Set 6

1.Which of the following guidelines should a nursing instructor provide to nursing students
who are now responsible for assessing their clients?
A) “Assessment data about the client should be collected continuously.”
“Assess your client after receiving the nursing report and again before giving a
B) report to the next shift of nurses.”
“Assess your client at least hourly if the client’s vital signs are unstable, and every
C) two hours if the vital signs are stable.”
D) “Assessment data should be collected prior to the physician
rounding on the unit.”

2.The nurse is using a systematic approach to the collection of assessment

data. The nurse uses an assessment guide that uses a hierarchy of five life
requirements universal to all persons. What model for organizing the
assessment data is the nurse
using?
E) Human Needs (Maslow) model
F) Functional Health Patterns model
G) Human Response Patterns model
H) Body System
model

3.A novice nurse collects data on a newly admitted client. Upon evaluation
of this data, the nurse provides an erroneous interpretation. What is a
corrective action for this interpretation?

Encourage the novice nurse to independently observe the same situation with a peer,
A) validate the data, and discuss the situation afterward.

B) Encourage the novice nurse to develop his or her own tool for

data collection. Encourage the novice nurse to collect and

interpret the data for the client

C) repeatedly, until the novice nurse arrives at the correct interpretation.
Encourage the novice nurse to meet with the nurse manager to discuss the situation
D) and seek mentoring for communication skills.

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2. When documenting subjective data, the nurse should do which of the following?
A) Use the client’s own words placed in quotation marks.
B) Paraphrase the information stated by the client.
C) Validate the information with the client’s family prior to documentation.
D) Record the information using
nonspecific words.

3.The nurse has entered a client’s room to find the client diaphoretic (sweat-
covered) and shivering, inferring that the client has a fever. How should the
nurse best follow up this cue and inference?
E) Measure the client’s oral temperature.
F) Ask a colleague for assistance.
G) Give the client a clean gown and warm blankets.
H) Obtain an order for blood
cultures.

3.The nurse completes a health history and physical assessment on a client

who has been admitted to the hospital for surgery. What is the purpose of
this initial
assessment?
I) To gather data about a specific and current health problem
J) To identify life-threatening problems that require immediate attention
K) To compare and contrast current health status to baseline data
L) To establish a database to identify problems and
strengths

4.A client comes to her health care provider’s office because she is having
abdominal pain. She has been seen for this problem before. What type of
assessment would the
nurse do?
M) Initial assessment
N) Focused assessment
O) Emergency assessment
P) Time-lapsed
assessment
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5.A nurse is assisting with lunch at a nursing home. Suddenly, one of the
residents begins to choke and is unable to breathe. The nurse assesses the
resident’s ability
to breathe and then begins CPR. Why did the nurse assess respiratory status?
Q) To identify a life-threatening problem
R) To establish a database for medical care

S) To practice respiratory assessment skills

T) To facilitate the resident’s ability to
breathe

6.A nurse performs an assessment of a client in a long-term care facility and

records baseline data. The nurse reassesses the client a month later and
makes revisions in
the plan of care. What type of assessment is the second assessment?
U) Comprehensive
V) Focused
W) Time-lapsed
X) Emergen
cy Ans: C
Feedback:
The time-lapsed assessment is scheduled to compare a client’s current
status to baseline data obtained earlier. Most clients in residential
settings and those receiving nursing care over longer periods of time,
such as homebound clients with visiting nurses, are scheduled for
periodic time-lapsed assessments to reassess health status and to
make necessary revisions in the plan of care.
7.Of the following information collected during a nursing assessment, which are
subjective data?
Y) vomiting, pulse 96
Z) respirations 22, blood pressure 130/80
AA) nausea, abdominal pain
BB) pale skin, thick
toenails Ans: C
Feedback:

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 Subjective data are information perceived only by the affected person.
They cannot be perceived or verified by another person. Other terms
for subjective data are symptoms or covert data.
8.A nurse in the emergency department is completing an emergency
assessment for a
teenager just admitted from a car crash. Which of the following is
objective data?
CC) “My leg hurts so bad. I can’t stand it.”
DD) “Appears anxious and frightened.”
EE) “I am so sick; I am about to throw up.”
FF) “Unable to palpate femoral pulse in
left leg.” Ans: D
Feedback:
Objective data are observable and measurable data that can be seen,
heard, or felt by someone other than the person experiencing them.
Objective data observed by one person can be verified by another
person observing the same client. Objective data are also called signs
or overt data. The only objective data in this question would be that the
nurse is unable to palpate a femoral pulse.
9.A nurse is collecting information from a client with dementia. The
client’s daughter accompanies the client. Which of the following
statements by the nurse would
recognize the client’s value as an individual?
GG) “Can you tell me how long your father has been this way?”
HH) “Sarah, I have to go and read your father’s old charts before we talk.”
II) “Mr. Koeppe, tell me what you do to take care of yourself.”
JJ) “Mr. Koeppe, I know you can’t answer my questions, but
it’s okay.” Ans: C
Feedback:
Clients such as older adults with dementia, and their children, cannot
be relied on to report accurately. However, they should be encouraged
to respond to interview questions as best as they can. Bypassing the
client communicates that the nurse does not have time or has doubts in
the client’s ability to communicate.
10.A nurse is collecting data from a home care client. In addition to information about
the client’s health status, what is another observation the nurse should make?
KK) Number of rooms in the house
LL) Safety of the immediate environment

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MM) Frequency of home visits to be made
NN) Friendliness of the client and
family Ans: B
Feedback:
The nurse should also observe the safety of the immediate
environment. Observation is the conscious and deliberate use of the
five senses to gather data. Each time a client is observed, the nurse
observes current responses, ability to provide self-care, the immediate
environment, and the larger environment.
11.A nurse is preparing to conduct a health history for a client who is confined to bed.
How should the nurse position herself?
OO) Standing at the end of the bed
PP) Standing at the side of the bed
QQ) Sitting at least six feet from the beside
RR) sitting at a 45-degree angle to the
bed Ans: D
Feedback:
If the patient is in bed, placing a chair at a 45-degree angle is helpful in
facilitating an easy exchange of information. If the nurse stands at the
side or foot of the bed and physically looks down at the client, a
superior–inferior relationship is communicated and can negatively
affect the interview.
12.Which of the following questions or statements would be appropriate in eliciting
further information when conducting a health history interview?
SS) “Why didn’t you go to the doctor when you began to have this pain?”
TT) “Are you feeling better now than you did during the night?”
UU) “Tell me more about what caused your pain.”
VV) “If I were you, I would not wait to get medical help next
time.” Ans: C
Feedback:
Avoid questions that impede communication during the interview,
including those that can be answered by yes or no, why or how
questions, and giving advice.
13.Which of the following questions or statements would be an appropriate termination
of the health history
interview?

