wayground logo

Free Printable Worksheets

Font size

S
M
L
XL
Worksheets

Q.1E,1M,1N,1D

Total questions: 150

Worksheet time: 1hrs 28mins

Name
Class
Date
1.

Name the steps of the nursing process

a)

assessment, diagnosis, planning, intervention, evaluation

b)

assessment, diagnosis, planning, implementation, evaluation

c)

acknowledge, decision-making, planning, implementation, evaluation

d)

assessment, decision-making, planning, intervention, evaluation

2.

What are two types of nursing diagnosis?

a)

direct and indirect

b)

independent and collaborative

c)

actual and potential

d)

independent and dependent

3.

Which of the following are valid sources for patient assessment data?

a)

patient's family

b)

medical record/chart

c)

healthcare team

d)

All of the above

4.

What are the parts of the nursing diagnosis statement.

a)

assessment, diagnosis, plan, implementation, evaluation

b)

actual and potential

c)

cause and effect

d)

problem, etiology, symptoms

5.

Which of the following is objective data?

a)

client reports a fever

b)

itching

c)

headache

d)

temp of 99.1

6.

The purpose of the Nursing Process is to:

a)

Cure illness

b)

Guide written documentation

c)

Achieve care that is person centered and holistic

d)

help plan your day

7.

Although all sections of the nursing process (APIE) are important, which step provided the foundations of the process?

a)

Assessment

b)

Planning

c)

Implementation

d)

Evaluation

8.

Each phase Of nursing process affects the others ▪ Overlapping, continuing processes

a)

TRUE

b)

FALSE

9.

What phase of Nursing process involves Collecting, organizing, validating, and documenting client data

a)

ASSESSMENT

b)

DIAGNOSIS

c)

PLANNING

d)

IMPLEMENTATION

e)

EVALUATION

10.

What phase of Nursing process involves Analyzing and synthesizing data

a)

ASSESSING

b)

DIAGNOSING

c)

PLANNING

d)

IMPLEMENTING

e)

EVALUATING

11.

Nurses use critical thinking skills to interpret assessment data and identify client strengths and problems.

a)

TRUE

b)

FALSE

12.

NANDA stands for (a)  

13.

A statement of nursing judgment based on education, experience, expertise and license to treat

a)

nURSING DIAGNOSIS

b)

MEDICAL DIAGNOSIS

14.

Describes human response, the client’s physical, sociocultural, psychological, and spiritual responses to an illness or health problem

a)

NURSING DIAGNOSIS

b)

MEDICAL DIAGNOSIS

15.

Remains the same as long as the disease process is present

a)

NURSING DIAGNOSIS

b)

MEDICAL DIAGNOSIS

16.

Risk for Ineffective Airway Clearance related to accumulation of secretions in lungs

a)

BASIC TWO-PART STATEMENT

b)

BASIC THREE-PART STATEMENT

17.

Risk for Impaired Skin Integrity related to immobility as evidenced by red blisters on the sacral area.

a)

BASIC TWO-PART STATEMENT

b)

BASIC THREE-PART STATEMENT

18.

Oriented to the individual

a)

NURSING DIAGNOSIS

b)

MEDICAL DIAGNOSIS

19.

Oriented to pathology

a)

NURSING DIAGNOSIS

b)

MEDICAL DIAGNOSIS

20.

Which of the following behaviors would indicate that the nurse was utilizing the assessment phase of the nursing process to provide nursing care?

a)

Proposes hypotheses

b)

Generates desired outcomes

c)

Review results of laboratory tests

d)

Documents care

21.

Which of the following is the purpose of assessing?

a)

Establish a database of client responses to his or her health status

b)

Identify client strengths and problems

c)

Develop an individualized plan of care

d)

Implement care, prevent illness, and promote wellness

22.

