Test Ban For LPN to RN Transitions 3rd Edition By Claywell

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Test Ban For LPN to RN Transitions 3rd Edition By Claywell

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WITH ANSWERS

 

Claywell LPN to RN Transitions 3rd Edition

 

Chapter 01: Honoring Your Past, Planning Your Future

Test Bank

 

MULTIPLE CHOICE

 

  1. A nursing advisor is meeting with a student who is interested in earning her RN degree. She knows that LPN/LVNs who enter nursing school to become RNs come into the learning environment with prior knowledge and understanding. Which statement by the nursing advisor best describes her understanding of the effect experience may have on learning?
a. Experience may be a source of insight or a barrier.
b. Experience is usually a stumbling block for LPN/LVNs.
c. Experience never makes learning more difficult.
d. Once something is learned, it can never be truly modified.

 

 

ANS:  A

Experience accentuates differences among learners and serves as a source of insight and motivation, but it can also be a barrier. Experience can serve as a foundation for defining the self.

 

DIF:    Cognitive Level: Application          REF:   Page 3

OBJ:   Identify how experiences influence learning in adults.   TOP:   Adult Learning

 

  1. There is a test on the cardiovascular system on Friday morning, and it is now Wednesday night. The student has already taken a vacation day from work Thursday night so that she can stay home and study. She is considering skipping her exercise class on Thursday morning to go to the library to prepare for the test. Which response best identifies the students outcome priority?
a. Exercise class
b. Going to the library
c. Avoiding work by taking a vacation
d. Doing well on the test on Friday

 

 

ANS:  D

The outcome priority is the most important goal, and other tasks are prioritized in order based on their importance toward meeting the identified goal.

 

DIF:    Cognitive Level: Application          REF:   Page 2

OBJ:   Identify motivations and personal outcome priorities for returning to school.

TOP:   Motivation to Learn

 

  1. A nurse who has been an LPN/LVN for 10 years is meeting with an advisor to discuss the possibility of taking classes to become an RN. The advisor interprets which statement by the nurse as the driving force for returning to school?
a. Ill need to schedule time to attend classes.
b. Ill have to budget for paying tuition.
c. Ill have to rearranging my schedule.
d. There is a possibility of advancement into administration.

 

 

ANS:  D

Driving forces are those that tend to lead toward making the change, as opposed to restraining forces, which are those that usually present a challenge that needs to be overcome for the change to take place or present a negative effect the change may initiate.

 

DIF:    Cognitive Level: Application          REF:   Page 8

OBJ:   Identify motivations and personal outcome priorities for returning to school.

TOP:   Motivations for Change

 

  1. An RN is caring for a diabetic patient. The patient appears interested in changing her lifestyle and has been asking questions about eating better. The nurse can interpret this behavior as which stage of Lewins Change Theory?
a. Moving
b. Unfreezing
c. Action
d. Refreezing

 

 

ANS:  B

The patient is in the first phase of Lewins Change Theory, known as unfreezing. This phase involves determining that a change needs to occur and deciding to take action. Moving is the second phase and involves actively planning changes and taking action on them. Refreezing is the last stage, and it occurs when the change has become a part of the persons life.

 

DIF:    Cognitive Level: Analysis               REF:   Page 8

OBJ:   Understand Change Theory and how it applies to becoming an RN.

TOP:   Change Theory

 

  1. An LPN is talking with her clinical instructor about her decision to return to school to become an RN. The clinical instructor interprets the LPNs outcome priority based on which statement?
a. My family wanted me to go back to school.
b. I want to better my financial situation.
c. I really enjoy school.
d. I would like to advance to a teaching role someday.

 

 

ANS:  B

The outcome priority is the essential need that must be addressed, determined by internal and external factors, such as needing to better a financial situation. The other statements indicate reasons for returning to school, but they are not essential needs or issues to be addressed.

 

DIF:    Cognitive Level: Analysis               REF:   Page 2

OBJ:   Identify how experiences influence learning in adults.   TOP:   Adult Learning

 

  1. A nurse notices a posting for a management position for which she is qualified. If the nurse is in the moving phase of Lewins Change Theory, which statement reflects the action she is most likely to take?
a. Does nothing to obtain the position
b. Applies for the position
c. Identifies that change is needed
d. Settles into the routine of her job

 

 

ANS:  B

Unfreezing begins when reasons for change are identified. The moving phase involves active planning and action. Refreezing occurs after the change has become routine.