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A) “Well, I can’t think of anything else to ask you right now.”
B) “Can you think of anything else you would like to tell me?”
C) “I wish you could have remembered more about your illness.”
D) “Perhaps we can talk again sometime.
Goodbye.” Ans: B
Feedback:
The successful interview is concluded carefully. After summarizing the
data, it is helpful to ask the client if he or she has anything else to tell
the nurse. This gives the client the chance to add data the nurse did not
think to include.
A nurse is conducting a health history interview for a woman at an
assisted-living facility. The woman says, “I have been so constipated
lately.” How should the nurse
respond?
WW)“Do you have a family history of chest problems?”
XX) “Why don’t you use a laxative every night?”
YY) “Do you take anything to help your constipation?”
ZZ) “Everyone who ages has bowel
problems.” Ans: C
Feedback:
A possible cause of omission of pertinent data is failing to follow up on
cues during data collection. The nurse should ask about what the client
uses to self-treat her constipation in order to identify further important
information. It is not correct to ignore the statement, ask “why”
questions, or make assumptions.
A nurse who collected and organized data during a client history
realizes that there is not enough information to plan interventions.
Which of the following would be the
best remedy to prevent this from happening in the future?
AAA) The nurse should practice interviewing strategies.
BBB) The nurse should modify data collection tool.
CCC) The nurse should determine specific purpose of data collection.
DDD) The nurse should update the
database. Ans: A
Feedback:

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 Strong interviewing skills are needed to obtain the necessary patient
data. A common cause of data omission is the nurse’s failure to know
what information is wanted or not following up on client cues. The
nurse only needs to modify the data collection tool if the database is
inappropriately organized. If irrelevant or duplicate data is collected,
the nurse should determine specific purpose of data collection. Data
collection should be ongoing. If the nurse notices that data collection
stopped after the initial assessment data were collected, the nurse
should update the database.
3. What is the primary purpose of validation as a part of assessment?
A) To identify data to be validated
B) To establish an effective nurse–client communication
C) To maintain effective relationships with coworkers
D) To plan appropriate nursing
care Ans: D
Feedback:
Validation is the act of confirming or verifying to plan appropriate
nursing care. Validation is an important part of assessment because
invalid information can lead to inappropriate nursing care. Validation
does not identify data to be validated, nor does it establish effective
nurse–client communication or relationships with coworkers.
A client is being prepared for cardiac catheterization. The nurse
performs an initial assessment and records the vital signs. Which of the
following data collected can be
classified as subjective data?
E) Blood pressure
F) Nausea
G) Heart rate
H) Respiratory
rate Ans: B
Feedback:
Subjective data are those which the client can feel and describe. Nausea
is subjective data, as it can only be described and not measured. Blood
pressure, heart rate, and respiratory rate are measurable factors and
are therefore objective data.
A client is brought to the emergency department in an unconscious
condition. The client’s wife hands over the previous medical files and
points out that the client had suddenly fallen unconscious after trying
to get out of bed. Which of the following is a
primary source of information?

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A) Client’swife
B) Medical documents
C) Test results
D) Assessment
data Ans: A
Feedback:
In this case, the primary source of information is the client’s wife, as
she can provide a detailed description of the incident as well as provide
the medical history of the client. The medical files, test results, and
assessment data are secondary sources of information.
The nurse is performing an assessment of a client who has a small
wound on the knee, collecting cues about the client’s health status.
Which of the following would
the nurse identify as a subjective cue?
I) Sharp pain in the knee
J) Small bloody drainage on dressing
K) Temperature of 102 degrees F
L) Pulse rate of 90 beats per
minute Ans: A
Feedback:
Sharp pain in the knee is an example of a subjective cue. Subjective
cues are imperceptible, immeasurable, and abstract. Small bloody
drainage on dressing, a temperature of 102 degrees F, and a pulse rate
of 90 beats per minute are examples of objective cues.
A nurse caring for a client admitted to the intensive care unit with a
stroke assesses the client’s vital signs, pupils, and orientation every few
minutes. The nurse
is performing which type of assessment?
M) Initial assessment
N) Focused assessment
O) Time-lapsed reassessment
P) Emergency
assessment Ans: B
Feedback:

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 The nurse is performing a focused assessment to determine whether the
problem still exists, and whether the status of the problem has changed.
An initial or admission assessment is the initial identification of normal
function, functional status, and collection of data concerning actual or
potential dysfunction. Time-lapsed reassessment is performed after the
initial assessment when substantial periods of time have elapsed
between assessments. An emergency assessment is performed any
time a physiologic, psychological, or emotional crisis occurs.
When the nurse inspects a postoperative incision site for infection, which one of the
following types of assessments is being performed?
Q) Complete
R) Focused
S) General
T) Time-
lapse Ans: B
Feedback:
In focused assessments, the nurse determines whether the problem
still exists and whether the status of the problem has changed.
An unconscious patient is brought to the emergency department. Which of the
following assessments should be implemented first?
U) The client’s airway should be assessed.
V) The nurse should determine the reason for admission.
W) The nurse should review the client’s medications.
X) The client’s past medical history is
assessed. Ans: A
Feedback:
Emergency assessment takes place in life-threatening situations in
which the preservation of life is the top priority. Often, the client’s
difficulty involves airway, breathing, and circulatory problems.
The nurse observes the client as he walks into the room. What information will this
provide the nurse?
Y) Information regarding the client’s gait
Z) Information regarding the client’s personality

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AA) Information regarding the client’s psychosocial status
BB) Information on the rate of recovery from
surgery Ans: A
Feedback:
Observation includes looking, watching, examining, scrutinizing,
surveying, scanning, and appraising.
After assessment of a client in an ambulatory clinic, the nurse records the data on
the computer. The nurse recognizes which of the following as objective data?
CC) Auscultation of the lungs
DD) Complaint of nausea
EE) Sensation of burning in her epigastric area
FF) Belief that demons are in her
stomach Ans: A
Feedback:
Objective data include techniques of inspection, palpation, percussion,
and auscultation. Symptoms, values, perceptions, feelings, beliefs,
attitudes, and sensations are sources of subjective data.
A nurse performing triage in an emergency room makes assessments
of clients using critical thinking skills. Which of the following are critical
thinking activities linked to
assessment? Select all that apply.
GG) Carrying out a physician’s order to intubate a client
HH) Educating a novice nurse on the principles of triage
II) Using the nursing process to diagnose a blocked airway

JJ) Interviewing privately a client suspected of being a victim of

abuse Checking with the family about the data supplied by a

client suffering from

KK) dementia
Ans: C, D, E
Feedback:
Since the entire nursing process rests on the initial and ongoing
assessment of the client, it is imperative to use excellent critical
thinking skills when gathering, validating, analyzing, and
communicating data. The nurse using critical thinking skills assesses
information systematically using the nursing process, detects biases,
makes
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 judgments about the significance of data, and identifies assumptions
and inconsistencies. Carrying out physician’s orders and educating a
novice nurse involve the implementation stage of the nursing process.
Which of the following data regarding a client with a diagnosis of colon cancer are
subjective? Select all that apply.
LL) The client’s chemotherapy causes him nausea and loss of appetite.
MM) The client became teary when his daughter from out of state came to the bedside.
NN) The client’s ileostomy put out 125 mL of effluent in the past four hours.
OO) The patient is unwilling to manipulate or empty his ostomy bag.
PP) The patient has been experiencing fatigue in
recent weeks. Ans: A, E
Feedback:
Reports of nausea, anorexia, and fatigue are subjective data that
depend on the client’s self-report. Weeping, ostomy output, and an
inability to perform a kinesthetic task are observable assessment
findings that would be characterized as objective.
Which of the following examples of client data needs to be validated? Select all that

apply.
QQ) A client has trouble reading an informed consent, but states he does
not need glasses.
An elderly client explains that the black and blue marks on his arms
RR) and legs are due to a fall.

SS) A nurse examining a client with a respiratory infection documents fever and chills.
TT) A client in a nursing home states that she is unable to eat the food being served.
UU) A pregnant client is experiencing contractions that are two
minutes apart. Ans: A, B
Feedback:
Because validation of all data is neither possible nor necessary, nurses
need to decide which items need verification. For example, data need
to be verified when there are discrepancies: A patient tells the nurse he
is fine and has no concerns, but the nurse notes that he demonstrates
tense body musculature and seems curt in his responses. When there
is a discrepancy between what the person is saying and what the nurse
is observing, validation is necessary to determine accuracy. Data also
need verification when they lack objectivity.