The nurse is conducting the diagnosing phase (nursing diagnosis) of the nursing process for a client with a seizure disorder. Which step exists between data analysis and formulating the diagnostic statement?

a)

Assess the client’s needs

b)

Delineate the client’s problems and strengths

c)

Determine which interventions are most likely to succeed.

d)

Estimate the cost of several different approaches

23.

Which of the following nursing diagnoses contains the proper components?

a)

Risk for Caregiver Role Strain related to unpredictable illness course

b)

Risk for Falls related to tendency to collapse when having difficulty breathing

c)

Impaired Communication related to stroke

d)

Sleep Deprivation secondary to fatigue and a noisy environment

24.

Which of the following is likely to occur if a goal statement is poorly written?

a)

There is no standard against which to compare outcomes.

b)

The nursing diagnoses cannot be prioritized.

c)

Only dependent nursing interventions can be used

d)

It is difficult to determine which nursing interventions can be delegated.

25.

Which of the following principles does the nurse use in selecting interventions for the care plan?

a)

Actions should address the etiology of the nursing diagnosis

b)

Always select independent interventions when possible

c)

There is one best intervention for each goal/outcome.

d)

Interventions should be “doing,” not just “monitoring.”

26.

When initiating the implementation phase of the nursing process, the nurse performs which of the following phases first?

a)

Carrying out nursing interventions

b)

Determining the need for assistance

c)

Reassessing the client

d)

Documenting interventions

27.

Which of the following is true regarding the relationship of implementing to the other phases of the nursing process?

a)

The findings from the assessing phase are reconfirmed in the implementing phase.

b)

After implementing, the nurse moves to the diagnosing phase

c)

The nurse’s need for involvement of other health care team members in implementing occurs during the planning phase

d)

Once all interventions have been completed, evaluating can begin.

28.

The primary purpose of the evaluation phase of the care planning process is to determine whether

a)

Desired outcomes have been met

b)

Nursing activities were carried out.

c)

Nursing activities were effective

d)

Client’s condition has changed

29.

Which of the following represents application of the components of evaluating?

a)

Goal achievement must be written as either completely met or unmet.

b)

Data related to expected outcomes must be collected

c)

If the outcome was achieved, conclude that the plan was effective

d)

After determining that the outcome was not met, start over with a new nursing care plan.

30.

The nurse repositions a client who has difficulty breathing. Which nursing action, when performed following the intervention, demonstrates evaluation?

a)

Instructing the client the importance of mobility

b)

Arranging the pillows behind the client's back

c)

Checking the client's respiratory status

d)

Changing the rate of flow for the oxygen delivery system

31.

Which statement is correctly stated as an expected client outcome?

a)

Client will ambulate safely.

b)

Client will be able to safely walk down the hallway.

c)

Nurse will assist the client with ambulation three times daily.

d)

Client will ambulate with assistance to nurse's station on second postoperative day.

32.

The nurse is caring for a one day postoperative client with a new colostomy. What nursing diagnosis would be the primary concern for the nurse?

a)

Activity intolerance

b)

Ineffective Health Maintenance

c)

Impaired bowel elimination

d)

Ineffective coping

33.

The nurse knows which intervention is a dependent intervention?

a)

Obtaining a client's BP

b)

Massaging a client's back

c)

Administering medications to a client

d)

Assessing a client's lung sounds

34.

The nurse is caring for a client recovering from a CVA (cerebrovascular accident). When reviewing orders, the nurse notes that a healthcare provider has written an order for the client to ambulate, while another has written for strict bedrest. What is the most appropriate nursing intervention?

a)

Collaborate with the physical therapist to determine if the client can ambulate

b)

Assess the client to determine the client's ability to ambulate

c)

Instruct the client to clarify with the healthcare provider ambulation orders

d)

Clarify ambulation orders with healthcare providers

35.

One hour after receiving pain medication, a postoperative client reports intense pain. What is the nurse's most appropriate first action?

a)

Discuss the frequency of pain medication orders with the client.

b)

Assess the client to determine the cause of the pain

c)

Consult with the healthcare provider for additional pain orders

d)

Assist the client to reposition and splint the incision site

36.

