07/02/2017

2nd day -Nursing Process-Omar ... Total Questions: 58

Most Correct Answers: #1 Least Correct Answers: #43

1.    Nursing Process-Training Program--Omar Hammad-0561523465- join us to get

the answer with explanation

Arrange the steps of the nursing process in the sequence in which they generally
occur.
A. Assessment
B. Evaluation
C. Planning outcomes
D. Planning interventions
E. Diagnosis
A E, B, A, D, C
3/100
B A, B, C, D, E
4/100
C A, E, C, D, B
83/100
D D, A, B, E, C
4/100

2.    Nursing Process-Training Program-Omar Hammad-0561523465- join us to get

the answer with explanation

A client comes in a clinic with reports of abdominal pain and diarrhea. While taking
the client’svital signs, the nurse is implementing which phase of the nursing
process?
A Assessment
65/100
B Diagnosis
11/100
C planing
6/100
D Implementation
9/100

3.    Nursing Process-Training Program--Omar Hammad-0561523465- join us to get

the answer with explanation

The nurse in charge identifies a patient's responses to actual or potential health

problems during which step of the nursing process?
A Assessing
7/100
B Diagnosis
49/100
C Planning
12/100
D Evaluating
18/100

Page 1 of 19
4.    Nursing Process-Training Program--Omar Hammad-0561523465- join us to get
the answer with explanation

A nurse is revising a client's care plan. During which step of the nursing process
does such a revision take place?
A Assessment
4/100
B Panning
15/100
C Implementation
12/100
D Evaluation
53/100

5.    Nursing Process-Training Program--Omar Hammad-0561523465- join us to get

the answer with explanation

During what phase of the nursing process would the nurse be required to consider
the efficacy of nursing interventions related to drug therapy?
A Assessment
3/100
B Diagnosis
10/100
C Planning
30/100
D Evaluation
39/100

6.    Nursing Process-Training Program-Omar Hammad-0561523465- join us to get

the answer with explanation

The nurse informs the physical therapy department that the client is too weak to
use a walker and needs to be transported by wheelchair. Which step of the nursing
process is the nurse engaged in at this time?
A Assessment
13/100
B Planning
17/100
C Implementation
40/100
D Evaluation
10/100

Page 2 of 19
7.    Nursing Process-Training Program-0561523465-Omar Hammad-0561523465- join
us to get the answer with explanation

A nurse refers to a client's postsurgical written plan of care, noting that the client
has a drainage device collecting wound drainage. The surgeon is to be notified when
drainage in the device exceeds 100 ml for the day. The nurse carefully notes the
amount of drainage currently in the device. This is an example of:
A Planning
12/100
B Evaluation
12/100
C Assessment
30/100
D Intervention
24/100

8.    Nursing Process-Training Program-Omar Hammad-0561523465- join us to get

the answer with explanation

In taking care of patients for cardiac catheterization, the nurse noted that the
patient manifested fear related to cardiac catheterization and its outcome, this
statement is anexample of:
A Nursing diagnosis
57/100
B Implementation
4/100
C Evaluation
7/100
D Intervention
7/100

9.    Nursing Process-Training Program-Omar Hammad-0561523465- join us to get

the answer with explanation

The planning step of the nursing process includes which of the following activities?
A Assessing and diagnosing
8/100
B Evaluating goal achievement.
6/100
C Performing nursing actions and documenting them.
5/100
D Setting goals and selecting interventions.
56/100

Page 3 of 19
10.    Nursing Process-Training Program-Omar Hammad-0561523465- join us to get
the answer with explanation

A nurse who is taking care of a patient with severe dehydration decided to first
provide liquids and gave health instructions on sanitation and hygiene.

What is the nurse doing inthe element of nursing process?

A Implementations
52/100
B Evaluation
3/100
C Planning
12/100
D Assessment
7/100

11.    Nursing Process-Training Program-Omar Hammad-0561523465- join us to get

the answer with explanation

Which is an objective statement?