 

DIF:    Cognitive Level: Application          REF:   Page 8

OBJ:   Understand Change Theory and how it applies to becoming an RN.

TOP:   Change Theory

 

  1. An Orthopedic Nurse is contemplating changes in her professional life and identifying goals. Which action should the nurse take if she is interested in pursuing a long-term goal?
a. Studies for a telemetry exam scheduled for next week
b. Enrolls in a Nurse Practitioner program
c. Attends a seminar to become a charge nurse
d. Continues to work on the orthopedic floor full-time

 

 

ANS:  B

A short-term goal is one that can be attained in a period of 6 months or less. Short-term goals include becoming a charge nurse and passing the telemetry exam. A long-term goal is attained in greater than 6 months and includes studying to become a Nurse Practitioner. Continuing to work on the orthopedic floor does not represent either a short-term or a long-term goal.

 

DIF:    Cognitive Level: Application          REF:   Page 7

OBJ:   Identify both short- and long-term personal and professional goals.

TOP:   Setting Goals

 

  1. A group of cardiac nurses with common experiences meet monthly for a staff meeting to discuss ways to improve patient care. This group is known as a:
a. scheme.
b. cohort.
c. team.
d. unit.

 

 

ANS:  B

A cohort is a group of people who share common experiences with each other. A scheme is a web of connections, a team is a group linked together for common purposes, and a unit consists of groups or individuals that make up a whole.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 3

OBJ:   Identify how experiences influence learning in adults.   TOP:   Adult Learning

 

  1. Although experience may be a source of motivation for the adult learner, it may also serve as a(n) __________ to new learning.
a. stepping stone
b. barrier
c. avenue
d. detour

 

 

ANS:  B

Experience accentuates differences among learners, serves as a source of insight and motivation, can be a barrier to new learning, and serves as a foundation for defining the self.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 4

OBJ:   Identify motivations and personal outcome priorities for returning to school.

TOP:   Adult Learning

 

MULTIPLE RESPONSE

 

  1. A student nurse and the staff RN are discussing recent changes on the nursing unit. Which of the following are examples of change processes? (Select all that apply.)
a. Coercive
b. Collaborative
c. Technocratic
d. Planned
e. Organized

 

 

ANS:  A, C, D

Coercive is a type of change that is forced or pushed on another. A decision for change made by the most knowledgeable person is known as technocratic. Planned change involves careful thought and decision making. Collaborative and organized are not considered to be types of change.

 

DIF:    Cognitive Level: Application          REF:   Page 9

OBJ:   Understand Change Theory and how it applies to becoming an RN.

TOP:   Change Theory

 

COMPLETION

 

  1. A(n) ________ effect experience is one in which movement of the learner toward the desired outcome was constructive.

 

ANS:

positive

Experiences may be either positive or negative in effect based on the influence on the ultimate outcome.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 4

OBJ:   Delineate both positive and negative effect experiences.           TOP:    Adult Learning

Chapter 03: Classroom Study Habits That Work

Test Bank

 

MULTIPLE CHOICE

 

  1. A first semester student is struggling in class and did not do well on her last exam. She has determined the problem to be her lack of skill in note-taking. What can the student do in order to take more effective notes during lecture?
a. Focus on writing key words and phrases.
b. Photocopy someone elses notes.
c. Write verbatim all that is said.
d. Practice memorization in class instead of taking notes.

 

 

ANS:  A

The student should focus on writing key words and phrases in order to be more effective at note-taking. Photocopying someone elses notes, writing verbatim, and memorizing lecture will not help the student with effective note-taking.

 

DIF:    Cognitive Level: Application          REF:   Page 36

OBJ:   Describe the components of effective listening.              TOP:   Note-Taking

 

  1. A student nurse feels that his reading skills are not adequate. Which action would he take in order to have effective reading skills?
a. Focus on improving reading speed.
b. Read slowly and thoroughly.
c. Ask his friends and family read to him.
d. Passively engage in reading.

 

 

ANS:  A

Evidence relates reading speed to comprehension; the faster you read, the more you understand what you are reading.

 

DIF:    Cognitive Level: Application          REF:   Pages 37-38

OBJ:   Describe how to improve reading skills.                          TOP:   Reading Skills

 

  1. A struggling student admits that she is reading the same paragraph over and over when she tries to read the text. The instructor recognizes this as inhibitory to her comprehension of the material. Which suggestion could the instructor make to the student to help correct the situation?
a. Just keep trying. Maybe you need to read it over a few times to get it.
b. Maybe you are waiting too late at night to study. Try studying earlier in the day.
c. Try putting your finger under the words one at a time.
d. If the words are a stumbling block, study them alone first, and then as you read, you will be less likely to stumble over them and regress.