A discipline specific, reflective reasoning process that guides a nurse in generating, implementing and evaluating approaches for dealing with client care and professional concerns which is essenial to safe, competent, skillful nursing practice.

a)

Assessment

b)

Planning

c)

Implementation

d)

Critical Thinking

37.

The cornerstone of the nursing profession

a)

Nursing Process

b)

Critical Thinking

c)

Concept of Man

d)

Health

38.

It is involved in every step of the nursing process. Nurses are not bound by standard responses. This facilitates the individualization of the nurses's plan of care.

a)

Assessment

b)

Diagnosing

c)

Decision Making

d)

Interventions

39.

The process of gathering information about a client's health status.

a)

Collecting

b)

Organizing

c)

Validating

d)

Documenting

40.

The best source of data

a)

Community

b)

Diagnosis

c)

Chart

d)

Client

41.

To define, refine and promote a taxonomy of nursing diagnostic terminology of general use to professional nurses

a)

NURSING PROCESS

b)

North American Nursing Diagnosis Association

c)

FDAR

d)

SOAPIE

42.

The nurse refers to the client's assessment data and diagnostic statement for direction in formulating client goals and designing the nursing interventions required to prevent client's heath problems.

a)

Assessment

b)

Planning

c)

Implementation

d)

Documentation

43.

Any treatment, based upon clinical judgement and knowledge, that a nurse performs to enhance patient/client outcomes

a)

Assessment

b)

Evaluation

c)

Nursing Intervention

d)

Cues

44.

Characteristics of a Good Goal and Expected Outcome

a)

NANDA

b)

EVALUATE

c)

GOAL

d)

SMART-C

45.

The Last step of the nursing process but not the end of it.

a)

Assessment

b)

Planning

c)

Evaluation

d)

GOAL

46.

The following are examples of Objective Data, EXCEPT:

a)

RBS: 180mg/dl

b)

Grade 1, slight pitting Edema on lower extremities

c)

Anosmia

d)

Skin is warm to touch

47.

A patient comes to the clinic with a 1st degree burn on his left dorsal hand. Which among these are considered a priority nursing diagnosis.

a)

Risk for ineffective airway clearance

b)

Acute pain

c)

Risk for infection

d)

Impaired skin integrity

48.

A good nursing plan objective must be SMART, which stands for:

a)

Specific, measurable, attainable, realistic, timely

b)

Specific, manageable, achievable, relative, timely

c)

Sustainable, meaningful, admirable, retainable, true

d)

Specific, measurable, alternative, risky, transferrable

49.

Which among these interventions is considered a direct care intervention?

a)

Wound cleaning

b)

Telephone consultation

c)

Documentation

d)

Shift endorsement

50.

A good nursing intervention must have the following characteristics, EXCEPT for:

a)

Acceptability

b)

Evidence base

c)

Feasibility

d)

Communication

51.

You noticed that your evaluation did not align with your expected outcome from your planning phase, hence your goal was not met. What would be your next step?

a)

Revise your goal to meet your evaluation

b)

Reassess the situation and make another nursing care plan

c)

Notify your supervisor and document your findings

d)

Change your evaluation no one will notice anyway

52.

_______ assessments can be done with an initial assessment. They identify new or overlooked problems. They are important because they can "flag" existing problems.

a)

Initial

b)

Focused

c)

On-going

d)

Emergency

53.

Time lapsed assessments compare current status to the ______data

a)

Subjective

b)

Projected

c)

Objective

d)

Baseline

54.

The E in the HELP mnemonic ensure systematic person-centered observation stand for

a)

Environmental equipment

b)

Essential equipment

c)

Environmental essentials

55.

_______ data is observable and measurable data that can be seen, heard, felt or measured by someone other than the person experiencing them

a)

Objective

b)

Subjective

56.

_______ is the conscious and deliberate use of the five senses to gather data

a)

Assessment

b)

Interview

c)

Observation

57.