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 Which of the following are examples of common factors in a client that may influence
assessment priorities? Select all that apply.
VV) Diet and exercise program
WW)Standing in the community
XX) Ability to pay for services
YY) Developmental stage
ZZ) Need for
nursing Ans: A, D,
E
Feedback:
The purpose for which the assessment is being performed offers the
best guideline about what type and how much data to collect.
Assessment priorities are influenced by the client’s health orientation,
developmental stage, culture, and need for nursing. After the
comprehensive nursing assessment has been completed, client health
problems dictate assessment priorities for future nurse–client
interactions.
The nurse is conducting a nursing history of a client with a respiratory
rate of 30, audible wheezing, and nasal flaring. During the interview,
the client denies problems
with breathing. What action should the nurse take next?
AAA) Clarify discrepancies of assessment data with the client.
BBB) Validate client data with members of the health care team.
CCC) Document all data collected in the nursing history and physical examination.
DDD) Seek input from family members regarding the client’s
breathing at home. Ans: A
Feedback:
First, the nurse needs to validate the data with the client, who is the
primary source. The nurse can validate data with the health care
provider but consulting with the client is the best option. The client
must give permission for family members to participate in the health
history. Ultimately, the nurse documents all assessment data, both
from the history and the physical exam.
The nurse is reviewing information about a client and notes the
following documentation Client is confused. The nurse recognizes this
information is an example
of what?
EEE) Subjective data
FFF) A data cue
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GGG) An inference
HHH) Primary
data Ans: C
Feedback:
Making a judgment that the client is confused is an inference. An
inference must be validated with subjective and/or objective data cues.
Sources of data cues can be primary or secondary.
While bathing the client, the nurse observes the client grimacing. The
nurse asks if the client is experiencing pain. The client nods yes and
refuses to continue the bath. The nurse removes the wash basin,
makes the client comfortable, and documents the event in the client’s
chart. Which of the following actions clearly demonstrates
4. assessing?
A) The nurse bathing the client
B) The nurse documenting the incident
C) The nurse asking if the client is having pain
D) The nurse removing the wash
basin Ans: C
Feedback:
The nurse asking if the client is having pain clearly demonstrates
assessing. Bathing the client and removing the wash basin demonstrate
implementation. Documentation is part of every step of nursing process.
6.The nurse has entered a client’s room to find the client diaphoretic
(sweat-covered) and shivering, inferring that the client has a fever.
How should the nurse best follow up this cue and inference?
E) Measure the client’s oral temperature.
F) Ask a colleague for assistance.
G) Give the client a clean gown and warm blankets.
H) Obtain an order for blood
cultures Ans: A
Feedback:

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 An inference must be followed by a validation process. In this case, the
inference of fever is best validated or rejected by measuring the
client’s temperature. This should precede interventions such as blood
work or even providing a warm blanket.

Set 7

Which of the following is a correct guideline to follow when composing a nursing

diagnosis statement?
Place defining characteristics after the etiology and link them by the phrase
A) “as evidenced by.”
B) Phrase the nursing diagnosis as a client need.
C) Place the etiology prior to the client problem and linked by the phrase “related to.”
D) Incorporate subjective and judgmental
terminology. Ans: A
Feedback:
Defining characteristics should follow the etiology and be linked by the
phrase “as evidenced by” when included in the nursing diagnosis. The
nursing diagnosis should be phrased as a client problem or alteration
in health state, rather than as a client need. The client problem
precedes the etiology and is linked by the phrase “related to.” Avoid
using judgmental language and write in legally advisable terms.
In planning the care for a client who has pneumonia, the nurse collects data
and develops nursing diagnoses. Which of the following is an example of a
properly
developed nursing diagnosis?
E) Ineffective airway clearance as evidenced by inability to clear secretions
F) Ineffective health maintenance as evidenced by unhealthy habits

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G) Ineffective breathing pattern related to pneumonia
H) Ineffective therapeutic regimen management due to
smoking Ans: A
Feedback:
The appropriately written nursing diagnosis is “ineffective airway
clearance related to inability to clear secretions.” “Ineffective health
maintenance related to unhealthy habits” is incorrect because it shows
value judgments by the nurse. “Ineffective breathing pattern related to
pneumonia” is incorrectly written because it includes a medical
diagnosis. “Ineffective therapeutic regimen management due to
smoking” is incorrect because the clause “due to” implies a direct
cause-and-effect relationship.
The nurse has identified a number of risk nursing diagnoses in the care of an
adolescent who has been admitted to the hospital for treatment of an eating
disorder. These risk diagnoses indicate which of the following?
I) The client is more vulnerable to certain problems than other individuals would be.
J) The diagnoses present significant risks for the development of medical diagnoses.
K) The data necessary to make a definitive nursing diagnosis is absent.
L) The diagnosis has yet to be confirmed by another
practitioner. Ans: A
Feedback:
Risk nursing diagnoses are clinical judgments that an individual, family,
or community is more vulnerable to develop the problem than others in
the same or similar situation. They do not denote a particular link to
medical diagnoses nor do they require independent confirmation.
Missing data is associated with possible nursing diagnoses.
A client with a new colostomy often becomes short and sarcastic when
nurses attempt to teach him about the management of his new
appliance. The nurse has consequently documented “Noncompliance
related hostility” on the client’s chart. What
2. mistake has the nurse made when choosing and documenting this nursing diagnosis?
A) Presuming to know the factors contributing to the problem
B) Identifying a problem that cannot be changed
C) Identifying a problem without corroborating evidence in the statement
D) Neglecting to identify potential complications related to
the problem Ans: A
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 Feedback:
Multiple factors may underlie the client’s response to education in a
complex and emotionally charged situation, such as receiving a new
ostomy. As a result, it is likely presumptuous to ascribe the client’s
response to hostility. The problem is likely modifiable with a correct
approach; the evidence underlying a nursing diagnosis is not normally
explicit in the statement itself. The existence of potential complications
is not central to the psychosocial nature of this client’s situation.
The nurse has drafted a nursing diagnosis of Imbalanced Nutrition: More
Than Body Requirements in the care of moderately obese client. How
should the nurse proceed
3. after writing this diagnosis?
A) Validate the nursing diagnosis
B) Identify potential complications
C) Cross-reference the nursing diagnosis with medical diagnoses
D) Modify interventions based on the
diagnosis Ans: A
Feedback:
After writing a nursing diagnosis, it is important to verify and validate
the diagnosis. This action should precede the modification of the
client’s care. Nursing diagnoses do not always correlate with medical
diagnoses and not every nursing diagnosis is accompanied by
potential complications.
Which of the following provides the nurse with the most reliable basis on which to
4. choose a nursing diagnosis?
A cluster of several significant cues of data that suggest a particular health
A) problem
B) A single, definitive cue that is closely associated with a common diagnosis
C) A cue that can be verified by objective, medical data
A group of related nursing diagnoses that exist within the same NANDA-approved
D) domain
Ans: A
Feedbac
k:
A data cluster is a grouping of client data or cues that points to the
existence of a client health problem. Nursing diagnoses should always
be derived from clusters of significant data rather than from a single
cue. Medical corroboration is not always

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 possible or necessary. The presence of multiple nursing diagnoses
within one domain does not necessarily validate further diagnoses in
that same domain.
In addition to identifying responses to actual or potential health problems, what is
5. another purpose of the diagnosing step in the nursing process?
A) To collect information about subjective and objective data
B) To correlate nursing and medical diagnostic criteria
C) To identify etiologies of health problems
D) To evaluate mutually developed expected
outcomes Ans: C
Feedback:
The purpose of diagnosing, the second step in the nursing process, is to
identify how an individual, a group, or a community responds to actual
or potential health and life processes; to identify etiologies (factors that
contribute to or cause health problems); and to identify resources or
strengths that the individual, group, or community can draw on to
prevent or resolve problems.
6. Which of the following client care concerns is clearly a nursing responsibility?
A) Prescribing medications
B) Monitoring health status changes
C) Ordering diagnostic examinations
D) Performing surgical
procedures Ans: B
Feedback:
Monitoring for health status changes is clearly a nursing responsibility.
The other options are medical responsibilities, although in some
instances an advanced practice nurse practitioner may be responsible
for A and C.
After completing assessments, a nurse uses the data collected to identify
7. appropriate nursing diagnoses for a client. For what are the nursing diagnoses used?
A) Selecting nursing interventions to meet expected outcomes
B) Establishing a database of information for future comparison
C) Mutually establishing desired outcomes of the plan of care
D) Evaluating the effectiveness of the established plan of care

