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    Exam Review

    1. The nurse has completed a reassessment of the client and notes that the client has reached their goals. What is the next action by the nurse?
      A)
      Perform a health history on the client.
      B)
      Write a new diagnostic statement.
      C)
      Implement the nursing interventions that are relevant to the client.
      D)
      Discontinue the care plan and state how the client met their goals.
    2. Which guidelines should the nurse follow when implementing nursing interventions? Select all that apply.
      (SATA)
      A)
      Base nursing interventions on scientific knowledge.
      B)
      Consider time management as a priority.
      C)
      Delegation should not be considered when implementing nursing interventions.
      D)
      Adapt activities to the individual client.
      E)
      Only include independent nursing interventions in the nursing care plan.
      F)
      Respect the dignity of the client.
      G)
      Encourage the client to participate.
    3. Which desired outcome is correctly written?
      A)
      The client will be adequately hydrated by discharge.
      B)
      The client will walk better after resting for 10 minutes
      C)
      The nurse will provide emotional support at least 3 times each day.
      D)
      The client will lose 5 pounds within the next 2 weeks.
    4. A nurse documents on a client's care plan, "Goal not met. Client refuses to ambulate, and states they are afraid of falling. The nurse should take which action?
      A)
      Notify the primary health-care provider.
      B)
      Consult physical therapy.
      C)
      Write a new nursing diagnosis.
      D)
      Modify the nursing interventions.
    Page 1 of 13

    Exam Review

    1. When prioritizing a client's care plan based on Maslow's hierarchy of needs, a nurse's priority nursing intervention should be which action?
      A)
      Ambulate the client in the hallway.
      B)
      Place the client in wrist restraints.
      C)
      Allow family members to visit a newly admitted client.
      D)
      Assist the client with feeding.
    2. Choose the NANDA diagnosis from highest priority to lowest priority according to Maslow's hierarchy of needs.
      (SATA)
      A)
      Decreased cardiac output related to enlargement of the myocardium.
      B)
      Dysfunctional family process related to divorce of parents
      C)
      Imbalanced nutrition less than body requirements related failure to ingest adequate calories
      D)
      Ineffective breathing pattern related to opioid consumption
      E)
      Situational low self-esteem related to loss of job.
    3. A nurse would like to include ambulation assistance as a care plan intervention. Which is the best way to state this in the plan?
      A)
      Client will understand the for using the gait belt.
      B)
      Client will ambulate in hallway twice daily.
      C)
      Nurse will ambulate with client, using a gait belt, twice daily for 15 minutes.
      D)
      Nurse will assist the client with ambulation.
    4. What critical thinking attitude is the nurse using when they are persistent to clarify the information and determined to find effective solutions to patient care problems?
      A)
      Curiosity.
      B)
      Humility.
      C)
      Integrity.
      D)
      Perseverance.
    Page 2 of 13

    Exam Review

    1. A nurse questions a routine that has been practiced for a long time, researching whether there might be a better routine, in the best interest of the patients. Which critical- thinking attitude is this nurse practicing?
      A)
      Reflection.
      B)
      Curiosity.
      C)
      Integrity.
      D)
      Fairness
    2. Which steps should a nurse use to avoid errors in writing a nursing diagnosis? Select all that apply.
      (SATA)
      A)
      Assign the LPN the responsibilities of developing the nursing plan of care.
      B)
      Build appropriate nursing knowledge by using evidence-based journals.
      C)
      Verify the data is correct by consulting with the patient and family.
      D)
      Base the diagnosis on patterns or behaviors over time rather than an isolated incident.
      E)
      Have a working knowledge of population norms regarding vital signs, laboratory tests, and assessment data.
    3. A nurse's aide obtains vital signs for a newly admitted client and reports: respirations 26 breaths/min (normal adult range 12-20 breaths/minute), pulse = 98 beats/minute (normal adult range 60-100 beats/minute), and blood pressure = 200/146 mmHg (normal adult range 100-120/60-80 mmHg) What should be the next action by the nurse?
      A)
      Report the findings to the charge nurse.
      B)
      Confirm the accuracy of the vital signs.
      C)
      Continue with the physical assessment as soon as possible.
      D)
      Call the primary health-care provider.
    4. Which behaviors by a nurse demonstrate that the nurse is practicing critical thinking? Select all that apply.
      A)
      Accepting without question the knowledge acquired in nursing school.
      B)
      Gathering assistance to move a client after noting the client weighs 300 pounds.
      C)
      Admitting not knowing how to do a procedure and requesting help.
      D)
      Using unsubstantiated experiences to support an opinion or position.
      E)
      The nurse examined their own feelings of bias prior to taking care of the patient with cultural differences.
      F)
      The nurse admits when they made a medication error and completes the required reporting.
    Page 3 of 13