The act of confirming or verifying data is__________

a)

Interview

b)

Inference

c)

Validation

58.

The four methods used to collect data during an assessment (select all that apply)

a)

Inspection

b)

Palpitation

c)

Percussion

d)

Clarify

e)

Auscultation

59.

The _____ step of the nursing process interprets and analyzes data gathered

a)

Assessment

b)

Diagnosis

c)

Implementation

d)

Evaluation

60.

Alfaro-LaFevre in her book identifies the shift from diagnose and treat to _______, prevent, manage and promote (PPMP)

a)

Preside

b)

Propose

c)

Pattern

d)

Predict

61.

The formulation of nursing diagnosis statements include

(select all that apply)

a)

Problem

b)

Defining characteristics

c)

Related factors

d)

Medical diagnosis

e)

Etiology

62.

Caring for a patient who presents with labored respirations, productive cough, and fever. What would be an appropriate nursing diagnosis for this patient? (select all that apply)

a)

Bronchial pneumonia

b)

Impaired gas exchange

c)

Ineffective airway clearance

d)

Potential complications: sepsis

e)

Risk for septic shock

63.

The systematic problem-solving approach towards providing individualized nursing care is known as

a)

Clinical process

b)

Nursing process

c)

Clinical reasoning cycle

64.

This step of the nursing process includes the systematic collection of all subjective and objective data about the client in which the nurse focuses holistically on the client- physical, psychological, emotional, sociocultural, and spiritual.

a)

Planning

b)

Nursing Diagnosis

c)

Assessment

d)

Data collection

65.

Observable and measurable information is known as

(a)  

66.

Subjective data is information verbalised or stated by the patient.

a)

True

b)

False

67.

Which could be considered objective data from the following?

a)

nausea and vomiting

b)

Pain

c)

BP120/60mmHg

68.

Name the association established to develop, refine, and promote the taxonomy of nursing diagnostic terminology used by nurses.

a)

NANDA

b)

NMBA

c)

APHRA

d)

ICN

69.

The purpose of the Nursing Process is to:

a)

Cure illness

b)

Guide written documentation

c)

Achieve care that is person centered and holistic

d)

help plan your day

70.

What are the 6 Cs?

a)

Caring, Collaborative, Creative, Commitment, Common and Commendable

b)

Care, Compassion, Competence, Courage, Communication and Commitment

c)

Care, Compassion, Candid, Clinical, Compatible and Conscientious

71.

What is the purpose of the 6Cs?

a)

They sound good!

b)

They are the values which need to underpin the culture and practice of individuals and organisations delivering care

c)

To help us pass this module

d)

It is the process of how to carry out a patient assessment

72.

The term APIE is an acronym and it stands for:

a)

Assessment, Purpose, Investigation, Exercise

b)

Assessment, Planning, Interpretation and Evaluation

c)

Appendix, Pancreas, Intestine and Epiglottis

d)

Assessment, Planning, Implementation and Evaluation

73.

What is the purpose of Roper, Logan and Tierney's Activities of Living Model?

a)

A framework for nurses to use to plan and deliver appropriate nursing care

b)

It estimates when a patient will be discharged

c)

It plans for what the patient will do when they leave hospital

d)

It assess the patients ability to sustain life

74.

Although all sections of the nursing process (APIE) are important, which step provided the foundations of the process?

a)

Assessment

b)

Planning

c)

Implementation

d)

Evaluation

75.

During which part of the client interview would it be best for the nurse to ask, "What's the weather forecast for today?"

a)

Introduction

b)

Body

c)

Closing.

d)

Orientation

76.

The nurse is most likely to collect timely, specific information by asking which of the following questions?

a)

"Would you describe what you are feeling?"

b)

How are you today?

c)

What would you like to talk about?

d)

"Where does it hurt?"

77.

