will administer pain medication every 4 hours to keep the patient free from discomfort.

c. The patient will feed self at all mealtimes today without reports of shortness of breath.

A nursing assessment for a patient with a spinal cord injury leads to several pertinent nursing diagnoses. Which nursing diagnosis is the highest priority for this patient?
a. Risk for impaired skin integrity
b. Risk for infection
c. Spiritual distress
d. Reflex urinary incontinence

d. Reflex urinary incontinence

The novice nurse is caring for six patients in this shift. After completing their assessments, the nurse asks where to begin in developing care plans for these patients. Which statement is an appropriate suggestion by the nurse’s preceptor?
a. ―Choose all the interventions and perform them in order of time needed for each one.
b. ―Make sure you identify the scientific rationale for each intervention first.
c. ―Decide on goals and outcomes you have chosen for the patients.
d. ―Begin with the highest priority diagnoses, then select appropriate interventions.

d. ―Begin with the highest priority diagnoses, then select appropriate interventions.

A patient’s son decides to stay at the bedside while his father is experiencing confusion. When developing the plan of care for this patient, what should the nurse do to best meet the patient’s needs?
a. Individualize the care plan only according to the patient’s needs.
b. Request that the son leave at bedtime, so the patient can rest.
c. Suggest that a female member of the family stay with the patient.
d. Involve the son in the plan of care as much as possible.

d. Involve the son in the plan of care as much as possible.

A nurse is caring for a patient with a nursing diagnosis of Constipation related to slowed gastrointestinal motility secondary to pain medications. Which outcome is most appropriate for the nurse to include in the plan of care?
a. Patient will have one soft, formed bowel movement by end of shift.
b. Patient will walk unassisted to bathroom by the end of shift.
c. Patient will be offered laxatives or stool softeners this shift. d. Patient will not take any pain medications this shift.

a. Patient will have one soft, formed bowel movement by end of shift.

The nurse performs an intervention for a collaborative problem. Which type of intervention did the nurse perform?
a. Dependent
b. Independent
c. Interdependent
d. Physician-initiated

c. Interdependent

A registered nurse administers pain medication to a patient suffering from fractured ribs. Which type of nursing intervention is this nurse implementing?
a. Collaborative
b. Independent
c. Interdependent
d. Dependent

d. Dependent

Which action indicates the nurse is using a PICOT question to improve care for a patient?
a. Practices nursing based on the evidence presented in court.
b. Implements interventions based on scientific research.
c. Uses standardized care plans for all patients.
d. Plans care based on tradition.

b. Implements interventions based on scientific research.

A nurse is developing a care plan. Which intervention is most appropriate for the nursing diagnostic statement Risk for loneliness related to impaired verbal communication?
a. Provide the patient with a writing board each shift.
b. Obtain an interpreter for the patient as soon as possible.
c. Assist the patient in performing swallowing exercises each shift.
d. Ask the family to provide a sitter to remain with the patient at all times.

a. Provide the patient with a writing board each shift.

A nurse is completing a care plan. Which intervention is most appropriate for the nursing diagnostic statement Impaired skin integrity related to shearing forces?
a. Administer pain medication every 4 hours as needed.
b. Turn the patient every 2 hours, even hours.
c. Monitor vital signs, especially rhythm.
d. Keep the bed side rails up at all times.

b. Turn the patient every 2 hours, even hours.

A patient has reduced muscle strength following a left-sided stroke and is at risk for falling. Which intervention is most appropriate for the nursing diagnostic statement Risk for falls?
a. Keep all side rails down at all times.
b. Encourage patient to remain in bed most of the shift.
c. Place patient in room away from the nurses’ station if possible.
d. Assist patient into and out of bed every 4 hours or as tolerated.

d. Assist patient into and out of bed every 4 hours or as tolerated.