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Ans: A
Feedbac
k:
The nurse formulates, validates, and lists nursing diagnoses for each
client. Nursing diagnoses provide the basis for selecting nursing
interventions that will achieve valued client outcomes for which the
nurse is responsible.
Which of the following statements accurately describes the legal responsibility of the
8. nurse making a diagnosis for a client?
The nurse may make a diagnosis, but the physician is responsible for
A) making sure it is appropriate for the client.
The nurse practitioner is responsible for making all nursing diagnoses
B) and determining if they are appropriate for the client.
The nurse must decide if he or she is qualified to make a nursing
C) diagnosis and will accept responsibility for treating it.
The health care facility directs the nursing diagnosis in order to receive
D) payment for services performed.
Ans: C
Feedbac
k:
The term diagnosis means there is a problem requiring qualified
treatment. The nurse must decide if he or she is qualified to make the
diagnosis and will be able to treat it. If not, the nurse must refer the
client to a qualified person for treatment.
A student is reviewing a client’s chart before giving care. She notes the
following diagnoses in the contents of the chart: “appendicitis” and
“acute pain.” Which of the
9. diagnoses is a medical diagnosis?
A) Neither appendicitis nor acute pain
B) Both appendicitis and acute pain
C) Appendicitis
D) Acute
pain Ans: C
Feedback:
Medical diagnoses identify diseases (in this case, appendicitis). Nursing
diagnoses describe problems treated by the nurse within the scope of
independent nursing practice.

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 A nurse develops a plan of care to meet the needs of a client who has
had a large loss of blood after a snowmobile crash. Intravenous fluids
and blood are administered
10. and the nurse monitors the client’s physiologic response. This action is known as a:
A) medical diagnosis.
B) nursing diagnosis.
C) collaborative problem.
D) goal for
care. Ans: C
Feedback:
Collaborative problems are certain physiologic complications that
nurses monitor to detect onset or changes in status. Nurses manage
collaborative problems by using physician-prescribed and nursing-
prescribed interventions to minimize the complications of the event.
A nurse is reviewing the health history and physical assessment findings
for a client who is having respiratory problems. Of the following data
collected, what data from
11. the health history would be a cue to a nursing diagnosis for this problem?
A) “I often have diarrhea after I eat spicy foods.”
B) “My skin is so dry I just can’t keep from scratching.”
C) “I get out of breath when I walk a few steps.”
D) “I just feel so bad about myself these
days.” Ans: C
Feedback:
Most experienced nurses begin the work of interpreting and analyzing
data while they are still collecting it. The term cue is often used to
denote significant data, which “raises a red flag” to look for patterns or
clusters of data that signal a nursing diagnosis. In this instance, the
client’s statement of getting out of breath when walking would be a cue
to assess other subjective and objective data related to the respiratory
system.
12. What is the focus of a diagnostic statement for a collaborative problem?
A) The client problem
B) The potential complication
C) The nursing diagnosis

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D) The medical
diagnosis Ans: B
Feedback:
To write a diagnostic statement for a collaborative problem, the nurse
should focus on the potential complications of the problem and use
“PC” (for potential complication), followed by a colon, and list the
complications that might occur. For clarity, the nurse should link the
potential complications and the collaborative problem by using
“related to.”
Successful implementation of each step of the nursing process requires
high-level skills in critical thinking. Which of the following statements
accurately describe a
13. guideline for using this process?
A) Trust clinical judgment and experience over asking for help.
B) Respect clinical intuition, but never allow it to determine a diagnosis.
C) Recognize personal biases as a strength in formulating diagnoses.
D) Keep an open mind and trust your intuition when
formulating diagnoses. Ans: D
Feedback:
To correctly diagnose health problems, the nurse must be familiar with
nursing diagnoses and other health problems; read professional
literature and keep reference guides handy; trust clinical experience
and judgment but be willing to ask for help when the situation demands
more than his or her qualifications and experience can provide; respect
clinical intuitions, but before writing a diagnosis without evidence,
increase the frequency of observations and continue to search for clues
to verify intuition. The nurse must also recognize personal biases and
keep an open mind.
A nurse observes a new mother tenderly holding and softly talking to her baby. What
14. does this observation tell the nurse about the baby’s strengths?
A) Nothing; this observation is not important.
B) The mother is just behaving as all mothers do.
C) A baby is not capable of having strengths.
D) Nurturing is a strength for developing
infants. Ans: D
Feedback:

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 A strength, as assessed by the nurse during data interpretation and
analysis, contributes to a client’s level of wellness. In this case, the
obvious love of the mother for her baby indicates a significant strength
in the normal growth and development of the baby.
A nurse completes a health history and physical assessment for an
adolescent before he begins football practice. Based on findings, the
nurse recommends reinforcing good health habits. What conclusion did
the nurse reach after interpreting and analyzing
15. the data?
A) No problem
B) Possible problem
C) Actual problem
D) Clinical
problem Ans: A
Feedback:
The nurse reaches one of four basic conclusions after interpreting and
analyzing the client data. Different nursing responses are possible for
each conclusion. In this case, the nurse would most likely conclude
there was no problem and reinforce the client’s health habits.
A nurse caring for an older adult client in a long-term care facility
notices that the bedding is wet when the client gets up in the morning.
The nurse collects more data
16. to form a conclusion. What type of problem is involved in this scenario?
A) No problem
B) Possible problem
C) Actual problem
D) Clinical
problem Ans: B
Feedback:
The nurse reaches one of four basic conclusions after interpreting and
analyzing the client data: no problem, possible problem, actual or
potential problem, or clinical problem. When dealing with a possible
problem, the nurse must collect more data to confirm or disprove a
suspected problem.
A nurse is formulating a nursing diagnosis for a client with a respiratory disease.
17. Which of the following would be correct?
A) “needs nasal oxygen to improve breathing”
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B) “cough related to ineffective airway clearance”
C) “ineffective airway clearance related to thick mucus”
D) “refuses to cough and expectorate thick
mucus” Ans: C
Feedback:
It is important to use guidelines to formulate correctly written nursing
diagnoses. The nurse would not use client needs, put defining
characteristics before the diagnoses, or judge the willingness of the
client to cough.
A nurse writes the following nursing diagnosis for a client with
Alzheimer’s disease: Disturbed Thought Processes related to
Alzheimer’s disease as evidenced by incoherent language. Which part
of this diagnosis is considered the problem
18. statement?
A) disturbed thought processes
B) related to
C) Alzheimer’s disease
D) incoherent
language Ans: A
Feedback:
The purpose of the problem statement is to describe the health state or
health problem of the client as clearly and concisely as possible.
Because this section of the nursing diagnosis identifies what is
unhealthy about the client and what the client would like to change in
his or her health status, it suggests client outcomes. NANDA
recommends the use of quantifiers or descriptors to limit or specify the
meaning of a problem statement. Disturbed thought processes is a
NANDA-approved descriptor for this client problem. The etiology
identifies the physiologic, psychological, sociologic, spiritual, and
environmental factors believed to be related to the problem as either a
cause or a contributing factor, and in this case is Alzheimer’s disease.
Incoherent language is considered a defining characteristic or
subjective/objective data signaling the existence of an actual or
potential health problem.
A nurse is formulating a diagnosis for a client who is reliving a brutal
mugging that took place several months ago. The client is crying
uncontrollably and states that he “can’t live with this fear.” Which of the
following diagnoses for this client is correctly
19. written?
A) Post-trauma syndrome related to being attacked
B) Psychological overreaction related to being attacked