Which phase of the nursing process involves analyzing and synthesizing data?

a)

Assessment

b)

Diagnosis

c)

Planning

d)

Implementation

e)

Evaluation

78.

This phase involves setting priorities and goals/ outcomes in collaboration with client.

a)

Assessment

b)

Diagnosis

c)

Planning

d)

Implementation

e)

Evaluation

79.

Which of the following is considered as the primary source of data?

a)

Laboratory result

b)

health professionals

c)

client

d)

family members

80.

It is a planned communication or a conversation with a purpose.

a)

Observing

b)

Interviewing

c)

Examining

d)

All of the above

81.

Which Gordon's functional health patter describes the client’s pattern of role participation and relationships?

a)

Health perception/health management pattern.

b)

Self-perception/ self-concept pattern

c)

Role/relationship pattern

d)

Sleep-rest pattern

82.

It is a statement or conclusion regarding the nature of phenomenon.

a)

Assessment

b)

Diagnosis

c)

Planning

d)

Evaluatin

83.

Which of the following type of diagnosis is a clinical judgment that a problem does not exist, but the presence of risk factors indicates that a problem is likely to develop unless nurses intervene?

a)

Actual nursing diagnosis

b)

Risk nursing diagnosis

c)

Wellness diagnosis

d)

Syndrome diagnosis

84.

Which type of nursing diagnosis that is associated with a cluster of other diagnoses?

a)

Actual nursing diagnosis

b)

Risk nursing diagnosis

c)

Wellness nursing diagnosis

d)

Syndrome nursing diagnosis

85.

Which of the following types of planning is initiated as soon as possible after the initial assessment, especially because of the trend toward shorter hospital stays?

a)

Initial planning

b)

Ongoing planning

c)

Discharge planning

d)

Emergency planning

86.

Which of the following type of goals are often used for clients who live at home and have

chronic health problems and for clients in nursing homes, extended

care facilities, and rehabilitation centers?

a)

Short term goal

b)

Long term goal

c)

Partial goal

d)

All of the above

87.

Identification:

What type of nursing intervention that nurses are licensed to initiate on the basis of their knowledge and skills.

(a)  

88.

Identification:

What type of nursing intervention that the nurse carries out in collaboration with other health team members, such as physical therapist, social workers, dietitians, and physicians.

(a)  

89.

Which of the following are Maslow's hierarchy of needs?

a)

survival needs

b)

Love and belonging needs

c)

Self needs

d)

Safety and security needs

90.

Which of the following are developmental theories?

a)

Erikson’s eight stages of development

b)

Piaget’s phases of cognitive development

c)

Physical fitness evaluation

d)

Body system model

91.

Which of the following is considered as an actual nursing diagnosis?

a)

Readiness for Enhanced Family Coping

b)

Risk for Infection

c)

Anxiety

d)

Activity Intolerance

e)

Chronic pain syndrom

92.

Essay: To be answered in 10 minutes (5 pts)

What is the importance of Nursing Process?

4 lines
93.

This step of the nursing process includes the systematic collection of all subjective and objective data about the client in which the nurse focuses holistically on the client- physical, psychological, emotional, sociocultural, and spiritual.

a)

Assessment

b)

Planning

c)

Implementation

d)

Diagnosis

94.

2. Which of the following is the subjective data?

a)

Patient verbalized feeling of pain

b)

The temperature is 38.5 degree celcius

c)

Wheezing lung sound present

d)

Heart rate is 100 beats per min

95.

3. Impaired skin integrity (pressure injury) related to bedridden as evidenced by present of wound laceration. Which part of the above nursing diagnosis statement indicates etiology?

a)

Impaired skin integrity

b)

Bedridden

c)

Pressure ulcer

d)

Wound laceration

96.

4. When planning nursing care for a client, objectives should be SMART. Specific, measurable, action-oriented, realistic, and timely. Which example best describes an outcome that is measurable?

a)

The client will ambulate to the end of the hallway within 2 days

b)

The client will verbalize feelings about her diagnosis

c)

The client will have control of his back pain

d)

The client's family will agree to the methods of treatment

97.