Which action will the nurse take after the plan of care for a patient is developed?
a. Placing the original copy in the chart, so it cannot be tampered with or revised
b. Communicating the plan to all health care professionals involved in the patient’s care
c. Filing the plan of care in the administration office for legal examination
d. Sending the plan of care to quality assurance for review

b. Communicating the plan to all health care professionals involved in the patient’s
care

A nurse is preparing to make a consult. In which order, beginning with the first step, will the nurse take?
1. Identify the problem.
2. Discuss the findings and recommendation.
3. Provide the consultant with relevant information about the problem.
4. Contact the right professional, with the appropriate knowledge and expertise.
5. Avoid bias by not providing a lot of information based on opinion to the consultant.
a. 1, 4, 3, 5, 2
b. 4, 1, 3, 2, 5
c. 1, 4, 5, 3, 2
d. 4, 3, 1, 5, 2

a. 1, 4, 3, 5, 2

A hospital’s wound nurse consultant made a recommendation for nurses on the unit about how to care for the patient’s dressing changes. Which action should the nurses take next?
a. Include dressing change instructions and frequency in the care plan.
b. Assume that the wound nurse will perform all dressing changes.
c. Request that the health care provider look at the wound.
d. Encourage the patient to perform the dressing changes.

a. Include dressing change instructions and frequency in the care plan.

A nurse is planning care for a patient with a nursing diagnosis of Impaired skin integrity. The patient needs many nursing interventions, including a dressing change, several intravenous antibiotics, and a walk. Which factors does the nurse consider when prioritizing interventions? (Select all that apply.)
a. Rank all the patient’s nursing diagnoses in order of priority.
b. Do not change priorities once they’ve been established.
c. Set priorities based solely on physiological factors.
d. Consider time as an influencing factor.
e. Utilize critical thinking.

a. Rank all the patient’s nursing diagnoses in order of priority.
d. Consider time as an influencing factor.
e. Utilize critical thinking.

A nurse is teaching the staff about the benefits of Nursing Outcomes Classification. Which information should the nurse include in the teaching session? (Select all that apply.)
a. Includes seven domains for level 1.
b. Uses an easy 3-point Likert scale.
c. Adds objectivity to judging a patient’s progress.
d. Allows choice in which interventions to choose.
e. Measures nursing care on a national and international level.

c. Adds objectivity to judging a patient’s progress.
e. Measures nursing care on a national and international level.

A nurse is providing nursing care to patients after completing a care plan from nursing diagnoses. In which step of the nursing process is the nurse?
a. Assessment
b. Planning
c. Implementation
d. Evaluation

c. Implementation

The nurse is teaching a novice nurse about protocols. Which information from the novice nurse indicates a correct understanding of the teaching?
a. Protocols are guidelines to follow that replace the nursing care plan.
b. Protocols assist the clinician in making decisions and choosing interventions for specific health care problems or conditions.
c. Protocols are policies designating each nurse’s duty according to standards of care and a code of ethics.
d. Protocols are prescriptive order forms that help individualize the plan of care.

b. Protocols assist the clinician in making decisions and choosing interventions for specific health care problems or conditions.

The standing orders for a patient include acetaminophen 650 mg every 4 hours prn for headache. After assessing the patient, the nurse identifies the need for headache relief and determines that the patient has not had acetaminophen in the past 4 hours. Which action will the nurse take next?
a. Administer the acetaminophen.
b. Notify the health care provider to obtain a verbal order.
c. Direct the nursing assistive personnel to give the acetaminophen.
d. Perform a pain assessment only after administering the acetaminophen.

a. Administer the acetaminophen.

Which action indicates a nurse is using critical thinking for implementation of nursing care to patients?
a. Determines whether an intervention is correct and appropriate for the given situation.
b. Reads over the steps and performs a procedure despite lack of clinical competency.
c. Establishes goals for a particular patient without assessment.
d. Evaluates the effectiveness of interventions.

a. Determines whether an intervention is correct and appropriate for the given situation.

A nurse is reviewing a patient’s care plan. Which information will the nurse identify as a nursing intervention?
a. The patient will ambulate in the hallway twice this shift using crutches correctly.
b. Impaired physical mobility related to inability to bear weight on right leg.
c. Provide assistance while the patient walks in the hallway twice this shift with crutches.

d. The patient is unable to bear weight on right lower extremity.

c. Provide assistance while the patient walks in the hallway twice this shift with
crutches.

A patient recovering from a leg fracture after a fall reports having dull pain in the affected leg and rates it as a 7 on a 0 to 10 scale. The patient is not able to walk around in the room with crutches because of leg discomfort. Which nursing intervention is priority?
a. Assist the patient to walk in the room with crutches.
b. Obtain a walker for the patient.
c. Consult physical therapy.
d. Administer pain medication.

d. Administer pain medication.