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C) Needs assistance coping with attack
D) Mental distress related to being
attacked Ans: A
Feedback:
Post-trauma syndrome is a NANDA-approved problem statement and
being attacked is the correct etiology. Overreaction and mental distress
implies a value judgment by the nurse. Needs assistance addresses the
need of the client.
Of the following types of nursing diagnoses, which one is validated by the presence of
20. major defining characteristics?
A) Risk nursing diagnosis
B) Actual nursing diagnosis
C) Possible nursing diagnosis
D) Wellness
diagnosis Ans: B
Feedback:
Actual nursing diagnoses represent problems that have been validated
by the presence of major defining characteristics. An actual nursing
diagnosis has four components: label, definition, defining
characteristics, and related factors.
A nursing diagnosis is written as Disturbed Self-Esteem related to presence of large
21. scar over left side of face. What does the phrase “Disturbed Self-Esteem” identify?
A) The expected outcome of the plan of care
B) A cue to determining a health problem
C) The major defining characteristic of a health problem
D) The health state or problem of the
client Ans: D
Feedback:
The problem, a part of a nursing diagnosis, describes the health state
or health problem of the client as clearly and concisely as possible. It
identifies what is unhealthy about the client and what the client would
like to change. It also suggests client outcomes but is not an outcomes
statement.

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 In the nursing diagnosis Disturbed Self-Esteem related to presence of
large scar over left side of face, what part of the nursing diagnosis is
“presence of large scar
22. over left side of face”?
A) Etiology
B) Problem
C) Defining characteristics
D) Client
need Ans: A
Feedback:
The etiology identifies the physiologic, psychological, sociologic,
spiritual, and environmental factors believed to be related to the
problem as either a cause or a contributing factor. The etiology directs
nursing interventions.
A student identifies Fatigue as a health problem and nursing diagnosis
for a client receiving home care for treatment of metastatic cancer.
What statement or
23. 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?” Ans: D
Feedback:
After a tentative nursing diagnosis is made, it should be validated.
Clients who are able to participate in decision making should be
encouraged to validate the diagnosis.
Of all the benefits of using nursing diagnoses, which one is probably the most
24. important to nurses?
A) Defining the domain of nursing practice
B) Informing patients of their care
C) Improving communication among nurses
D) Structuring curricular
content Ans: C
Feedback:

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 Although all the choices are correct, improved communication among
nurses and other health care professionals is probably the most
important benefit that accurate, up- to-date nursing diagnoses offer
nurses.
According to Maslow’s hierarchy of needs, which nursing diagnosis has
the lowest priority for a client admitted to the intensive care unit with a
diagnosis of
25. congestive heart failure?
A) Ineffective airway clearance
B) Ineffective coping
C) Impaired urinary elimination
D) Risk for body image
disturbance Ans: D
Feedback:
Risk for disturbed body image is the least priority among all the nursing
diagnoses mentioned, according to the Maslow’s hierarchy. Body image
disturbance is not vital for life. Secondly, it is a potential diagnosis, not
an actual diagnosis. The other options could be an actual diagnosis
present in the client. Ineffective airway clearance is the most
important diagnosis because it is vital to life. Impaired urinary
elimination is the next most important diagnosis because it is a
physiological need.
Ineffective coping is a social need, followed by the least important
diagnosis of disturbed body image.
A client has an external fixation device on his leg due to a compound
fracture. The client says that the device and swelling makes his leg look
ugly. Which nursing
26. diagnosis should the nurse document in his care plan based on the client’s concern?
A) Impaired physical mobility
B) Disturbed body image
C) Risk for infection
D) Risk for social
isolation Ans: B
Feedback:
The diagnosis of disturbed body image is appropriate for the client
because he is worried about the appearance of his legs due to swelling
and the external fixation device. There is no mention about impaired
physical mobility or risk for social isolation in the client’s concern. There
may be a risk of infection, but the client does not mention it.

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 A client who has to undergo a parathyroidectomy is worried that he
may have to wear a scarf around his neck after surgery. What nursing
diagnosis should the nurse
27. document in the care plan?
A) Risk for impaired physical mobility due to surgery
B) Ineffective denial related to poor coping mechanisms
C) Disturbed body image related to the incision scar
D) Risk of injury related to surgical
outcomes Ans: C
Feedback:
The client is concerned about the surgery scar on his neck, which would
disturb his body image; therefore, the appropriate diagnosis should be
disturbed body image related to the incision scar. Risk for impaired
physical mobility may be present after surgery, but is not related to the
concerns expressed by the client. Likewise, ineffective denial related to
poor coping mechanisms, and injury related to surgical outcomes are
also not related to the client’s concern.
A nurse who is caring for an unresponsive client formulates the nursing
diagnosis, “Risk for Aspiration related to reduced level of
consciousness.” The nurse documents this nursing diagnosis as correct
based on the understanding that which of the
28. following is a characteristic of this type of diagnosis?
A) Is written as a two-part statement
B) Describes human response to a health problem
C) Describes potential for enhancement to a higher state
D) Made when not enough evidence supports the
problem Ans: A
Feedback:
The risk diagnoses are written as two-part statements because they do
not include defining characteristics. An actual nursing diagnosis
describes human response to a health problem. Wellness diagnoses
describe potential for enhancement to a higher state. A possible
nursing diagnosis is made when not enough evidence supports the
problem.
After assessing a client, the nurse formulates several nursing diagnoses. Which of
29. the following would the nurse identify as an actual nursing diagnosis?
A) Impaired urinary elimination
B) Readiness for enhanced sleep
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C) Risk for infection
D) Possible impaired
adjustment Ans: A
Feedback:
Impaired urinary elimination is an actual nursing diagnosis because it
describes a human response to a health problem that is being
manifested. Readiness for enhanced sleep is a wellness diagnosis. Risk
for infection is a risk diagnosis, and possible impaired adjustment is a
possible nursing diagnosis.
30. What is the nurse accountable for, according to the state nurse practice act?
A) Continuing education
B) Nursing diagnoses
C) Prescribing medications
D) Mentoring other
nurses Ans: B
Feedback:
State nurse practice acts have included diagnosis as part of the domain
of nursing practice for which nurses are held accountable.
A client is experiencing shortness of breath, lethargy, and cyanosis. These three cues
31. provide organization or …
A) Categorizing
B) Diagnosing
C) Grouping
D) Clusteri
ng Ans: D
Feedback:
Cue clustering brings together cues that if viewed separately would not
convey the same meaning.
The nurse is providing care for a client who experienced an ischemic
stroke five days ago. Which of the following diagnoses would the nurse
be justified in identifying and
32. documenting in the care of this client? Select all that apply.
A) Dysphagia

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B) Bowel Incontinence
C) Impaired Swallowing
D) Impaired Physical Mobility
E) Risk for
Hemiparesis Ans: B,
C, D
Feedback:
Bowel Incontinence, Impaired Swallowing, and Impaired Physical
Mobility are all health problems that can be independently prevented or
resolved by nursing practice. Dysphagia and hemiparesis are medical
diagnoses.
33. Which of the following reflects the diagnosis phase?
A) The nurse identifies that the client does not tolerate activity.
B) The nurse performs wound care using sterile technique.
C) The nurse sets a tolerable pain rating with the client.
D) The nurse documents the client’s response to pain
medication. Ans: A
Feedback:
Recognition of a client health problem that can be prevented or
resolved by independent nursing intervention, such as activity
intolerance, is the focus of diagnosing. Performing wound care is an
example of implementation. Setting a tolerable pain rating with the
client is an example of planning. Documenting the client’s response to
pain medication is an example of evaluation.

Set 8

The nurse develops long-term and short-term outcomes for a client admitted with
1. asthma. Which of the following is an example of a long-term goal?