The following are the types of nursing diagnosis except

a)

Actual

b)

Risk

c)

Health promotion

d)

Safety

e)

Possible

98.

One hour after receiving pain medication, a postoperative client reports intense pain. What is the nurse's most appropriate first action?

a)

Discuss the frequency of pain medication orders with the client.

b)

Assess the client to determine the cause of the pain

c)

Consult with the healthcare provider for additional pain orders

d)

Assist the client to reposition and splint the incision site

99.

The nurse repositions a client who has difficulty breathing. Which nursing action, when performed following the intervention, demonstrates evaluation?

a)

Instructing the client the importance of mobility

b)

Arranging the pillows behind the client's back

c)

Checking the client's respiratory status

d)

Changing the rate of flow for the oxygen delivery system

100.

Which statement is correctly stated as an expected client outcome?

a)

Client will ambulate safely.

b)

Client will be able to safely walk down the hallway.

c)

Nurse will assist the client with ambulation three times daily.

d)

Client will ambulate with assistance to nurse's station on second postoperative day.

101.

The nurse is caring for a one day postoperative client with a new colostomy. What nursing diagnosis would be the primary concern for the nurse?

a)

Activity intolerance

b)

Ineffective Health Maintenance

c)

Impaired bowel elimination

d)

Ineffective coping

102.

The nurse knows which intervention is a dependent intervention?

a)

Obtaining a client's BP

b)

Massaging a client's back

c)

Administering medications to a client

d)

Assessing a client's lung sounds

103.

The nurse is caring for a client recovering from a CVA (cerebrovascular accident). When reviewing orders, the nurse notes that a healthcare provider has written an order for the client to ambulate, while another has written for strict bedrest. What is the most appropriate nursing intervention?

a)

Collaborate with the physical therapist to determine if the client can ambulate

b)

Assess the client to determine the client's ability to ambulate

c)

Instruct the client to clarify with the healthcare provider ambulation orders

d)

Clarify ambulation orders with healthcare providers

104.

Which of the following best describes the correct sequence of the nursing process?

a)

assessment, diagnosis, planning, implementation, and evaluation.

b)

planning, assessment, diagnosis, evaluation, and implementation.

c)

diagnosis, implementation, assessment, evaluation, and planning.

d)

implementation, planning, evaluation, assessment, and diagnosis.

105.

When preparing a plan of care, the nurse uses skillful reasoning and logical thought to determine the merits of an action. Which action is the nurse performing?

a)

Critical thinking

b)

Sensory overload

c)

Concrete thinking

d)

Logical reasoning

106.

While caring for a newly admitted client, the registered nurse (RN) gathers information by interviewing the client to obtain a health history and reviewing the results of laboratory and diagnostic tests. Which step in the nursing process did this nurse complete?

a)

Planning

b)

Evaluation

c)

Assessment

d)

Implementation

107.

The student is preparing a concept map prior to caring for a client during the next clinical day. Which should the student do when creating this map?

a)

Focus on assessment data

b)

Follow the nursing process

c)

Evaluate the outcome of care provided

d)

Validate the information with laboratory values

108.

Which of the following is an appropriate nursing diagnosis for a patient who has a history of excessive secretions in the lungs and wheezing?

a)

COPD

b)

Asthma

c)

Ineffective airway clearance

d)

Tuberculosis

109.

Which of the following are examples that fall under the implementation phase of the nursing process? (Select all that apply)

a)

Turning a patient every 2 hours

b)

Administer medications

c)

Patient teaching

d)

Taking a patient's oral temperature

e)

Performing a head-to-toe exam

110.

Which of the following belongs to assessment?

a)

Verbalization of patient.

b)

Difficulty of breathing

c)

BP 150/100mmhg

d)

All of the above

111.

Blank is the actions given to a patient when complaining of pain.

(a)  

112.