 

 

ANS:  D

Regression, or rereading what was just read, may be caused by stumbling over unfamiliar terms that cause reading to slow and decrease.

 

DIF:    Cognitive Level: Application          REF:   Pages 37-38

OBJ:   Describe how to improve reading skills.                          TOP:   Reading Skills

 

  1. The five-step method of thoroughly studying is composed of which steps in order?
a. Scan, skim, survey, read, recite, review.
b. Scan, skim, read, recite, review, reread.
c. Survey, question, read, recite, review.
d. Survey, question, read, review, reread.

 

 

ANS:  C

SQRRR is a tried and true method: survey, question, read, recite, and review.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 40

OBJ:   Prepare to study effectively using the SQRRR method.  TOP:   Study Methods

 

  1. A nursing student is preparing for her first day of lecture. She knows that in order to succeed, she should:
a. skip the first day of class and read the material at home.
b. sit in the front of the room, away from distractions.
c. take notes from the book during lecture time.
d. sit in the back of the class, next to her best friend.

 

 

ANS:  B

Students should sit in the front of the classroom for optimal learning, away from distractions.

 

DIF:    Cognitive Level: Application          REF:   Pages 34-35

OBJ:   Prepare for success in the classroom.                                        TOP:    Classroom Study Habits

 

  1. A patient comes to the emergency department with complaints of crushing chest pain that radiates down his left arm. While reviewing his health history with the RN, the patient states that he has been getting over a cold. He also has seasonal allergies and is allergic to peanuts. The nurse interprets the major detail for the patients ER visit as the patient:
a. has a peanut allergy.
b. is experiencing crushing chest pain.
c. is getting over a cold.
d. has seasonal allergies.

 

 

ANS:  B

The major detail in this scenario is the patients crushing chest pain, which brought him into the ER. All other are minor details.

 

DIF:    Cognitive Level: Analysis               REF:   Page 38

OBJ:   Distinguish between major and minor details.                 TOP:   Major/Minor Details

 

  1. The RN is performing an assessment on a patient being admitted for back pain. The nurse interprets which of the patients statements as a minor detail?
a. The patient has not been able to void in 12 hours.
b. The patient ate 90% of his meal.
c. The patient reports being unable to walk.
d. The patient was involved in a car accident 2 days ago.

 

 

ANS:  B

Minor details support the major details and peripherally support the main idea. In this scenario, the patient eating 90% of his meal is a minor detail. The other choices are major details.

 

DIF:    Cognitive Level: Analysis               REF:   Page 38

OBJ:   Distinguish between major and minor details.                 TOP:   Major/Minor Details

 

  1. A student has been out of school for a number of years. She is concerned that she may not be able to study effectively. What action can the student take that will increase her ability to focus on her studies?
a. Study for 1 hour a night.
b. Study in a loud coffee shop.
c. Stay up all night before tests to make sure she is proficient.
d. Study with the TV off.

 

 

ANS:  D

The student should learn ways to study effectively in order to succeed in school. Studying for only 1 hour per night, studying in a loud coffee shop, and staying up all night to study are not ways to study effectively.

 

DIF:    Cognitive Level: Application          REF:   Page 37

OBJ:   Describe positive classroom study habits.                       TOP:   Improving Study Habits

 

  1. A student is reviewing new material for an upcoming test. She has decided to highlight so that she can come back later to easily review the material. How can she use highlighting to be successful?
a. She should highlight the first time she reads the material.
b. She should highlight no more than 20% of the material.
c. She should use only one method of highlighting.
d. She should highlight the entire chapter.

 

 

ANS:  B

The student should read the material at least once before she begins highlighting. Highlighting during the first read through, using only one method of highlighting, and highlighting the entire chapter would not assist the student in being successful.

 

DIF:    Cognitive Level: Application          REF:   Page 38

OBJ:   Describe how to improve reading skills.                          TOP:   Highlighting

 

  1. A student is trying to develop better study habits. She knows that for every hour of class, it is advised that she study for ______ hours.
a. 3 to 4
b. 2 to 3
c. 4 to 5
d. 5 to 6

 

 

ANS:  B

For every hour of class the student should spend 2 to 3 hours studying in order to be successful.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 41

OBJ:   Prepare to study effectively using the SQRRR method.  TOP:   Study Habits

 

  1. Multiple incorrect options on a test are known as:
a. stems.
b. structured responses.
c. distractors.
d. negative indicators.

