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    Exam Review

    1. Show that documentation of patient care by the nurse is very important by selecting from the following: (select all that apply)
      (SATA)
      A)
      Incident reports must be recorded in the nurse's notes
      B)
      Institutions are only reimbursed for patient care that is documented
      C)
      Document only when not successful
      D)
      The patient record is a complete picture of individualized problems, treatments and responses to treatments
    2. Select the proper order of the phases of the Nursing Process:
      A)
      Evaluation, planning, assessment, implementation
      B)
      Assessment, planning, implementation, evaluation
      C)
      Implementation, assessment, planning, evaluation
      D)
      Planning, evaluation, assessment, implementation
    3. The nurse is reviewing the patient's plan of care and ordered treatments. Which of the following is (are) independent nursing interventions? (select all that apply)
      (SATA)
      A)
      Teaching deep breathing and relaxation techniques as needed
      B)
      Inserting a nasogastric tube (NG) to relieve gastric distention
      C)
      Placing the nurse call button within reach at all times
      D)
      Giving hand massages daily
      E)
      Repositioning the patient every 2 hours to reduce pressure injury risk
      F)
      Giving acetaminophen (Tylenol) 650 mg orally every 4 hours as needed
    4. A patient with edema has a problem of fluid overload. The nurse is developing a care plan and selecting interventions that will assist the patient in reducing the fluid. An important consideration when developing the care plan is to:
      A)
      use a Nursing Diagnosis from a source other than NANDA-I
      B)
      limit the number of interventions
      C)
      select interventions which will be easy to implement
      D)
      involve the patient in the process
    Page 1 of 11

    Exam Review

    1. Identify the person responsible for analyzing and interpreting data to arrive at a nursing diagnosis:
      A)
      CNA
      B)
      Technician
      C)
      RN
      D)
      LPN/LVN
    2. A charge nurse is reviewing documentation with a group of newly hired nurses. Which of the following guidelines should be followed when documenting in a patient record? (select all that apply)
      (SATA)
      A)
      Wait until the end of the shift to document
      B)
      Cover errors with correction fluid, and write in the correct information
      C)
      Use as many abbreviations as possible to save space
      D)
      Document objective data, leaving out opinions
      E)
      The date and time should be included with each entry
    3. The primary source of assessment information is:
      A)
      the patient's friends
      B)
      past medical records
      C)
      the patient's record
      D)
      the patient
    4. When using the SOAP method of charting, S stands for subjective data which means:
      A)
      patient provided data
      B)
      all of the answers are correct
      C)
      observed data
      D)
      measured data
    Page 2 of 11

    Exam Review

    1. Compare an actual nursing diagnosis with a risk for nursing diagnosis, recognizing that in the case of the actual nursing diagnosis
      A)
      the patient is vulnerable to develop the problem
      B)
      there is no evidence of defining characteristics
      C)
      a condition is currently present
      D)
      it is written as a two-part statement
    2. On what form/forms should the nurse chart when administering a narcotic?
      A)
      Physician's Order Sheet
      B)
      Narcotic Administration Sheet
      C)
      Care Plan
      D)
      MAR and Narcotic Administration Sheet
    3. JCAHO regulates standards of care to:
      A)
      ensure subjective documentation
      B)
      make sure that all nurses use the same charting system
      C)
      ensure quality patient care
      D)
      make sure insurance companies get paid correctly
    4. The nurse administered the stat insulin dose as ordered, in the presence of the nurse's aide and the dietary aide, however, the nurse failed to chart the medication on the MAR. During a legal deposition regarding charges of professional malpractice, it was determined that:
      A)
      the insulin was administered based per the nurse's testimony
      B)
      none of the answers are correct
      C)
      the insulin was administered based on the witness testimony
      D)
      the insulin was not administered because it was not charted
    Page 3 of 11

    Exam Review

    1. The patient is confined to bed rest. This contributes to immobility of the patient. How should bed rest be indicated on the nursing care plan?
      A)
      as difficult to maintain
      B)
      as a risk factor
      C)
      as a nursing responsibility
      D)
      as contributing to the patient's recovery
    2. In which step of the nursing process do nurses look at outcomes?
      A)
      Evaluation
      B)
      Assessment
      C)
      Implementation
      D)
      Planning
    3. When discovering subjective data, recognize that they relate to:
      A)
      signs
      B)
      objective cues
      C)
      symptoms
      D)
      observable data
    4. The patient with a nursing diagnosis of airway clearance, ineffective, might have a desired patient outcome of:
      A)
      oxygen will be continued
      B)
      the patient's coughing frequency will increase
      C)
      cyanosis may be present
      D)
      within 24 hours, the patient will demonstrate no signs or symptoms of dyspnea
    Page 4 of 11

    Exam Review

    1. Documenting the type of interventions carried out, the time care was given, and the signature of the care giver results in recording:
      A)
      patient's nursing problem
      B)
      interventions carried out to meet the patient's needs
      C)
      patient's medical problem
      D)
      the patient's response to the intervention carried out
    2. Which of the following assists the nurse in the identification of nursing diagnoses?
      A)
      validated data
      B)
      data clustering
      C)
      subjective data
      D)
      objective data
    3. During the shift, the nurse charts only additional treatments done or withheld, changes in patient condition, and new concerns. Charting these factors demonstrates which of the following type of charting?
      A)
      block
      B)
      by exception
      C)
      focused
      D)
      SOAP
    4. During a physical examination, the nurse discovers that the patient demonstrates signs of flushed, dry, hot skin, dry mucous membranes and temperature elevation. The nurse realizes grouping this data represents:
      A)
      signs of fluid overload
      B)
      symptoms
      C)
      data clustering
      D)
      urinary retention
    Page 5 of 11

    Exam Review

    1. Understanding that health care personnel must respect the confidentiality of patients' records, the nurse:
      A)
      ethically can look at a friend's chart to see the diagnosis
      B)
      shares information from a chart to protect a friend
      C)
      knows that only the Patient's Bill of Rights advocates confidentiality
      D)
      reads charts only for professional reasons
    2. How is Maslow's Hierarchy of Human Needs used by nurses in a clinical setting?
      A)
      It serves as a reminder of human growth and development across the life span
      B)
      It helps in prioritizing nursing diagnoses and care
      C)
      It outlines the basic psychological needs that people have when they are hospitalized and feel anxiety
      D)
      It is a framework for thinking critically
    3. Your patient is admitted with a serious injury of the left hip after a fall at home. She is crying with severe pain in her left hip and leg. Which nursing diagnosis would apply to this patient's immediate needs?
      A)
      pain
      B)
      skin integrity
      C)
      fluid volume
      D)
      knowledge deficit
    4. Select the type of assessment which is performed continuously throughout nurse-patient contact:
      A)
      focused
      B)
      body systems
      C)
      subjective
      D)
      complete
    Page 6 of 11