Fundamentals of Nursing

The Nursing Process - 26 questions...
*lifted fromNCLEX-RN Brunner Suddarth
> answers & rationale to be posted after 2-3 days...
> passing rate 18/26
> Score 17-19 = fair
20-23 = v. good
24-26 = excellent

1. A client is to be discharged from an acute care facility after treatment of right leg thrombophlebitis. The nurse notes that the client's leg is pain free, without redness or edema. The nurse's actions reflect which step in the nursing process?
A. Assessment
B. Analysis
C. Implementation
D. Evaluation

2. The nurse identifies a client's responses to actual or potential health problems during which step of the nursing process?
A. Assessment
B. Analysis
C. Planning
D. Evaluation

3. Which type of evaluation occurs continuously throughout the teaching and learning process?
A. Formative
B. Retrospective
C. Summative
D. Informative

4. The nurse is reviewing a client's arterial blood gas (ABG) report. Which ABG value reflects the acid concentration in the blood?
A. pH
B. Pao2
C. Paco2
D. HCO3_

5. The nurse is providing care for a client who underwent mitral valve replacement. The best example of a measurable client outcome goal is to:
A. change his own dressing.
B. walk in the hallway.
C. walk from his room to the end of the hall and back before discharge.
D. eat a special diet.

6. A client who received general anesthesia returns from surgery. Postoperatively, which nursing diagnosis takes highest priority for this client?
A. Acute pain related to surgery
B. Deficient fluid volume related to blood and fluid loss from surgery
C. Impaired physical mobility related to surgery
D. Risk for aspiration related to anesthesia

7. A blind client is admitted for treatment of gastroenteritis. Which nursing diagnosis takes highest priority for this client?
A. Anxiety
B. Risk for injury
C. Activity intolerance
D. Impaired physical mobility

8. One aspect of implementation related to drug therapy is:
A. developing a content outline.
B. documenting drugs given.
C. establishing outcome criteria.
D. setting realistic client goals.

9. A client has a nursing diagnosis of Risk for injury related to adverse effects of potassium-wasting diuretics. What is the correctly written client outcome for this nursing diagnosis?
A. By discharge, the client correctly identifies three potassium-rich foods.
B. The client knows the importance of consuming potassium-rich foods daily.
C. Before discharge, the client knows which food sources are high in potassium.
D. The client understands all complications of the disease process.

10. Shortly after being admitted to the coronary care unit with an acute myocardial infarction (MI), a client reports midsternal chest pain radiating down the left arm. The nurse notices that the client is restless and slightly diaphoretic, and measures a temperature of 99.6° F (37.6° C), a heart rate of 102 beats/minute; regular, slightly labored respirations at 26 breaths/minute; and a blood pressure of 150/90 mm Hg. Which nursing diagnosis takes highest priority?
A. Risk for imbalanced body temperature
B. Decreased cardiac output
C. Anxiety
D. Acute pain

11. A client with shock brought on by hemorrhage has a temperature of 97.6° F (36.4° C), a heart rate of 140 beats/minute, a respiratory rate of 28 breaths/minute, and a blood pressure of 60/30 mm Hg. For this client the nurse should question which physician order?
A. "Monitor urine output every hour."
B. "Infuse I.V. fluids at 83 ml/hr"
C. "Administer oxygen by nasal cannula at 3 L/minute"
D. "Draw samples for hemoglobin and hematocrit every 6 hours."

12. While caring for a client who is immobile, the nurse documents the following information in the client's chart: "Turn client from side to back every two hours." "Skin intact; no redness noted." "Client up in chair three times today." "Improved skin turgor noted." Which nursing diagnosis accurately reflects this information?
A. Risk for impaired skin integrity related to immobility
B. Impaired skin integrity related to immobility
C. Constipation related to immobility
D. Disturbed body image related to immobility

13. What is the most appropriate nursing diagnosis for the client with acute pancreatitis?
A. Deficient fluid volume
B. Excess fluid volume
C. Decreased cardiac output
D. Ineffective gastrointestinal tissue perfusion

14. After a cerebrovascular accident (CVA) a client develops aphasia. Which assessment finding is most typical in aphasia?
A. Arm and leg weakness
B. Absence of the gag reflex
C. Difficulty swallowing
D. Inability to speak clearly

15. Which intervention is an example of a primary prevention?
A. Administering digoxin (Lanoxicaps) to a client with heart failure
B. Administering a measles, mumps, and rubella immunization to an infant
C. Obtaining a Papanicolaou (Pap) test to screen for cervical cancer
D. Using occupational therapy to help a client cope with arthritis

16. A client is hospitalized with Pneumocystis carinii pneumonia. The nurse notes that the client has had no visitors, is withdrawn, avoids eye contact, and refuses to take part in conversation. In a loud and angry voice the client demands the nurse leave the room. The nurse formulates a nursing diagnosis of Social isolation. Based on this diagnosis what is an appropriate goal for this client?
A. Identifying one way to increase social interaction
B. Reporting increased adaptation to changes in health status
C. Identifying at least one factor contributing to altered sexuality patterns
D. Returning a demonstration of measures that can increase independence

17. Which client characteristic would be an example of noncompliance?
A. Undesired drug action
B. Multiple questions
C. Failure to progress
D. Resolved symptoms

18. The nurse is revising a client's plan of care. During which step of the nursing process does such revision take place?
A. Assessment
B. Planning
C. Implementation
D. Evaluation

19. The nurse is taking the health history of an 85-year-old client. Which information will be most useful to the nurse for planning care?
A. General health for the past 10 years
B. Current health promotion activities
C. Family history of diseases
D. Marital status

20. Which clinical characteristic affects client compliance?
A. Drug knowledge
B. Psychosocial factors
C. Nurse-client relationship
D. Disease duration and severity

21. When monitoring a client's central venous pressure (CVP), the nurse knows that a normal CVP measurement is:
A. 2 cm H20.
B. 1 mm Hg.
C. 10 mm Hg.
D. 5 cm H20.

22. The nurse may use one of the many nursing theories to guide client care. What are the four key concepts of most nursing theories?
A. Man, health, illness, and health care
B. Health, illness, health restoration, and caring
C. Man, environment, health, and nursing
D. Health, environment, disease, and treatment

23. Using Abraham Maslow's hierarchy of human needs, the nurse assigns highest priority to which client need?
A. Security
B. Elimination
C. Safety
D. Belonging

24. The nurse is caring for a client with a history of falls. The first priority when caring for a client at risk for falls is:
A. placing the call light for easy access.
B. keeping the bed at the lowest position possible.
C. instructing the client not to get out of bed without assistance.
D. keeping the bedpan available so that the client doesn't have to get out of bed.

25. A client is admitted with acute chest pain. When obtaining the health history, which question will be most helpful for the nurse to ask?
A. "Do you need anything now?"
B. "Why do you think you had a heart attack?"
C. "What were you doing when the pain started?"
D. "Has anyone in your family been sick lately?"

26. When developing a plan of care for an older adult the nurse should consider which challenges faced by clients in this age group?
A. Selecting vocation, becoming financially independent, and managing a home
B. Developing leisure activities, preparing for retirement, and resolving empty nest crisis
C. Managing a home, developing leisure activities, and preparing for retirement
D. Adjusting to retirement, deaths of family members, and decreased physical strength