 

 

ANS:  C

Multiple incorrect options on a test are known as distractors.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 43

OBJ:   Incorporate strategies to improve test taking.                   TOP:   Test-Taking Skills

 

MULTIPLE RESPONSE

 

  1. A nursing student knows that effective listening requires attention and preparation. What actions can she take to ensure that she is proficient? (Select all that apply.)
a. Read over the assigned material before class begins.
b. Read over the material as soon as class is over.
c. No special attention or preparation is required.
d. Read the material during class.
e. Study independently during discussion time.

 

 

ANS:  A, B

To listen effectively, prepare for what you will hear before class. In class maintain concentration and actively engage in the discussion, and then after class review notes and add clarifying comments.

 

DIF:    Cognitive Level: Application          REF:   Page 35

OBJ:   Describe the components of effective listening.              TOP:   Listening

 

  1. You are a first semester nursing student and have just received your first reading assignment for class tomorrow. You know that in order to succeed you will need to practice effective listening. Which actions would prepare you for class tomorrow? (Select all that apply.)
a. Read over the assigned material tonight.
b. Scan over the material before class, looking at the main points and subpoints.
c. Read the text during class instead of listening to lecture.
d. Review your notes immediately after class.
e. Do not review anything before class.

 

 

ANS:  A, B, D

In order to be prepared for class you should: Read over assigned material the night before; scan over the material before class, looking at both main points and subpoints; and review notes immediately after class. Practicing effective listening includes giving the instructor your undivided attention. Often instructors emphasize points that they do not want students to miss. These points often end up on exams.

 

DIF:    Cognitive Level: Application          REF:   Page 35

OBJ:   Learn effective listening skills.       TOP:   Effective Listening

 

  1. A student is studying for an upcoming test. She has read the assigned text once and is now ready to highlight. Which actions by the student indicate that she understands how to highlight? (Select all that apply.)
a. Uses circles to highlight key words or phrases
b. Draws an asterisk next to an important paragraph or sentence
c. Underlines sentences of importance
d. Draws squares around words for emphasis
e. Marks a section with a star for future reference

 

 

ANS:  A, B, C, E

Circles, asterisks, underlines, and stars are all acceptable ways of highlighting that would indicate differences in the material.

 

DIF:    Cognitive Level: Application          REF:   Page 38

OBJ:   Identify ways of highlighting.         TOP:   Highlighting

 

  1. A student has just listened to a lecture on better strategies for studying. Which of the students actions indicate understanding? (Select all that apply.)
a. Wait until the evening to study.
b. Begin with the most difficult subjects.
c. Create a conducive study environment.
d. Record the lectures and listen to them in your car.
e. Begin to study the day before an exam.

 

 

ANS:  B, C, D

Beginning study sessions with the most difficult subjects, creating a conducive study environment, and listening to lectures in your car are all ways to create better strategies for studying.

 

DIF:    Cognitive Level: Application          REF:   Page 41

OBJ:   Incorporate strategies to improve test taking.                   TOP:   Study Strategies

Chapter 11: Providing Patient-Centered Care Through the Nursing Process

Test Bank

 

MULTIPLE CHOICE

 

  1. Which statement by the nurse illustrates how a nursing patient assessment differs from a medical patient assessment?
a. The patient is able to stand for 30 seconds before walking 10 feet toward the bathroom without an assistive device.
b. The patient is fearful that he will not be discharged home after his hospitalization.
c. The patient stated he felt pain in his lower back after slipping on his icy driveway.
d. The patient experienced a persistent cough, and azithromycin was prescribed 6 weeks ago. Today, she presents with a recurrent cough, green sputum, and worsening shortness of breath.

 

 

ANS:  A

The patients being able to stand and walk is the correct answer. The nurse focuses on functional abilities and deficits in order to focus the plan of care and help identify the outcome priorities. These areas are not generally assessed by the physician. The patients feeling fearful of his disposition at discharge is incorrect because the nursing patient assessment does not focus on feelings and behavior. In addition to subjective data illustrated here by the patients stating the location of his pain, the nurse also uses objective data for the nursing patient assessment. The statement describing the patients medical history is not the focus of a nursing patient assessment.

 

DIF:    Cognitive Level: Evaluation           REF:   Page 164

OBJ:   Differentiate between the nursing patient assessment and the medical patient assessment.