The nurse is caring for a patient who requires a complex dressing change. While in the patient’s room, the nurse decides to change the dressing. Which action will the nurse take just before changing the dressing?
a. Gathers and organizes needed supplies.
b. Decides on goals and outcomes for the patient.
c. Assesses the patient’s readiness for the procedure.
d. Calls for assistance from another nursing staff member.

c. Assesses the patient’s readiness for the procedure.

A patient visiting with family members in the waiting area tells the nurse ―I don’t feel good, especially in the stomach. What should the nurse do?

a. Request that the family leave, so the patient can rest.
b. Ask the patient to return to the room, so the nurse can inspect the abdomen.
c. Ask the patient when the last bowel movement was and to lie down on the sofa.
d. Tell the patient that the dinner tray will be ready in 15 minutes and that may help the stomach feel better.

b. Ask the patient to return to the room, so the nurse can inspect the abdomen.

A newly admitted patient who is morbidly obese asks the nurse for assistance to the bathroom. Which action should the nurse take initially?
a. Ask for at least two other assistive personnel to come to the room.
b. Medicate the patient to alleviate discomfort while ambulating.
c. Review the patient’s activity orders.
d. Offer the patient a walker.

c. Review the patient’s activity orders.

A novice nurse is working in a unit that uses interdisciplinary collaboration. Which action will the nurse take to help assure effectiveness as a team member?
a. Act as a leader of the health care team.
b. Develop good communication skills.
c. Work solely with experienced nurses.
d. Avoid conflict.

b. Develop good communication skills.

Which action should the nurse take first during the initial phase of implementation?
a. Determine patient outcomes and goals.
b. Prioritize patient’s nursing diagnoses.
c. Evaluate interventions.
d. Reassess the patient.

d. Reassess the patient.

Vital signs for a patient reveal a blood pressure of 187/100. Orders state to notify the health care provider for diastolic blood pressure greater than 90. What is the nurse’s first action?
a. Follow the clinical protocol for a stroke.
b. Review the most recent lab results for the patient’s potassium level.
c. Assess the patient for other symptoms or problems, and then notify the health care provider.
d. Administer an antihypertensive medication from the stock supply, and then notify the health care provider.

c. Assess the patient for other symptoms or problems, and then notify the health care
provider.

Which initial intervention is most appropriate for a patient who has a new onset of chest pain?
a. Reassess the patient.

b. Notify the health care provider.
c. Administer a prn medication for pain.
d. Call radiology for a portable chest x-ray.

a. Reassess the patient.

A nurse is making initial rounds on patients. Which intervention for a patient with poor wound healing should the nurse perform first?
a. Reinforce the wound dressing as needed with 4  4–inch gauze.
b. Perform the ordered dressing change twice daily.
c. Observe wound appearance and edges.
d. Document wound characteristics.

c. Observe wound appearance and edges.

The nurse establishes trust and talks with a school-aged patient before administering an injection. Which type of implementation skill is the nurse using?
a. Cognitive
b. Interpersonal
c. Psychomotor
d. Judgmental

b. Interpersonal

The nurse inserts an intravenous (IV) catheter using the correct technique and following the recommended steps according to standards of care and hospital policy. Which type of implementation skill is the nurse using?
a. Cognitive
b. Interpersonal
c. Psychomotor
d. Judgmental

c. Psychomotor

A staff development nurse is providing an inservice for other nurses to educate them about the Nursing Interventions Classification (NIC) system. During the inservice, which statement made by one of the nurses in the room requires the staff development nurse to clarify the information provided?
a. ―This system can help medical students determine the cost of the care they provide to patients.
b. ―If the nursing department uses this system, communication among nurses who work throughout the hospital may be enhanced.
c. ―We could use this system to help organize orientation for new nursing employees because we can better explain the nursing interventions we use most frequently on our unit.
d. ―The NIC system provides one way to improve safe and effective documentation in the hospital’s electronic health record.

a. ―This system can help medical students determine the cost of the care they provide to patients.

The nurse is intervening for a family member with role strain. Which direct care nursing intervention is most appropriate?
a. Assisting with activities of daily living
b. Counseling about respite care options
c. Teaching range-of-motion exercises
d. Consulting with a social worker

b. Counseling about respite care options

The nurse is intervening for a patient with a risk for a urinary infection. Which direct care nursing intervention is most appropriate?
a. Teaches proper handwashing technique.
b. Properly cleans the patient’s toilet.
c. Transports urine specimen to the lab.
d. Informs the oncoming nurse during hand-off.

a. Teaches proper handwashing technique.