A The client weighs 152 pounds.
43/100
B The client appears to be anxious.
11/100
C The client's appears to be overweight.
6/100
D The spot on the client's leg appears to be a blister.
12/100

12.    Nursing Process-Training Program-Omar Hammad-0561523465- join us to get

the answer with explanation

Which is subjective data?

A The client's age.
31/100
B The client's pulse.
1/100
C The client's demeanor.
33/100
D The client's respiration rate
7/100

13.    Nursing Process-Training Program-Omar Hammad-0561523465- join us to get

the answer with explanation

The nurse is measuring the client’s urine output and straining the urine to assess
forstones. Which of the following should the nurse record as objective data?
A The client reports abdominal pain
3/100
B The client urine output was 450ml
65/100
C The client’s states, “ I didn’t see any stones in my urine.”
2/100
D The client’s states, “I feel like I have passed a stone.”
1/100

Page 4 of 19
14.    Nursing Process-Training Program-Omar Hammad-0561523465- join us to get
the answer with explanation

The following statement appears on the nursing care plan for an

immunosuppressed client: The client will remain free from infection throughout
hospitalization. This statement is an example of a (an):
A Nursing diagnosis
8/100
B Short-term goal
29/100
C Long-term goal
19/100
D Expected outcome
15/100

15.    Nursing Process-Training Program-Omar Hammad-0561523465- join us to get

the answer with explanation

Q17:The following statements appear on a nursing care plan for a client after a
mastectomy: Incision site approximated; absence of drainage or prolonged
erythema at incision site; and client remains afebrile. These statements are
examples of:
A Nursing interventions
10/100
B Short-term goals
10/100
C Long-term goals
18/100
D Expected outcomes
33/100

16.    Nursing Process-Training Program-Omar Hammad-0561523465- join us to get

the answer with explanation

The rehabilitation nurse wishes to make the following entry into a client's plan of
care: "Client will reestablish a pattern of daily bowel movements without straining
within two months."

The nurse would write this statement under which section of the plan of care?
A Nursing diagnosis/problem list
10/100
B Nursing orders
9/100
C Short-term goals
7/100
D Long-term goals
43/100

Page 5 of 19
17.    Nursing Process-Training Program-Omar Hammad-0561523465- join us to get
the answer with explanation

A desired outcome for a client immobilized in a long leg cast reads; Client will state
three signs of impaired circulation prior to discharge. When the nurse evaluates the
client's progress, the client is able to state that numbness and tingling are signs of
impaired circulation.

What would be an appropriate evaluation statement for the nurse to write?

A Client understands the signs of impaired circulation
14/100
B Goal met: Client cited numbness and tingling as sign of impaired circulation
22/100
C Goal not met: Client able to name only two signs of impaired circulation
25/100
D Goal not met: Client unable to describe signs of impaired circulation
5/100

18.    Nursing Process-Training Program-Omar Hammad-0561523465- join us to get

the answer with explanation

After determining a nursing diagnosis of acute pain, the nurse develops the
following appropriate client-centered goal:
A Encourage client to implement guided imagery when pain begins.
13/100
B Determine effect of pain intensity on client function.
12/100
C Administer analgesic 30 minutes before physical therapy treatment
11/100
D Pain intensity reported as a 3 or less during hospital stay.
28/100

19.    Nursing Process-Training Program-Omar Hammad-0561523465- join us to get

the answer with explanation

Mr. Jones comes into the doctor’s office with his wife. During the initial interview
with the nurse assessing the reason for the visit, the wife says that her husband .
The nurse knows this is what type of data?
A Secondary subjective data
43/100
B Secondary objective data
4/100
C Primary objective data
5/100
D Primary subjective data
12/100

Page 6 of 19
20.    Nursing Process-Training Program-Omar Hammad-0561523465- join us to get
the answer with explanation

Which of the following items of subjective client data would be documented in the
medical record by the nurse?
A Client's face is pale
5/100
B Cervical lymph nodes are palpable
5/100
C Nursing assistant reports client refused lunch
11/100
D Client feel nauseated
43/100

21.    Nursing Process-Training Program-Omar Hammad-0561523465- join us to get

the answer with explanation

The client recently became febrile and stated he felt hot. The nurse takes the clients
temperature and finds it to be 38.2 C. In addition, the pulse rate is 88 beats per
minute, and his blood pressure is 168/80 mm Hg.