TOP:   Nursing Process

MSC:  NCLEX: Safe, Effective Care Environment: Management of Care

 

  1. The nurse is using Gordons 11 categories for data collection in performing a health assessment. Which of the following represents assessment of cognition?
a. How educated is the patient?
b. How does the patient describe his or her health?
c. Is the patient well nourished?
d. Has the patient had treatment for emotional problems?

 

 

ANS:  A

Asking the patients educational level is an assessment of cognition. How the patient describes his or her health is an assessment of health perception and health management. Asking whether the patient is well nourished will assess metabolic pattern, and asking the patient about treatment for emotional problems will assess the patients pattern of coping and stress tolerance.

 

DIF:    Cognitive Level: Application          REF:   Page 165

OBJ:   Discuss the five realms that may affect a patients health status that should be addressed in order to complete a thorough nursing assessment.                              TOP:              Nursing Process

MSC:  NCLEX: Psychosocial Integrity

 

  1. The nurse is charting on the patient who is status post surgery for an abdominal abscess and notes: Pts temperature has not exceeded 37C this shift. This is an example of a(n):
a. intervention.
b. outcome.
c. plan.
d. diagnosis or analysis.

 

 

ANS:  B

An outcome measures the effectiveness of the plan of care. An intervention, a plan, and a diagnosis or analysis are incorrect.

 

DIF:    Cognitive Level: Analysis               REF:   Page 168

OBJ:   Compare and contrast the nursing tasks in each phase of the nursing process.

TOP:   Nursing Process

MSC:  NCLEX: Safe, Effective Care Environment: Management of Care

 

  1. Which outcome statement is a properly written goal?
a. The patient will be free of pain.
b. The patient will verbalize the importance of lifestyle changes.
c. The patient will get up into the chair one time daily for 1 hour.
d. The patient will demonstrate breathing techniques by the end of shift.

 

 

ANS:  C

To be evaluated, an expected outcome must be specific and measurable, meaning that the outcomes can be consistently evaluated. The patient will get up into the chair one time daily for 1 hour is specific and measurable. The other outcome statements are vague and open to interpretation. First, being free from pain may mean absolutely no pain or a tolerable level of pain. Second, identifying which lifestyle changes are important to teach the patient may differ from nurse to nurse. Finally, there may be several breathing techniques to teach the patient.

 

DIF:    Cognitive Level: Evaluation           REF:   Page 168

OBJ:   Explain the steps of the nursing process.                         TOP:   Nursing Process

MSC:  NCLEX: Safe, Effective Care Environment: Management of Care

 

  1. The nurse is planning care for a patient with hypertension and obesity. Which of the following is a reasonable and measurable outcome for the nursing diagnosis of noncompliance with treatment regimen related to side effects of medications?
a. The patient will state two lifestyle modifications for weight management by (date certain).
b. The patient will be compliant with the treatment regimen by (date certain).
c. The patient will understand the disease process by (date certain).
d. The patients blood pressure will never increase.

 

 

ANS:  A

The patients stating two lifestyle modifications for weight management is reasonable and measurable. The patients being compliant with the treatment regimen is vague. The patients understanding the disease process does not state how the effectiveness of teaching will be measured (e.g., by return demonstration or verbalization). The patients blood pressure not increasing is not reasonable.

 

DIF:    Cognitive Level: Application          REF:   Page 168

OBJ:   Formulate and apply reasonable and measurable outcomes to the practice setting.

TOP:   Nursing Process

MSC:  NCLEX: Safe, Effective Care Environment: Management of Care

 

  1. A patient admitted with a diagnosis of Alzheimers disease is anxious and dehydrated, has reportedly not been eating, and has had a weight loss of 5 lb in 1 week. Which nursing diagnosis is a priority?
a. Fluid volume deficit related to fluid loss
b. Altered nutrition: Less than body requirements related to anorexia
c. Fluid volume excess related to reduced urine output
d. Risk for impaired skin integrity

 

 

ANS:  A

Replacing fluids is the priority. Anorexia is common in the elderly and can be related to many conditions, including dementia. Fluid volume excess is not present. Risk for impaired skin integrity is not the priority.

 

DIF:    Cognitive Level: Analysis               REF:   Page 167

OBJ:   Formulate an actual, potential, and wellness nursing diagnosis.