The nurse is revising the care plan. In which order will the nurse perform the tasks, beginning with the first step?
1. Revise specific interventions.
2. Revise the assessment column.
3. Choose the evaluation method.
4. Delete irrelevant nursing diagnoses.
a. 2, 4, 1, 3
b. 4, 2, 1, 3
c. 3, 4, 2, 1
d. 4, 2, 3, 1

a. 2, 4, 1, 3

A nurse is implementing interventions for a group of patients. Which actions are nursing interventions? (Select all that apply.)
a. Order chest x-ray for suspected arm fracture.
b. Prescribe antibiotics for a wound infection.
c. Reposition a patient who is on bed rest.
d. Teach a patient preoperative exercises.
e. Transfer a patient to another hospital unit.

c. Reposition a patient who is on bed rest.
d. Teach a patient preoperative exercises.
e. Transfer a patient to another hospital unit.

A nurse is providing nursing care to a group of patients. Which actions are direct care interventions? (Select all that apply.)
a. Ambulating a patient
b. Inserting a feeding tube
c. Performing resuscitation
d. Documenting wound care
e. Teaching about medications

a. Ambulating a patient
b. Inserting a feeding tube
c. Performing resuscitation
e. Teaching about medications

A nurse is preparing to carry out interventions. Which resources will the nurse make sure are available? (Select all that apply.)

a. Equipment
b. Safe environment
c. Confidence
d. Assistive personnel
e. Creativity

a. Equipment
b. Safe environment
d. Assistive personnel

Which interventions are appropriate for a patient with diabetes and poor wound healing? (Select all that apply.)
a. Perform dressing changes twice a day as ordered.
b. Teach the patient about signs and symptoms of infection.
c. Instruct the family about how to perform dressing changes.
d. Gently refocus patient from discussing body image changes.
e. Administer medications to control the patient’s blood sugar as ordered.

a. Perform dressing changes twice a day as ordered.
b. Teach the patient about signs and symptoms of infection.
c. Instruct the family about how to perform dressing changes.
e. Administer medications to control the patient’s blood sugar as ordered.

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

d. Evaluation

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

d. Evaluation

A novice 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.

c. ―Nurses use evaluation to determine the effectiveness of nursing care.

After assessing the patient and identifying the need for headache relief, the nurse administers acetaminophen. 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.

c. Reassess the patient’s pain level in 30 minutes.

A nurse is getting ready to discharge a patient who is experiencing impaired 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.

b. Evaluate whether patient goals and outcomes have been met.

The nurse is evaluating whether patient goals and outcomes have been met for a patient with impaired physical mobility 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.

b. The patient is able to ambulate in the hallway with crutches.

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 understands the need for regular turning
d. Absence of skin breakdown

d. Absence of skin breakdown

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.

a. Reassess the patient and situation.

A novice nurse is confused about using evaluative measures when caring for patients and asks the charge nurse for an explanation. Which response by the charge nurse is most accurate?
a. ―Evaluative measures are multiple-page documents used to evaluate nurse performance.
b. ―Evaluative measures include assessment data used to determine whether patients have met their expected outcomes and goals.
c. ―Evaluative measures are used by quality assurance nurses to determine the progress a nurse is making from novice to expert nurse.
d. ―Evaluative measures are objective views for completion of nursing interventions.

b. ―Evaluative measures include assessment data used to determine whether patients have met their expected outcomes and goals.

The nurse is caring for a patient who has an open wound and is evaluating the progress of wound healing. Which priority action will the nurse take?
a. Asking the nursing assistive personnel if the wound looks better
b. Documenting the progress of wound healing as ―better in the chart
c. Measuring the wound and observe for redness, swelling, or drainage
d. Leaving the dressing off the wound for easier access and more frequent assessments

c. Measuring the wound and observe for redness, swelling, or drainage

The nurse is caring for a patient whose plan of care states that a change of dressing is to occur twice a day, at 0600 and 1800. At 1400, the nurse notices that the dressing is saturated and leaking. What is the nurse’s next action?
a. Wait and change the dressing at 1800 as ordered.
b. Revise the plan of care and change the dressing now.
c. Reassess the dressing and the wound in 2 hours.
d. Discontinue the plan of care for wound care.

b. Revise the plan of care and change the dressing now.