Which of the following is an example of subjective data?

A Pulse rate of 88 beats per minute
2/100
B Blood pressure of 168/80 mm Hg
5/100
C The statement regarding his feeling hot
50/100
D The supported fact that he became febrile
6/100

22.    Nursing Process-Training Program-Omar Hammad-0561523465- join us to get

the answer with explanation

John‘s temperature is 100.4 Fahrenheit. The skin on her forehead is warm and dry.
She has been incontinent and her bed is wet. She is complaining of being tired.

Which of the data is subjective?

A Temperature 100.4 Fahrenheit
2/100
B Skin warm and dry
6/100
C Bed is wet
3/100
D Complains of being tired
52/100

Page 7 of 19
23.    Nursing Process-Training Program-Omar Hammad-0561523465- join us to get
the answer with explanation

After visiting with the client, the nurse documents the assessment data. Both
objective and subjective information has been obtained during the assessment.

Which of the following is classified as objective data?

A Pain in the left leg
2/100
B Elevated blood pressure
53/100
C Fear of impending surgery
2/100
D Discomfort upon breathing
5/100

24.    Nursing Process-Training Program-Omar Hammad-0561523465- join us to get

the answer with explanation

Mr. Anderson says that his head has been hurting for 3 weeks. The nurse knows this
is what kind of data?
A Primary subjective data
48/100
B Secondary subjective data
6/100
C Primary objective data
7/100
D Secondary objective data
1/100

25.    Nursing Process-Training Program-Omar Hammad-0561523465- join us to get

the answer with explanation

The client reports nausea and constipation. Which of the following would be the
priority nursing action?
A Collect a stool sample
1/100
B Complete an abdominal assessment
43/100
C Administer an anti-nausea medication
10/100
D Notify the physician
8/100

Page 8 of 19
26.    Nursing Process-Training Program-Omar Hammad-0561523465- join us to get
the answer with explanation

Question:While the nurse is providing a patient personal hygiene, she observes that
his skin is excessively dry. During the procedure, he tells her that he is very thirsty.
An appropriate nursing diagnosis would be:
A Potential for impaired skin integrity R/T altered gland function
3/100
B Potential for impaired skin integrity R/T dehydration
25/100
C Impaired skin integrity R/T dehydration
29/100
D Impaired skin integrity R/T altered circulation
4/100

27.    Nursing Process-Training Program--Omar Hammad-0561523465- join us to get

the answer with explanation

A female patient is diagnosed with deep-vein thrombosis. Which nursing diagnosis

should receive the highest priority at this time?
A Impaired gas exchange related to increased blood flow
11/100
B Fluid volume excess related to peripheral vascular disease
7/100
C Risk for injury related to edema
3/100
D Altered peripheral tissue perfusion related to venous congestion
38/100

28.    Nursing Process-Training Program--Omar Hammad-0561523465- join us to get

the answer with explanation

The nursing diagnosis is Risk for impaired skin integrity related to immobility and
pressure secondary to pain and presence of a cast.

Which of the following desired outcomes should the nurse include in the care plan?
A Client will be able to turn self by day 3
4/100
B Skin will remain intact and without redness during hospital stay
25/100
C Client will state pain relieved within 30 minutes after medication
6/100
D Pressure will be prevented by repositioning client every 2 hours
24/100

Page 9 of 19
29.    Nursing Process-Training Program--Omar Hammad-0561523465- join us to get
the answer with explanation

The nurse begins the assessment of a client that has come to the emergency
department experiencing chest pain by asking the client about:
A A family history of heart problems
5/100
B Medications currently being taken at home
6/100
C Questions or concerns about hospitalization
0/100
D The onset, severity, and duration of the chest pain
48/100

30.    Nursing Process-Training Program-Omar Hammad-0561523465- join us to get

the answer with explanation

Question : Independent nursing interventions commonly used for patients with

pressure ulcers include:
A changing the patient's position regularly to minimize pressure
44/100
B Applying a drying agent such as an antacid to decrease moisture at the ulcer site
9/100
C Debriding the ulcer to remove necrotic tissue, which can impede healing
3/100
D Placing the patient in a whirlpool bath containing povidone-iodine solution as tolerated
3/100