TOP:   Nursing Process

MSC:  NCLEX: Safe, Effective Care Environment: Management of Care

 

  1. An RN team leader has one LPN and one medical assistant assigned to the unit. Which patient would be most appropriate to assign to the LPN?
a. Right lower lobectomy, one day postoperatively, whose temperature went from 37.1C to 38.3C during the last shift
b. 72-year-old right hip replacement, 2 days postoperatively, complaining of leg and chest pain
c. 48-year-old female patient who had a laparoscopic appendectomy 8 hours ago: urine output 165 mL, Hgb 7 g/dL, and Hct 21%
d. Post cerebral vascular accident 1 week ago who had a Dobhoff feeding tube inserted and is now on continuous feedings at 45 mL/hr

 

 

ANS:  D

Licensed practical nurses can implement actions specific to the patient care needs. Monitoring the stroke patient and maintaining the continuous feeding is an appropriate delegation. LPNs can also collect data, perform basic teaching, record data as well as interventions, and report to the RNs the progress the patient is making. The patient one-day post-op from the right lower lobectomy, the patient with the hip replacement, and the patient with the appendectomy are inappropriate to delegate to a LPN because each requires a focused assessment, advanced interventions, evaluation, and updating of the patients plans of care and outcome priorities.

 

DIF:    Cognitive Level: Application          REF:   Page 171

OBJ:   Explain the steps of the nursing process.                         TOP:   Nursing Process

MSC:  NCLEX: Safe, Effective Care Environment: Management of Care

 

  1. Which of these strategies should be a priority when the nurse is planning care for a patient with hypertension?
a. Obtain less expensive antihypertensive medications.
b. Assist with dietary changes as the first action.
c. Follow evidence-based guidelines for appropriate interventions.
d. Teach about the impact of exercise on hypertension.

 

 

ANS:  C

Planning goals and desired outcomes occurs in the planning phase. The plan of care includes the process of identifying the interventions needed for the patient to regain a level of independence at or higher than the patient had before admission into the hospital.

 

DIF:    Cognitive Level: Application          REF:   Page 169

OBJ:   Explain the steps of the nursing process.                         TOP:   Nursing Process

MSC:  NCLEX: Safe, Effective Care Environment: Management of Care

 

  1. The nurse reviews assessment findings for assigned patients. Based on this information, which patient demands the nurses immediate attention? The patient with:
a. renal failure on dialysis whose WBC is 10,000 mm3 (normal)
b. abdominal aneurysm whose blood pressure is 170/90
c. atrial fibrillation whose lab results show and INR of 2.5 (normal)
d. endocarditis who has a loud heart murmur

 

 

ANS:  B

Assessment contains both objective and subjective data. Among other things, the nurse interprets laboratory data to determine whom to see first. The hypertensive patient with an abdominal aneurysm presents the greatest emergency. The patient on dialysis, the patient with A-Fib, and the patient with endocarditis all have normal lab values and clinical findings and present no urgent need for attention.

 

DIF:    Cognitive Level: Application          REF:   Page 163

OBJ:   Explain the steps of the nursing process.                         TOP:   Nursing Process

MSC:  NCLEX: Safe, Effective Care Environment: Management of Care

 

  1. While the nurse is taking the health history, the patient states, My father and grandfather both had heart attacks and were unable to be very active afterward. This statement is related to the functional health pattern of:
a. activity-exercise.
b. cognitive-perceptual.
c. health perceptionhealth management.
d. coping-stress tolerance.

 

 

ANS:  C

The information in the patients statement relates to risk factors that may cause cardiovascular problems in the future. Identification of risk factors falls into the health perceptionhealth management pattern. This pattern describes a patients perceived pattern of health and how health is managed.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 164

OBJ:   Explain the steps of the nursing process.                         TOP:   Nursing Process

MSC:  NCLEX: Safe, Effective Care Environment: Management of Care

 

  1. Which of the following is an example of a measurable outcome for the patient who has undergone a surgical procedure with a pain rating of 7 on a scale of 0 to 10?
a. The patients pain will be under control by Sunday.
b. The patient will have no pain by the end of this shift.
c. The patients pain will decrease by the end of shift on (date).
d. The patients pain will decrease to 2 or lower by the end of shift on (date).

 

 

ANS:  D

The patients pain will decrease to 2 or lower by the end of shift on (date) states what is to be measured, how much it will decrease, and by when. The patients pain will be under control by Sunday, The patient will have no pain by the end of this shift, and The patients pain will decrease by the end of shift on (date) do not include these elements.

 

DIF:    Cognitive Level: Application          REF:   Page 168

OBJ:   Formulate and apply reasonable and measurable outcomes to the practice setting.