The following are the examples of Subjective Data except.

a)

Verbalization of pain

b)

BP 120/100mmhg

c)

Feeling cold

d)

Epigastric pain

113.

An example of subjective data for assessment is:

a)

"I feel like I have a fever"

b)

Patient appears flushed

c)

Patient's temperature is 101 degrees F - orally

d)

Patient is experiencing a high fever

114.

Which of the following does NOT fit within the cluster of impaired mobility

a)

Dragging left leg when walking

b)

Using a cane

c)

Complains of pain in left leg

d)

Requires assistance to ambulate

115.

Another term for "diagnostic label" is:

a)

Nursing diagnosis

b)

Cluster

c)

Problem

d)

Etiology

116.

What observation can be made about the following nursing diagnostic label:

Pneumonia related to bacterial infection.......

a)

Nothing is wrong with it

b)

Stated correctly

c)

It is a medical diagnosis

d)

It is a NANDA dx.

117.

Determining goals, outcomes and interventions is within which step of the Nursing Process?

a)

Assessment

b)

Diagnosis

c)

Planning

d)

Evaluation

118.

Which intervention represents one that is nurse initiated (Independent ) action

a)

Administer furosemide 40 mg po every am

b)

Assist the patient with a bed bath

c)

Patient's diet: Low sodium

d)

Change wound dressing daily

119.

Implementation best refers to:

a)

Deciding on the appropriate interventions

b)

Carrying out the physicians orders

c)

Determining if the goal has been met

d)

Carrying out the planned interventions

120.

The nursing assistant reports that a patient is complaining of SOB (shortness of breath). Which action should the nurse take next?

a)

Let the patient rest and check on him in 30 minutes

b)

Instruct the nursing assistant to take a set of vital signes

c)

Contact the physician immediately

d)

Assess the patient her/him self

121.

The blood pressure in the left arm per the electronic machine reads as 80/ 40. What is the next action by the RN?

a)

Check the other arm

b)

Obtain a different machine

c)

Re check the BP with a stethoscope

d)

Initiate the alarm for a code blue

122.

The patient's O2 saturation at 8 AM was 95%. At 2 p.m. when vital signs are checked again, it is 90%. What is the first action by the nurse?

a)

Call the physician

b)

Check it using another finger

c)

Do a further assessment

d)

Elevate the head of the bed.

123.

The nurse repositions a client who has difficulty breathing. Which nursing action, when performed following the intervention, demonstrates evaluation?

a)

Instructing the client the importance of mobility

b)

Arranging the pillows behind the client's back

c)

Checking the client's respiratory status

d)

Changing the rate of flow for the oxygen delivery system

124.

Which statement is correctly stated as an expected client outcome?

a)

Client will ambulate safely.

b)

Client will be able to safely walk down the hallway.

c)

Nurse will assist the client with ambulation three times daily.

d)

Client will ambulate with assistance to nurse's station on second postoperative day.

125.

The systematic problem-solving approach toward providing individualized nursing care is known as

a)

NURSING CARE PLAN

b)

NURSING PROCESS

c)

ASSESSMENT

d)

IMPLEMENTATION

126.

The systematic problem-solving approach toward providing individualized nursing care is known as

a)

NURSING CARE PLAN

b)

NURSING PROCESS

c)

ASSESSMENT

d)

IMPLEMENTATION

127.

This association was established to develop, refine, and promote taxonomy of nursing diagnostic terminology used by nurses

a)

ETHICAL NURSING ASSOCIATION

b)

NORTH AMERICAN NURSING DIAGNOSIS INTERNATIONAL

c)

AMERICAN NURSING ASSOCIATION

d)

APA

128.

THE TERM NURSING PROCESS WAS FIRST MENTIONED BY

a)

LYDIA HALL

b)

VERGINIA HENDERSON

c)

FLORENCE NIGHTINGALE

d)

DORATHY OREM

129.