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 Client returns home verbalizing an understanding of contributing factors,
A) medications, and signs and symptoms of an asthma attack.
By day 3 of hospitalization, the client verbalizes knowledge of factors that
B) exacerbate the symptoms of asthma.
Within one hour of a nebulizer treatment, adventitious breath sounds and cough are
C) decreased.
Within 72 hours of admission, the client’s respiratory rate returns to normal and
D) retractions disappear.
Ans: A
Feedbac
k:
An example of a long-term outcome is “Patient returns home
verbalizing an understanding of contributing factors, medications, and
signs and symptoms of an asthma attack.” The other three examples
are short-term outcomes that focus on short-term goals related to the
period of time during hospitalization.
Nurses make common errors in the identification and development of outcomes. Which
2. of the following is a common error made when writing client outcomes?
A) The nurse expresses the client outcome as a nursing intervention.

B) The nurse develops measurable outcomes using verbs that are

observable. The nurse develops a target time when the client is

expected to achieve that

C) outcome.
The outcome should include a subject, verb, conditions, performance criteria, and
D) target time.
Ans: A
Feedbac
k:
A common error made when writing client outcomes includes the nurse
expressing the client outcome as a nursing intervention. The other
mentioned criteria for writing client outcomes are correct.
Increasingly, health care institutions are implementing computerized plans of
3. nursing care. A benefit of using computerized plans includes which of the following?
A) Reduction in the time spent on care planning
B) Increased autonomy related to the nursing care planning process
C) Enhanced individualization of a care plan
D) Increased nursing expertise in care planning
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Ans: A
Feedbac
k:
The benefits of using computerized plans include ready access to a
large knowledge base; improved record keeping, with resultant
improvement in audits and quality assurance; documentation by all
members of the health care team; and reduced time spent on
paperwork. Research cautions that computerized systems for client
care planning contribute to loss of autonomy, loss of individualization of
care, and loss of nursing expertise.
The nurse is planning the care of a male client who is receiving
treatment for acute renal failure and who has begun dialysis three
times weekly. The nurse has identified the following outcome: “Client
will demonstrate the appropriate care of his
4. arteriovenous fistula.” This outcome is classified as which of the following?
A) Psychomotor
B) Affective
C) Cognitive
D) Holistic
Ans: A
Feedbac
k:
Psychomotor outcomes describe the client’s achievement of new skills,
such as the safe and aseptic care of a new fistula. Cognitive outcomes
are focused on knowledge and effective outcomes address values,
beliefs, and attitudes. Outcomes are not classified as holistic.
The nurse is caring for a client who has been newly diagnosed with
diabetes. One of the outcomes the nurse read on the client’s plan of
care this morning was: “Client will demonstrate correct technique for
self-injecting insulin.” The client required insulin prior to his lunch and
successfully drew up and administered his insulin while the
5. nurse observed. How should the nurse follow up this observation?
A) Record an evaluative statement in the client’s plan of care.
B) Remove the outcome from the client’s care plan.
C) Ask the nurse who wrote the plan of care to document this development.
D) Reassess the client’s psychomotor skills at
dinner time. Ans: A
Feedback:

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 The client has successfully met this outcome, and the nurse should note
the time and date that it was achieved in the client’s plan of care. The
outcome should not be removed from the plan of care and it is
unnecessary to have the original author of the plan update it. Further
observation may or may not be necessary at dinner time, but an
evaluative statement should nonetheless be recorded at the present
time.
A male client is scheduled to be fitted with a prosthesis following the
loss of his nondominant hand in a farm accident several weeks earlier.
Nurses have documented the following outcome during this stage of his
care: “After attending an educational session, client will demonstrate
correct technique for applying his prosthesis.” Which
6. of this client’s following statements would signal a need to amend this outcome?
A) “I’m not interested one bit in wearing an artificial hand.”
“I’m worried that I’m going to get some really strange looks when I wear this
B) thing.”
C) “I don’t have a clue how this thing goes on and comes off.”
D) “I don’t understand the technology that’s used in this
artificial hand.” Ans: A
Feedback:
It is imperative that interventions and outcomes be valued by the
client. The client’s resistance to using a prosthesis likely invalidates
the outcome that addresses his technique for its use. The other
statements express cognitive and affective learning needs that would
need to be addressed, but none of those precludes his eventual
mastery of the prosthesis.
What is the primary purpose of the outcome identification and planning step of the
7. nursing process?
A) To collect and analyze data to establish a database
B) To interpret and analyze data so as to identify health problems
C) To write appropriate client-centered nursing diagnoses
D) To design a plan of care for and with the
client Ans: D
Feedback:
The primary purpose of outcome identification and planning is to design
a plan of care for (and with) the client that, once implemented, results
in the prevention, reduction, or resolution of client health problems and
the attainment of the client’s health expectations, as identified in the
client outcomes.

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 Critical thinking is an essential component in all phases of the nursing
process. What question might be used to facilitate critical thinking
during outcome identification
8. and planning?
A) “How do I best cluster these data and cues to identify problems?”
B) “What problems require my immediate attention or that of the team?”
C) “What major defining characteristics are present for a nursing diagnosis?”
D) “How do I document care accurately and
legally?” Ans: B
Feedback:
Questions to facilitate critical thinking during outcome identification
and planning include those related to setting priorities, such as “Which
problems require my immediate attention or that of the team?” and
“Which problems are most important to the client?”
A nurse is discharging a client from the hospital. When should discharge planning be
9. initiated?
A) At the time of discharge from an acute health care setting
B) At the time of admission to an acute health care setting
C) Before admission to an acute health care setting
D) When the client is at home after
acute care Ans: B
Feedback:
Discharge planning is best carried out by the nurse who worked most
closely with the client and family. In acute care settings,
comprehensive discharge planning begins when the client is admitted
for treatment.
The nursing diagnosis Impaired Gas Exchange, prioritized by Maslow’s hierarchy of
10. basic human needs, is appropriate for what level of needs?
A) Physiologic
B) Safety
C) Love and belonging
D) Self-
actualization Ans: A

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 Feedback:
Because basic human needs must be met before a person can focus on
higher-level needs, client needs may be prioritized according to
Maslow’s hierarchy. Physiologic needs, including the need for oxygen,
are the most basic and have the highest priority.
A resident of a long-term care facility refuses to eat until she has had her hair
11. combed and her make-up applied. In this case, what client need should have priority?
A) The need to have nutrition
B) The need to feel good about oneself
C) The need to live in a safe environment
D) The need for love from
others Ans: B
Feedback:
When setting priorities, it is best to first meet the needs that the client
believes are most important. In this situation, the woman is not
refusing food altogether; rather, she wants to feel good about herself
(self-esteem) when she does eat.
During outcome identification and planning, from what part of the nursing diagnoses
12. are outcomes derived?
A) The defining characteristics
B) The related factors
C) The problem statement
D) The
database Ans: C
Feedback:
Outcomes are derived from the problem statement of the nursing
diagnosis. For each nursing diagnosis, at least one outcome should
be written that, if achieved, demonstrates a direct resolution of the
problem statement.
A nurse is developing outcomes for a specific problem statement. What is one of the
13. most important considerations the nurse should have?
A) The written outcomes are designed to meet nursing goals
B) To encourage the client and family to be involved
C) To discourage additions by other healthcare providers
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D) Why the nurse believes the outcome is
important Ans: B
Feedback:
One of the most important considerations in writing outcomes is to
encourage the client and family to be involved in goal development as
their abilities and interest permit. The more involved they are, the
greater the probability the goals will be achieved.
14. Which of the following outcomes is correctly written?
A) Abdominal incision will show no signs of infection.
B) On discharge, client will be free of infection.
C) On discharge, client will be able to list five symptoms of infection.
D) During home care, nurse will not observe symptoms
of infection. Ans: C
Feedback:
To be measurable, outcomes should have a subject (client or part of the
client), verb (action to be performed), conditions (not always included),
performance criteria (observable, measurable), and target time (to
achieve the outcome).
15. Which of the following illustrates a common error when writing client outcomes?
A) Client will drink 100 mL of fluid every 2 hours from 6 a.m. to 9 p.m.
B) Client will demonstrate correct sequence of exercises by next office visit.
C) Client will be less anxious and fearful before and after surgery.
D) On discharge, client will list five symptoms of infection
to report. Ans: C
Feedback:
Common errors when writing client outcomes include expressing the
outcome as a nursing intervention, using verbs that are not observable
and measurable (as is done here), and writing vague outcomes (also
done here).
16. Which of the following groups of terms best describes a nurse-initiated intervention?
A) Dependent, physician-ordered, recovery
B) Autonomous, clinical judgment, client outcomes