TOP:   Nursing Process

MSC:  NCLEX: Safe, Effective Care Environment: Management of Care

 

  1. Which of the following would be a priority nursing diagnosis for a 73-year-old male patient with heart failure?
a. Constipation related to immobility
b. Risk for infection related to IV lines
c. Activity intolerance related to an imbalance of oxygen and demand
d. Self-care deficit

 

 

ANS:  C

Remember your ABCs. The highest priority for this patient is to conserve energy. Constipation related to immobility, risk for infection related to IV lines, and self-care deficit are not priorities.

 

DIF:    Cognitive Level: Analysis               REF:   Page 166

OBJ:   Examine and prioritize nursing diagnoses in the practice setting.

TOP:   Nursing Process

MSC:  NCLEX: Safe, Effective Care Environment: Management of Care

 

  1. Which of the following would be an expected outcome for a patient who is 12 hours status post hip replacement?
a. Increase mobility and decrease pain.
b. Care for the catheter independently.
c. Walk without assistance.
d. Bathe daily in a tub.

 

 

ANS:  A

A reasonable outcome is that the patients mobility will increase as pain decreases. Care for the catheter independently is incorrect because the patient would not be expected to have a catheter. Walking without assistance and bathe daily in a tub are not reasonable for the patient 12 hours status post hip replacement.

 

DIF:    Cognitive Level: Analysis               REF:   Page 168

OBJ:   Formulate and apply reasonable and measurable outcomes to the practice setting.

TOP:   Nursing Process

MSC:  NCLEX: Safe, Effective Care Environment: Management of Care

 

  1. An RN is making assignments on a medical-surgical unit. Which patient could the RN assign to a float RN from the maternity unit?
a. A 68-year-old female patient with COPD and viral pneumonia
b. A 60-year-old female patient with atrial fibrillation and a heart rate of 150
c. A 50year-old male patient post open heart surgery whose blood pressure is 90/50
d. A 36-year-old male patient who is severely neutropenic awaiting chemotherapy

 

 

ANS:  A

When prioritizing nursing care, the most critical problems receive the highest priority. In this scenario, the float nurse from another department serves as another health care team member unfamiliar with the medical-surgical patient population. The medical-surgical RN serves as an all-around organizer of care and interventions that other health care team members provide. The patient with COPD and viral pneumonia is the most stable of the group. The patient with A-Fib, the post open heart surgery patient with dangerously low blood pressure, and the neutropenic patient awaiting chemotherapy all require close attention and advanced interventions by the RN familiar with these types of patients.

 

DIF:    Cognitive Level: Application          REF:   Pages 167, 171

OBJ:   Explain the steps of the nursing process.                         TOP:   Nursing Process

MSC:  NCLEX: Safe, Effective Care Environment: Management of Care

 

  1. A patient with pneumonia has been using the incentive spirometer four times daily while awake during his 3-day hospitalization. How would the nurse explore the effectiveness of this intervention?
a. The nurse would ask whether the patient was breathing better.
b. The nurse would add turn, cough, and deep breathing exercises.
c. The nurse would watch the patient use the incentive spirometer.
d. The nurse would auscultate the lungs for adventitious breath sounds.

 

 

ANS:  D

The nurse would evaluate the effectiveness of the incentive spirometer treatment by listening for adventitious lung sounds. Asking whether the patient is breathing better; adding turn, cough, and deep breathing exercises; and watching the patient using the incentive spirometer do not examine the effectiveness of the plan of care.

 

DIF:    Cognitive Level: Synthesis             REF:   Page 171

OBJ:   Explain the steps of the nursing process.                         TOP:   Nursing Process

MSC:  NCLEX: Safe, Effective Care Environment: Management of Care

 

  1. Which nursing diagnosis would be a priority for a patient in acute respiratory distress?
a. Pain
b. Impaired gas exchange
c. Activity intolerance
d. Deficient knowledge

 

 

ANS:  B

Remember your ABCs. Airway is always a priority. Pain, activity intolerance, and deficient knowledge are not priorities.

 

DIF:    Cognitive Level: Analysis               REF:   Page 167

OBJ:   Examine and prioritize nursing diagnoses in the practice setting.