THE APPROACH FOR EFFECTIVE PROVISION OF NURSING CARE IS

a)

POE

b)

GOSH

c)

SOAPIE

d)

DAR

130.

THE PHASE OF NURSING PROCESS THAT INVOLVES COLLECTING,ORGANIZING,VALIDATING AND DOCUMENTING CLIENT DATA IS

a)

Assessment

b)

Diagnosis

c)

Planning

d)

Implementation

131.

The purpose of Nursing Process is to

a)

cure illness

b)

Guide written documentation

c)

Achieve care that is person centered and holistic

d)

help to plan your day

132.

The valid source for patient assessment data is

a)

Patient's family

b)

Medical record/Chart

c)

Health care team

d)

All the above

133.

Assessment performed to identify the problems like choking,M.I is

a)

Emergency assessment

b)

Focus assessment

c)

Initial assessment

d)

Physical assessment

134.

Expand AVPU

a)

Alert Voice Pain Unresponse

b)

Active Verbal Passive Unconscious

c)

Airway ventilation perfusion Uncooperative

d)

Airway Verbal Perfusion Unresponse

135.

The best example for objective data is

a)

client reports a fever

b)

client verbalizes Itching

c)

Client reports Head ache

d)

Temperature of 99.2 degree F

136.

Example for focus assessment except

a)

intake and output chart

b)

VAS

c)

SPO2

d)

CAB

137.

The phase of Nursing Process that involves analyzing,synthesizing data is

a)

Assessment

b)

Nursing Diganosis

c)

Planning

d)

Implementation

138.

The 3 part of Nursing Diagnosis are

a)

Patient,Signs and Symptoms

b)

Problem, Etiology and Symptoms

c)

Patient,Etiology and Signs

d)

Physical assessment,etiology and signs

139.

client uses signs and symptoms that furnish evidence that the problem exists

a)

Risk factors

b)

Defining Characteristics

c)

Description of problem

d)

Nursing Diagnosis

140.

Readiness for enhanced nutrition is

a)

Actual nursing diagnosis

b)

Risk nursing diagnosis

c)

Health Promotion Nursing diagnosis

d)

Possible nursing diagnosis

141.

The Nursing diagnosis is not in recent NANDA Diagnosis List

a)

Imbalanced nutritional status more than body requirement

b)

Activity intolerance

c)

Ineffective thermoregulation

d)

obesity

142.

The planning stage in the nursing process involves

a)

Outcomes and goals

b)

Goals,Outcomes and interventions

c)

Interventions based on medical diagnosis

d)

Goals based on medical diagnosis

143.

The components of expected outcome are

a)

subject,verb,modifiers,criteria

b)

subject,noun,verb,criteria

c)

Subject,conditioner,verb, noun

d)

subject, verb,conditioner,noun

144.

Dependent Nursing intervention is

a)

Provide Oral care

b)

Provide Cold compress

c)

Administer Oral Medication

d)

Provide Perineal care

145.

The goal should be in

a)

general term

b)

specific term

c)

broad term

d)

clear term

146.

Prioritize the nursing intervention for the patient with body temperature 102 degree F

i. Monitor vital signs q4h

ii.Administer antipyretics as per Physician Order

iii.Provide Tepid sponging

iv.Instruct Patient to drink fluids adequately as tolerated

a)

i,ii,iii,iv

b)

i,iv,ii,iii

c)

i,iv,iii,ii

d)

i,iii,iv,ii

147.

The Student Nurse revises care plan in the step

a)

Assessment

b)

Nursing Diagnosis

c)

Planning

d)

Evaluation

148.

The evaluation stage involves

a)

determining progress toward goals completion

b)

assessing outcomes for completion

c)

editing nursing care plan

d)

all the above

149.

The process of putting the nursing care plan into action is

a)

Assessment

b)

Planning

c)

Implementation

d)

Evaluation

150.

The skill required to implement the nursing care

a)

cognitive skill

b)

psychomotor skill

c)

interpersonal skill

d)

all the above