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C) Medical diagnosis, medication administration
D) Other health care providers, skill
acquisition Ans: B
Feedback:
A nursing intervention is any treatment, based on clinical judgment and
knowledge, that a nurse performs to enhance client outcomes. Nurse-
initiated interventions are autonomous (independently performed).
What part of the nursing diagnosis statement suggests the nursing interventions
17. to be included in the plan of care?
A) Problem statement
B) Defining characteristics
C) Etiology of the problem
D) Outcomes
criteria Ans: C
Feedback:
In contrast to the client goals, which are suggested by the problem
statement of the diagnosis, it is the cause of the problem (etiology) that
suggests the nursing interventions. Effective nurses select nursing
interventions that specifically address factors that cause, or contribute
to, the client’s problem.
What name is given to tools that are used to communicate a
standardized interdisciplinary plan of care for clients within a case
management health care
18. delivery system?
A) Kardex care plans
B) Computerized plans of care
C) Clinical pathways
D) Student care
plans Ans: C
Feedback:
Clinical pathways (critical pathways, CareMaps) are tools used to
communicate the standardized interdisciplinary plan of care for clients.
The emphasis in case management is on clearly stating expected client
outcomes and the specific times targeted to achieve these outcomes.

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 A nurse has developed a plan of care with nursing interventions
designed to meet specific client outcomes. The outcomes are not met
by the time specified in the plan.
19. What should the nurse do now in terms of evaluation?
A) Continue to follow the written plan of care.
B) Make recommendations for revising the plan of care.
C) Ask another health care professional to design a plan of care.
D) State “goal will be met at a later
date.” Ans: B
Feedback:
Client outcomes are meaningless unless the nurse evaluates the
client’s progress toward their achievement. If the plan is not achieved
(not met), recommendations for revising the plan of care are included
in the evaluative statement.
Which of the following types of care plans is most likely to enable the nurse to take a
20. holistic view of the client’s situation?
A) Kardex
B) Case management
C) Critical pathways
D) Concept map care
plan Ans: D
Feedback:
A concept map care plan is a diagram of client problems and
interventions. The nurse’s ideas about client problems and treatments
are the “concepts” that are diagrammed. These maps are used to
organize client data, analyze relationships in the data, and enable the
nurse to take a holistic view of the client’s situation (Schuster, 2002).
21. Which of the following is an example of a well-stated nursing intervention?
A) Client will drink 100 mL of water every 2 hours while awake.
B) Offer client 100 mL of water every 2 hours while awake.
C) Offer client water when he complains of thirst.
D) Client will continue to increase oral intake
when awake. Ans: B

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 Feedback:
Nursing interventions describe in writing the specific nursing care to be
implemented for the client. They include information that answers the
questions who, what, where, when, and how.
22. What common problem is related to outcome identification and planning?
A) Failing to involve the client in the planning process
B) Collecting sufficient data to establish a database
C) Stating specific and measurable outcomes based on nursing diagnoses
D) Writing nursing orders that are clear and resolve the
problem Ans: A
Feedback:
One of the most important considerations in outcome achievement is to
encourage the client and family to be as involved in goal development
as their abilities and interest permit. The more involved they are, the
greater the probability that the outcomes will be achieved.
A nurse is assigned to care for a client diagnosed with asthma who has
just been admitted to the health care facility. The nurse determines the
client’s priorities for
23. care using which of the following?
A) Assessment skills
B) Nursing books
C) Client’s records
D) Supervisor’s
advice Ans: A
Feedback:
The nurse should use assessment skills to determine the priority of
nursing care for the client. Books on nursing can give only the
theoretical aspect of nursing care.
Client’s records reveal information about the client’s condition but do
not convey the client’s needs. Advice from supervisors can be taken if
confronted with a problem.
A client is scheduled for surgery for an abdominal hysterectomy. During
the preoperative assessment, the client states, “I am very nervous and
scared to have
24. surgery.” What client outcome is the priority?
A) Evaluate the need for antibiotics.