TOP:   Nursing Process

MSC:  NCLEX: Safe, Effective Care Environment: Management of Care

 

  1. Determine which example is true of measurability within the context of the nursing diagnosis.
a. The patient will list signs of infection such as redness, pain, swelling, and warmth by the end of the shift.
b. The patient will be pain-free and then walk to the bathroom.
c. The patient reported abdominal pain for 2 days but denies nausea, vomiting, and diarrhea.
d. The patient received Dilaudid 1 mg IV and 2 hours later received Lortab 500/5.

 

 

ANS:  A

Measurability provides the means to evaluate outcomes consistently. The outcome criterion of listing the specific signs of infection is consistently measurable by anyone choosing to attain that outcome criterion. Being pain-free and then walking to the bathroom is not measurable because one outcome criterion cannot depend on completion of another criterion. Each outcome criterion is considered an individual goal. The statements addressing abdominal pain and nausea, vomiting, diarrhea are collected data and taking account of the pain medications administered to the patient have nothing in common with measurability.

 

DIF:    Cognitive Level: Evaluation           REF:   Page 168

OBJ:   Explain the steps of the nursing process.                         TOP:   Nursing Process

MSC:  NCLEX: Safe, Effective Care Environment: Management of Care

 

  1. The nurse is admitting a 64-year-old Hispanic male patient to the rehabilitation facility following surgical intervention for a broken hip. The nurse should first assess which of the following?
a. Self-care ability
b. Self-esteem
c. Communication
d. Pain

 

 

ANS:  D

Pain is the first priority for the patient admitted for rehabilitation following surgical intervention. Self-care ability and self-esteem are not the first to be assessed. The ability to communicate pain can be facilitated using graphic representations if the patient does not speak English.

 

DIF:    Cognitive Level: Analysis               REF:   Page 167

OBJ:   Examine and prioritize nursing diagnoses in the practice setting.

TOP:   Nursing Process

MSC:  NCLEX: Safe, Effective Care Environment: Management of Care

 

  1. The nurse is attempting to take the history of a newly admitted 92-year-old patient but is unable to obtain the information because of the patients cognitive status. The nurse should:
a. refuse to complete the admission without more information.
b. contact the family for information on the patients history.
c. call the doctor in the emergency room for a history.
d. ask another nurse to try to obtain the information from the patient.

 

 

ANS:  B

The nurse should contact the family to obtain the needed information. Refusing to complete the admission without more information is not professional. Calling the doctor in the emergency room for a history is not likely to be helpful, and asking another nurse to try to obtain the information from the patient is not likely to change the outcome because of the patients cognitive status.

 

DIF:    Cognitive Level: Analysis               REF:   Page 164

OBJ:   Explain the steps of the nursing process.                         TOP:   Nursing Process

MSC:  NCLEX: Safe, Effective Care Environment: Management of Care

 

  1. The nurse is planning care for an 82-year-old obese female patient with Alzheimers dementia. The patient wanders, is unsteady on her feet, and is visually impaired. What should the nurse give priority to when developing the plan of care?
a. Laboratory results
b. Skin condition
c. Safety
d. Nutrition

 

 

ANS:  C

Safety is the first priority for this patient who is cognitively and visually impaired, wanders, and is unsteady. Laboratory results should be monitored, but safety is the priority. Skin condition and nutrition are of concern but are not immediate priorities.

 

DIF:    Cognitive Level: Analysis               REF:   Page 167

OBJ:   Examine and prioritize nursing diagnoses in the practice setting.

TOP:   Nursing Process

MSC:  NCLEX: Safe, Effective Care Environment: Management of Care

 

  1. Which of the following is true about collaborative problems?
a. Collaborative problems fall within the definition of nursing diagnoses.
b. Collaborative problems are managed using two physicians.
c. Collaborative problems require the nurse to monitor for changes in status.
d. Collaborative problems emphasize prevention, treatment, or health promotion.

 

 

ANS:  C

Collaborative problems require the nurse to monitor for changes in patient status and for the onset of complications for specific situations. Collaborative problems do not fall within the definition of nursing diagnoses. The statement that collaborative problems are managed using two physicians is not true, and the statement that collaborative problems emphasize prevention, treatment, or health promotion is true of the nursing diagnosis phase of the nursing process.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 170

OBJ:   Explain collaborative problems with respect to formulating the nursing diagnosis in the practice setting.           TOP:              Nursing Process

MSC:  NCLEX: Safe, Effective Care Environment: Management of Care

 

  1. Errors may occur with the use of data in formulating an appropriate nursing diagnosis. Based on what you know, which of the following represents the main source of errors in the nursing diagnosis process?
a. Making assumptions without supporting data
b. Placing data in incorrect categories
c.

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