Nursing Process Practice Questions Quizlet

Nursing Process Practice Questions Quizlet Related

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The NAP states that was busy and had not had a chance to tell the nurse yet. The patient begins to complain of feeling dizzy and light-headed. The blood pressure is rechecked and it has dropped even lower. In which phase of the nursing process did the nurse first make an error? NursingStoreRN

  • A. Assessment
  • B. Diagnosis
  • C. Implementation
  • D. Evaluation
Correct Answer: A

Rationale: The correct answer is A: Assessment. The nurse made an error in the assessment phase by not communicating the patient's condition promptly. Assessment involves collecting data and recognizing changes in the patient's condition. By not informing the nurse about feeling dizzy and light-headed, the nurse missed crucial information that could have indicated a deteriorating condition. The other choices are incorrect because: B: Diagnosis comes after assessment and involves analyzing data to identify the patient's problems. C: Implementation is the phase where nursing interventions are carried out based on the diagnosis. D: Evaluation is the final phase where the nurse assesses the effectiveness of interventions and outcomes.

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A nurse identifies Fatigue as a health problem and nursing diagnosis for a client receiving home care for metastatic cancer. What statement or question would be best to validate this client problem?

  • A. I have assessed you and find you are fatigued.
  • B. I analyzed and interpreted your information as fatigue.
  • C. Why are you so tired all the time?
  • D. I think fatigue is a problem for you. Do you agree?
Correct Answer: D

Rationale: The correct answer is D because it involves collaboration with the client to validate the identified health problem. By asking the client directly if they agree that fatigue is a problem for them, it promotes client-centered care and empowers the client in their own care. Choice A is incorrect as it assumes the nurse's assessment is enough to confirm fatigue. Choice B is incorrect as it focuses on the nurse's analysis rather than the client's experience. Choice C is incorrect because it is a closed-ended question that may not encourage open communication or validation from the client.

Nurse Norma’s discharge teaching for Mr. Aurelio, diagnosed with heart failure, should stress the significance of:

  • A. maintaining a sedentary lifestyle most of the day
  • B. obtain daily weights at the same time
  • C. walking 2 miles daily
  • D. maintaining a high fiber die
Correct Answer: B

Rationale: The correct answer is B: obtaining daily weights at the same time. This is crucial in monitoring fluid retention, a common issue in heart failure patients. Daily weights help detect early signs of fluid buildup. Option A is incorrect as physical activity is important for heart failure patients. Option C is incorrect as walking 2 miles daily may be too strenuous for some heart failure patients. Option D is incorrect as a high fiber diet is beneficial, but monitoring fluid retention is more critical in this case.

The nurse is caring for a client who is HIV positive. To prevent the spread of the HIV virus, what do the Centers for Disease Control and Prevention recommend?

  • A. Universal blood and body fluid precautions
  • B. Body systems isolation
  • C. Laminar flow room during active infection
  • D. Needle and syringe precautions
Correct Answer: A

Rationale: The correct answer is A: Universal blood and body fluid precautions. This is recommended by the CDC to prevent the spread of HIV because the virus can be present in blood and certain body fluids. Universal precautions involve treating all blood and body fluids as potentially infectious.

Incorrect choices:
B: Body systems isolation - This is not specific to preventing the spread of HIV and is not recommended by the CDC.
C: Laminar flow room during active infection - This is not a standard recommendation for preventing the spread of HIV.
D: Needle and syringe precautions - While important in preventing needlestick injuries, it is not the primary method recommended by the CDC for preventing the spread of HIV.

The nurse is attempting to prompt the patient to elaborate on the reports of daytime fatigue. Which question should the nurse ask?

  • A. “Is there anything that you are stressed about right now that I should know?”
  • B. “What reasons do you think are contributing to your fatigue?”
  • C. “What are your normal work hours?”
  • D. “Are you sleeping 8 hours a night?”
Correct Answer: B

Rationale: The correct answer is B because it encourages the patient to reflect on potential causes of their fatigue, leading to a more in-depth exploration of the issue. Option A focuses on stress, not necessarily fatigue. Option C is too specific and may not uncover underlying causes. Option D assumes sleep duration is the only factor contributing to fatigue.

During outcome identification and planning, from what part of the nursing diagnoses are outcomes derived?

  • A. The defining characteristics
  • B. The related factors
  • C. The problem statement
  • D. The database
Correct Answer: C

Rationale: During outcome identification and planning, outcomes are derived from the problem statement of the nursing diagnoses. This is because the problem statement clearly defines the patient's health issue or condition that needs to be addressed, thus guiding the development of specific, measurable, and achievable outcomes. The defining characteristics (choice A) describe the signs and symptoms of the health problem but do not directly lead to outcome identification. The related factors (choice B) represent the potential causes or contributing factors to the health problem and are not used to derive outcomes. The database (choice D) consists of the patient's health history, assessment data, and laboratory findings, which are essential for diagnosing but do not directly determine outcomes. Therefore, the correct answer is C as it directly informs the outcomes to be achieved.

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