31.    Nursing Process-Training Program--Omar Hammad-0561523465- join us to get

the answer with explanation

Question: Which intervention should the nurse in charge try first for a client that
exhibits signs of sleep disturbance?
A Administer sleeping medication before bedtime
4/100
B Ask the client each morning to describe the quantity of sleep the night before
7/100
C Teach the client relaxation techniques, such as guided imagery and progressive muscle
28/100
relaxation
D Provide the client normal sleep aids, such as pillows, back rubs, and snacks
20/100

Page 10 of 19
32.    Nursing Process-Training Program--Omar Hammad-0561523465- join us to get
the answer with explanation

Question:A nurse is assigned to care for a postoperative male client who has
diabetes mellitus. During the assessment interview, the client reports that he's
impotent and says he's concerned about the effect on his marriage.

In planning this client's care, the most appropriate intervention would be to:
A Encourage the client to ask questions about personal sexuality
17/100
B Provide time for privacy
9/100
C Suggest referral to a sex counselor or other appropriate professional
27/100
D Provide support for the spouse
6/100

33.    Nursing Process-Training Program-Omar Hammad-0561523465- join us to get

the answer with explanation

Question: When two nursing diagnoses appear closely related, what should the
nurse do first to determine which diagnosis most accurately reflects the needs of a
patient?
A Reassess the patient
21/100
B Examine the related to factors
12/100
C Analyze the secondary to factors
8/100
D Review the defining characteristics
18/100

34.    Nursing Process-Training Program--Omar Hammad-0561523465-join us to get

the answer with explanation

Question: The nurse performs an assessment of a newly admitted patient. The

nurse understands that this admission assessment is conducted primarily to:
A Diagnose if the patient is at risk for falls.
10/100
B Ensure that the patient's skin is intact
0/100
C Establish a therapeutic relationship
6/100
D Identify important data
40/100

Page 11 of 19
35.    Nursing Process-Training Program-Omar Hammad-0561523465- join us to get
the answer with explanation

The guidelines for writing an appropriate nursing diagnosis include all of the
following except:
A State the diagnosis in terms of a problem, not a need
11/100
B Use nursing terminology to describe the patient's response
7/100
C Use statements that assist in planning independent nursing interventions
5/100
D Use medical terminology to describe the probable cause of the patient's response
32/100

36.    Nursing Process-Training Program-Omar Hammad-0561523465- join us to get

the answer with explanation

Question : Independent nursing interventions commonly used for immobilized

patients include all of the following except:
A Active or passive ROM exercises, body repositioning, and ADLs as tolerated
10/100
B Deep-breathing and coughing exercises with change of position every 2 hours
4/100
C Diaphragmatic and abdominal breathing exercises
13/100
D Weight bearing on a tilt table, total parenteral nutrition, and vitamin therapy
27/100

37.    Nursing Process-Training Program-Omar Hammad-0561523465- join us to get

the answer with explanation

The most important nursing intervention to correct skin dryness is:

A avoid bathing until the condition is remedied and notify physician
2/100
B ask physician to refer the patient to a dermatologist
7/100
C Consult the dietitian about increasing fat intake, and take necessary measures to prevent
1/100
infection
D encourage the patient to increase fluid intake, use nonirritating soap, and apply lotion to
44/100
involved areas

Page 12 of 19
38.    Nursing Process-Training Program-Omar Hammad-0561523465- join us to get
the answer with explanation

When developing a nursing care plan for a client with a fractured right tibia, the
nurse includes in the plan of care independent nursing interventions, including:
A Apply a cold pack to the tibia.
14/100
B Elevate the leg 5 inches above the heart.
21/100
C Perform range of motion to right leg every 4 hours.
8/100
D Administer aspirin 325 mg every 4 hours as needed.
11/100