A goal for a patient diagnosed with diabetes is to demonstrate effective coping skills. Which patient behavior will indicate to the nurse achievement of this outcome?
a. States, ―It really helps talking about my health with family and friends.
b. Observed consuming high-carbohydrate foods when stressed.
c. Expresses a dislikes with the support group meetings.
d. Spends most of the day reading in bed.

a. States, ―It really helps talking about my health with family and friends.

A nurse is providing education to a patient about self-administering subcutaneous injections. The patient demonstrates the self-injection. Which type of indicator did the nurse evaluate?
a. Health status
b. Health behavior
c. Psychological self-control
d. Health service utilization

b. Health behavior

A nurse is evaluating the goal of acceptance of body image in a young teenage girl. Which statement made by the patient is the best indicator of progress toward the goal?
a. ―I’m worried about what those other girls will think of me.
b. ―I can’t wear dresses that make my hips stick out.
c. ―I’ll wear the blue dress. It matches my eyes.
d. ―I hope I can go to the pool next summer.

c. ―I’ll wear the blue dress. It matches my eyes.

A nurse is evaluating goals and expected outcomes for a confused patient. Which finding indicates positive progress toward resolving the confusion?
a. Patient wanders halls only at night.
b. Patient’s side rails are up with bed alarm activated.
c. Patient denies pain while ambulating with assistance.
d. Patient correctly states names of family members in the room.

d. Patient correctly states names of family members in the room.

A nurse identifies a fall risk when assessing a patient upon admission. The nurse and the patient agree that the goal is for the patient to remain free from falls. However, the patient fell just before shift change. Which action is the nurse’s priority when evaluating the patient after the fall?
a. Identifying factors interfering with goal achievement
b. Counseling the nursing assistive personnel on duty when the patient fell
c. Removing the fall risk sign from the patient’s door because the patient has suffered a fall
d. Requesting that the more experienced charge nurse complete the documentation about the fall

a. Identifying factors interfering with goal achievement

A patient was recently diagnosed with pneumonia. The nurse and the patient have established a goal that the patient will not experience shortness of breath with activity in 3 days with an expected outcome of having no secretions present in the lungs in 48 hours. Which evaluative measure will the nurse use to demonstrate progress toward this goal?
a. No sputum or cough present in 4 days
b. Congestion throughout all lung fields in 2 days
c. Shallow, fast respirations 30 breaths per minute in 1 day
d. Lungs clear to auscultation following use of inhaler

d. Lungs clear to auscultation following use of inhaler

A nurse is evaluating an expected outcome for a patient that states heart rate will be less than 80 beats/min by 12/3. Which finding will alert the nurse that the goal has been met?
a. Heart rate 78 beats/min on 12/3
b. Heart rate 78 beats/min on 12/4
c. Heart rate 80 beats/min on 12/3
d. Heart rate 80 beats/min on 12/4

a. Heart rate 78 beats/min on 12/3

A nurse is modifying a patient’s care plan after evaluation of patient care. In which order, starting with the first step, will the nurse perform the tasks?
1. Revise nursing diagnosis.
2. Reassess blood pressure reading.
3. Retake blood pressure after medication.
4. Administer new blood pressure medication.
5. Change goal to blood pressure less than 140/90.
a. 1, 5, 2, 4, 3

b. 2, 1, 5, 4, 3
c. 4, 3, 1, 5, 2
d. 5, 4, 5, 1, 2

b. 2, 1, 5, 4, 3

Which evaluative measures will the nurse use to determine a patient’s responses to nursing care? (Select all that apply.)
a. Observations of wound healing
b. Daily blood pressure measurements
c. Findings of respiratory rate and depth
d. Completion of nursing interventions
e. Patient’s subjective report of feelings about a new diagnosis of cancer

a. Observations of wound healing
b. Daily blood pressure measurements
c. Findings of respiratory rate and depth
e. Patient’s subjective report of feelings about a new diagnosis of cancer

Which nursing actions will the nurse perform in the evaluation phase of the nursing process? (Select all that apply.)
a. Set priorities for patient care.
b. Determine whether outcomes or standards are met.
c. Ambulate patient 25 feet in the hallway.
d. Document results of goal achievement.
e. Use self-reflection and correct errors.

b. Determine whether outcomes or standards are met.
d. Document results of goal achievement.
e. Use self-reflection and correct errors.