    Exam Review

    1. A nurse is performing an initial assessment of a spanish-speaking client. What is the best method to interview this client?
      A)
      Document that the initial assessment cannot be completed due to a language barrier.
      B)
      Ask the nursing assistant that is fluent in Spanish to assist you.
      C)
      Ask a family member to interpret for the patient.
      D)
      Use a professional interpreter.
    2. A nurse enters a client's room to provide education about how to care for the client's new colostomy. Upon entering the room, the client is crying. The nurse decides that listening to the client's fears takes priority over the planned education. This is an example of which component of the nursing process?
      A)
      Implementing the nursing intervention.
      B)
      Supervising delegated care.
      C)
      Determining the nurse's need for assistance.
      D)
      Assessing/Reassessing the client.
    3. Which clinical manifestation is considered objective data?
      A)
      Nausea.
      B)
      Irregular heart sounds.
      C)
      Pain level of 3 on a 0-10 scale.
      D)
      Fatigue.
    4. What is the first component of the evaluation process?
      A)
      Identifying desired outcomes.
      B)
      Implementation of nursing interventions.
      C)
      The client's progression towards the goals.
      D)
      Documentation of the nursing activities.
    Page 4 of 13

    Exam Review

    1. A nurse is documenting a complete health history to establish a database of problems for a client. What type of assessment is the nurse performing?
      A)
      Initial
      B)
      Problem-focused.
      C)
      Emergency.
      D)
      Time-lapsed
    2. Which statement is correct concerning the goal "Client will state pain is less than or equal to a 3 on a 0 to 10 pain scale?"
      A)
      The goal is not realistic.
      B)
      The goal is written correctly.
      C)
      The goal is not measurable.
      D)
      The goal has no target time.
    3. Which question is considered an open-ended question when performing a health history on a newly admitted patient?
      A)
      What medications are you currently taking?
      B)
      Do you have a health care power of attorney?
      C)
      What worries you the most about your disease process?
      D)
      Do you currently use any alcohol or tobacco products?
    4. Which actions should a nurse implement when conducting an interview with a new client? Select all that apply.
      A)
      Sit stiffly and professional in the chair.
      B)
      If there are questions you cannot answer, say so and let the patient know that you will return with follow-up answers.
      C)
      Greet the patient by the name that they prefer to be addressed.
      D)
      Avoid making the patient tired during the interview. You do not need to complete the interview in one session.
      E)
      At the end of the interview, ask the client to summarize the discussion.
      F)
      Respect silence and be flexible and open-minded.
      G)
      Login into the computer system when you enter the room so you can document the information as you complete the interview.
    Page 5 of 13

    Exam Review

    1. A nurse documents: "Client avoids eye contact and gives only vague, nonspecific answers to direct questioning by the professional staff. Laughs aloud, smiles, uses hand gestures in conversation with spouse." Which method of data collection does this documentation demonstrate?
      A)
      Examining
      B)
      Observing.
      C)
      Listening.
      D)
      Interviewing
    2. In developing a goal for a client with chronic high blood pressure, which nursing activity would be priority?
      A)
      Write patient centered interventions that address the client's high blood pressure compliance.
      B)
      Instruct the client to make dietary changes by reducing sodium intake.
      C)
      include the client in goal setting and plan of care.
      D)
      Educate the client and family of the importance of each medication.
    3. A client has just had a baby following a long labor and difficult delivery. Which nursing diagnosis is formulated correctly?
      A)
      Constipation due to exhaustion manifested by no bowel movement for 2 days.
      B)
      Altered urinary elimination secondary to childbirth as evidenced by inability to void since childbirth.
      C)
      Ineffective breast-feeding related to exhaustion secondary to childbirth as evidenced by no observable signs of oxytocin release.
      D)
      Risk for infection because of new incision related to episiotomy.
    4. A client reports back pain. The client has not had an injury and x-rays are within defined limits. Which is the most appropriately written nursing diagnosis for this client?
      A)
      Pain related to complex factors
      B)
      Pain related to unknown etiology.
      C)
      Pain related to psychosomatic condition.
      D)
      Pain related to client's report
    Page 6 of 13