39.    Nursing Process-Training Program-Omar Hammad-0561523465- join us to get

the answer with explanation

The nurse is reviewing the critical paths of the clients on the nursing unit. In
performing a variance analysis, which of the following would indicate the need for
further action and analysis? ✖
A A client’s family attending a diabetic teaching session
5/100
B Normal VS and absence of wound infection in a post-op client.
15/100
C A client demonstrating accurate medication administration following teaching.
12/100
D Canceling physical therapy sessions on the weekend.
22/100

40.    Nursing Process-Training Program-Omar Hammad-0561523465- join us to get

the answer with explanation

While assisting a client from bed to chair, the nurse observes that the client looks
pale and is beginning to perspire heavily. The nurse would then do which of the
following activities as a reassessment?
A Help client into the chair but more quickly
6/100
B Document client's vital signs taken just prior to moving the client
13/100
C Help client back to bed immediately
7/100
D Observe client's skin color and take another set of vital signs
27/100

Page 13 of 19
41.    Nursing Process-Training Program-Omar Hammad-0561523465- join us to get
the answer with explanation

After instructing the client on crutch walking technique, the nurse should evaluate
the client's understanding by using which of the following methods?
A Return demonstration
30/100
B Explanation
9/100
C Achievement of 90 on written test
5/100
D Have client explain produce to the family
9/100

42.    Nursing Process-Training Program-Omar Hammad-0561523465- join us to get

the answer with explanation

For the nursing diagnostic statement, Self-care deficit: feeding related to bilateral
fractured wrists in casts, what is the major related factor or risk factor identified by
the nurse?
A Discomfort
7/100
B Deficit
12/100
C Feeding
9/100
D Fractured wrists
25/100

43.    Nursing Process-Training Program-Omar Hammad-0561523465- join us to get

the answer with explanation

The nurse comes to the conclusion that a patient’s elevated temperature, pulse
andrespiration are significant. What step of the nursing process is being used when
the nursecomes to this conclusion?
A Implementation
5/100
B Assessment
20/100
C Evaluation
18/100
D Diagnosis
9/100

Page 14 of 19
44.    Nursing Process-Training Program-Omar Hammad-0561523465- join us to get
the answer with explanation

The nurse is collecting subjective data associated with a patient’s anxiety. Which
assessment method should be used to collect this information?
A Observing
13/100
B Inspecting
6/100
C Auscultation
1/100
D Interviewing
32/100

45.    Nursing Process-Training Program-Omar Hammad-0561523465- join us to get

the answer with explanation

Which one of the following is the etiologic factor in the nursing diagnosis “Impaired
physical mobility related to left sided muscular weakness as evidenced by the
inability to bear weight on the left leg”?
A Impaired physical mobility
11/100
B Left sided muscular weakness
22/100
C As evidenced by
6/100
D Inability to bear weight on the left leg
13/100

46.    Nursing Process-Training Program-Omar Hammad-0561523465

Through the course of Nurse’s interaction with the family, he learned that the
couple has 6 children, 2 of which are in the secondary, 3 in the elementary and the
three-year old babystays at home. In addition, he learned that the family’s income is
about P400/day. Nurse is utilizing what type of assessment?
A Interview
26/100
B Record Review
20/100
C Observation
4/100
D Physical Assessment
1/100

Page 15 of 19
47.    Nursing Process-Training Program-Omar Hammad-0561523465-

When Jack roamed around the community to visit other families, one of the
mothers approached him and told him that her child is having colds and fever. Jack
examined the child and took the child’s vital signs. Jack utilizes which of the
following types of data gathering?
A Observation
5/100
B Laboratory examination
3/100
C Record review
6/100
D Physical assessment
37/100

48.    Nursing Process-Training Program-Omar Hammad-0561523465- join us to get

the answer with explanation

A nurse is teaching a client with coronary artery disease about dietary measures to
follow. During the session, the client expresses frustration in learning the dietary
regimen.

The nurse would initially

A Identify the cause of the frustration
30/100
B Continue with the dietary teaching
4/100
C Notify the physician
8/100
D Tell the client that the diet needs to be followed
9/100

49.    Nursing Process-Training Program-Omar Hammad-0561523465- join us to get

the answer with explanation

A nurse is reviewing the laboratory results of an infant suspected of having

hypertrophic pyloric stenosis. Which of the following laboratory findings would the
nurse most likely to expect to note in this infant?
A A blood pH of 7.50
26/100
B A blood pH of 7.30
5/100
C A blood bicarbonate of 22 mEq/L
16/100
D A blood bicarbonate of 19 mEq/L
4/100

Page 16 of 19
50.    Nursing Process-Training Program-Omar Hammad-0561523465- join us to get
the answer with explanation

A nurse is caring for a client with angina pectoris who begins to experience chest
pain. The nurse administers a sublingual nitroglycerin (Nitrostat) tablet sublingually
as prescribed, but the pain is unrelieved. The nurse should take which of the
following actions next?
A Contact the physician
19/100
B Call the client's family
3/100
C Administer another nitroglycerin tablet
18/100
D Reposition the client
11/100

51.    Nursing Process-Training Program-Omar Hammad-0561523465- join us to get

the answer with explanation

A client with multiple sclerosis has been taking oxybutynin (Ditropan). The nurse
determines the degree of the effectiveness of the medication by asking the client
about changes in the following:
A Extent of muscle spasm
25/100
B Level of fatigue
4/100
C Bowel movements
10/100
D Patterns of urination
11/100

52.    Nursing Process-Training Program-Omar Hammad-0561523465- join us to get

the answer with explanation

The clinic nurse prepares to develop a diabetic teaching program. To meet the
clients’ needs, the nurse should take which action first?
A Assess the clients’ functional abilities.
37/100
B Ensure that insurance will pay for participation in the program.
4/100
C Discuss the focus of the program with the interprofessional team.
9/100
D Include everyone who comes into the clinic in the teaching sessions.
0/100

Page 17 of 19
53.    Nursing Process-Training Program-Omar Hammad-0561523465- join us to get
the answer with explanation

Q53 :The nurse is performing range-of-motion (ROM) exercises on a client when the
client unexpectedly develops spastic muscle contractions. The nurse should
implement which interventions?
A Stop movement of affected part.
23/100
B Massage the affected part vigorously.
13/100
C Notify the health care provider immediately.
4/100
D Force movement of the joint supporting the muscle.
3/100
E Ask the client to stand and walk rapidly around the room.
7/100

54.    When clustering data according to functional health patterns, the nurse

determines that the client is only able to ambulate short distances without
becoming fatigued and requires rest periods during morning care.

The health pattern that requires intervention is identified by the nurse as:
A Respiratory
11/100
B Activity and exercise
19/100
C Sleep and rest pattern
6/100
D Self-care deficit: activities of daily living
14/100

55.    While discussing a clients medication history, the client tells the nurse that she
thinks she is allergic to a particular type of medication.

Which of the following nursing actions has priority in this situation?

A Note the allergy on the clients Kardex.
15/100
B Inform the provider of the clients possible allergy.
7/100
C Review the clients medical record for confirmation of the allergy.
25/100
D Tell the client to have all medications identified before taking them.
3/100

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56.    In order that they are clear and easily understood by other members of the
health care team, the nurse recognizes that client goals or outcomes should be
documented according to specific criterion.

Of the following, the outcome statement that best meets the established criteria is:
A Client will describe activity restrictions.
6/100
B Client will verbalize understanding of treatments
15/100
C Client will be ambulated in hallway 3 times each day.
7/100
D Clients respiratory rate will remain within 20 to 24 breaths per minute by 9/24.
22/100

57.    The nurse is performing a dressing change for a client and notices that there is
a new area of skin breakdown near the site of the dressing. On closer examination,
it appears to be caused from the tape used to secure the dressing. This would be an
example of which phase of the nursing process?
A Assessment
18/100
B Diagnosis
14/100
C Implementation
9/100
D Evaluation
9/100

58.    An infant has been admitted to the pediatric unit. The parents are quite
worried and upset, and the grandmother is also present. In this situation, what
would be the best source of data?
A Medical record from the childs birth
13/100
B Grandmother, since the parents are upset
14/100
C Parents
22/100
D Admitting physician
1/100

Page 19 of 19