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B) Resolve the client’s anxiety.
C) Provide preoperative education.
D) Prepare the client for
surgery. Ans: B
Feedback:
A priority is something that takes precedence in position, deemed the
most important among several items. The client’s preparation for
surgery is important, but to have a successful outcome, the nurse
must address the psychosocial issues related to anxiety.
Which of the following client outcomes best describes the parameters for achieving
25. the outcome?
A) The client will eat a well-balanced diet.
The client will consume a 2,400-calorie diet, with three meals and two snacks,
B) starting tomorrow.
The client will cleanse his wound with soap and water and apply a dry sterile
C) dressing.
D) The client will be without pain in 24
hours. Ans: B
Feedback:
The client will consume a 2,400-calorie diet, with three meals and two
snacks, starting tomorrow possesses all parameters for achieving the
outcome.
Nurses identifying outcomes and related nursing interventions must
refer to the standards and agency policies for setting priorities,
identifying and recording expected client outcomes, selecting evidence-
based nursing interventions, and recording the
26. plan of care. Which of the following are recognized standards? Select all that apply.
A) Professional physicians’ organizations
B) State Nurse Practice Acts
C) The Joint Commission
D) The Agency for Health Care Research and Quality
E) The Patient Health
Partnership Ans: B, C, D
Feedback:
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 To plan health care correctly, the nurse must be familiar with standards
and agency policies for setting priorities, identifying and recording
expected client outcomes, selecting evidence-based nursing
interventions, and recording the plan of care. These standards include
the law, national practice standards, specialty professional nursing
organizations, The Joint Commission, the Agency for Health Care
Research and Quality, and employers.
In which of the following clients has the order of priorities for nursing diagnoses
27. changed? Select all that apply.
A) A client in a long-term care facility who had a stroke
B) A client who is recovering from a broken leg
C) A client who insists on using the bathroom instead of a bedpan
D) A client who appears confused after taking pain medication
E) A pregnant client whose contractions are progressing as
anticipated Ans: A, C, D
Feedback:
The work of setting priorities demands careful critical thinking. When
planning nursing care, the nurse should consider the following: Have
changes in the client’s health status influenced the priority of nursing
diagnoses? Have changes in the way the client is responding to health
and illness (or the plan of care) affected those nursing diagnoses that
can be realistically addressed? Are there relationships among
diagnoses that require that one be worked on before another can be
resolved? Do several client problems need to be dealt with together.
Which of the following statements accurately describes the impact on nursing of
28. using NIC/NOC standardized languages? Select all that apply.
They demonstrate the impact that nurses have on the system of
A) health care delivery.
B) They standardize and define the knowledge base for nursing curricula
and practice.
C) They limit the number of appropriate nursing interventions to be
selected.
D) They hinder the teaching of clinical decision making to novice nurses.
E) They enable researchers to examine the effectiveness and cost of
nursing care. Ans: A, B, E
Feedback:
Using NIC/NOC standardized language demonstrates the impact that
nurses have on the system of health care delivery; standardizes and NursingStoreRN
defines the knowledge base
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 for nursing curricula and practice; facilitates the selection of
appropriate nursing interventions; facilitates the teaching of clinical
decision making to novice nurses; enables researchers to examine the
effectiveness and cost of nursing care; assists educators to develop
curricula that better articulate with clinical practice; assists
administrators in planning more effectively for staff and equipment
needs; promotes the development and use of nursing information
systems; and communicates the nature of nursing to the public.
29. Which of the following is a correctly written client goal? Select all that apply.
A) The client will identify five low-sodium foods by October 9.
B) The client will know the signs and symptoms of infection.
C) The client will rate pain as a 3 or less on a 10-point scale by 5 pm today.
D) The client will understand the side effects of digoxin (Lanoxin).
E) The client will eat at least 75% of all meals by
May 5. Ans: A, C, E
Feedback:
Outcomes are client-centered, use action verbs, identify measurable
criteria, and include a time frame as to when the outcome should be
achieved. A correctly written outcome will identify who (the client) will
do what (eat), how well (75%) under what circumstances (not always
included), and by when (May 5). Understand and know are vague and
are not action-oriented.
30. Which intervention does the nurse recognize as a collaborative intervention?
A) Teach the client how to walk with a three-point crutch gait.
B) Administer spironolactone (Aldactone).
C) Perform tracheostomy care every eight hours.
D) Straight catheterize every six
hours. Ans: A
Feedback:
Collaborative interventions are treatments initiated by other providers,
such as pharmacists, respiratory therapists, physical therapists, and
other members of the health care team. Teaching the client how to
walk with crutches would be a collaborative intervention. Administering
medications, performing tracheostomy care, and catheterizing a client
require a physician’s order and are physician-initiated interventions.
31. Which of the following is a correctly written client goal?
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A) The client will eliminate a soft formed stool.
B) The client understands what foods are low in sodium.
C) The client will ambulate 10 feet with a walker by October 12.
D) The client correctly self-administers the morning dose
of insulin. Ans: C
Feedback:
Outcomes are client-centered, use action verbs, identify measureable
criteria, and include a time frame as to when the outcome should be
achieved. A correctly written outcome will identify who (the client) will
do what (ambulate), how well (10 feet), under what circumstances (with
a walker), and by when (October 12). Understand is vague and not
action-oriented. The outcomes regarding eliminating a stool and self-
administering insulin are missing the time frame.
The nursing student asks the nurse about nurse-initiated and physician-initiated
32. interventions. Which of the following is a physician-initiated intervention?
A) Teach client how to transfer from bed to chair and chair to bed.
B) Administer oxygen 4 L/min per nasal cannula.
C) Assist the client with coughing and deep breathing every hour.
D) Monitor intake and output every 2
hours. Ans: B
Feedback:
A physician-initiated intervention is an intervention initiated by a
physician in response to a medical diagnosis but carried out by a nurse
in response to a physician’s order. A physician’s order is required for the
nurse to administer drugs, such as oxygen. A nurse-initiated
intervention is an autonomous action based on scientific rationale that
a nurse executes to benefit the client in a predictable way related to the
nursing diagnosis and expected outcomes. Nursing-initiated
interventions, such as teaching client how to transfer, assisting with
coughing and deep breathing, and monitoring intake and output do not
require a physician’s order.
The nurse formulates the following client outcome: Client will correctly
draw up morning dose of insulin and identify four signs and symptoms
of hypoglycemia by
33. September 7. Which error has the nurse made?
A) Expressed the client outcomes as a nursing intervention
B) Wrote vague outcomes that will confuse other nurses
C) Included more than one client behavior in the outcome
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D) Used verbs that are not observable and
measurable Ans: C
Feedback:
Two client behaviors have been included in the outcome statement:
drawing up insulin and identifying four signs and symptoms.
Which of the following is not appropriate in writing client-centered measurable
34. outcomes?
A) The client or a part of the client
B) A flexible time frame
C) Observable, measurable terms
D) The action the client will
perform Ans: B
Feedback:
In writing client-centered measurable outcomes, a target time is
required. This target time specifies when the client is expected to be
able to achieve the outcome. The other options given (the client or
part of the client; observable and measurable terms; the action the
patient will perform) are all part of client-centered measurable
outcomes.
While developing the plan of care for a new client on the unit the nurse
must identify expected outcomes that are appropriate for the new
client. What is a resource for
35. identifying these appropriate outcomes?
A) Community Specific Outcomes Classification (CSO)
B) The Nursing-Sensitive Outcomes Classification (NOC)
C) State Specific Nursing Outcomes Classification (SSNOC)
D) Department of Health and Human Resources Outcomes
Classification (HHROC) Ans: B
Feedback:
Resources for identifying appropriate expected outcomes include the
Nursing- Sensitive Outcomes Classification (NOC) (Chart 3-6) and
standard outcome criteria established by health care agencies for
people with specific health problems. The other options are incorrect
because they do not exist.

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Set 9

A client being prepared for discharge to his home will require several
interventions in the home environment. The nurse informs the
discharge planning team, consisting of a home health care nurse,
physical therapist, and speech therapist, of the client’s discharge
needs. This interaction is an example of which professional nursing
1. relationship?
A) Nurse-health care team
B) Nurse-patient
C) Nurse-patient-family
D) Nurse-
nurse Ans: A
Feedback:
A nurse-health care team professional relationship occurs when the
nurse coordinates the input of the multidisciplinary team into a
comprehensive plan of care. The nurse may also serve as a liaison
between the client and family and the health care team, as necessary.
A graduate nurse recently attended a conference on acute coronary
syndrome. In preparing a plan of care for a client admitted with acute
coronary syndrome, the nurse considers the information she learned at
the conference. Which nursing variable
2. is the nurse utilizing in the development of the plan of care?
A) Research findings
B) Resources
C) Current standards of care
D) Ethical and legal guides to practice

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Ans: A
Feedbac
k:
Nurses concerned about improving the quality of nursing care use
research findings to enhance their nursing practice. Reading
professional journals and attending continuing education workshops
and conferences are excellent ways to learn about new nursing
strategies that have proved effective.
The American Nurses Association recommends adherence to defined
principles when delegating care tasks to unlicensed assistive
personnel. According to these principles,
3. who is responsible and accountable for nursing practice?
A) The registered nurse
B) The American Nurses Association
C) The nurse manager
D) The unit’s medical
director Ans: A
Feedback:
It is the registered nurse who is responsible and accountable for nursing practice.
An older adult client is receiving care on a rehabilitative medicine unit
during her recovery from a stroke. She complains that the physical
therapist, occupational therapist, neurologist, primary care physician,
and speech language pathologist “don’t seem to be on the same
page” and that “everyone has their own plan for me.”
4. How can the nurse best respond to the client’s frustration?
Facilitate communication between the different professionals and attempt to
A) coordinate care.
Educate the client about the unique scope and focus of each member of the
B) healthvcare team.
Modify the client’s plan of care to better reflect the commonalities between the
C) different disciplines.
Arrange for each professional to perform bedside assessments and interventions
D) simultaneously rather than individually.
Ans: A
Feedbac
k:
Nurses play a pivotal role in the coordination of care and often need to
facilitate communication between members of different disciplines.
Educating the client about the role of each professional may be useful,
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but it does not achieve coordination of
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 care. Similarly, amending the client’s plan of care will not create unity
and collaboration. It is unrealistic to expect each member of the care
team to always visit simultaneously.
A male client 30 years of age is postoperative day 2 following a
nephrectomy (kidney removal) but has not yet mobilized or dangled at
the bedside. Which of the following
5. is the nurse’s best intervention in this client’s care?

A) Educate the client about the benefits of early mobilization and offer to

assist him. Respect the client’s wishes to remain in his bed and ask

him when he would like to

B) begin mobilizing.
Show the client the expected outcomes on his clinical pathway that relate to
C) mobilization.
Document the client’s noncompliance and reiterate the consequences of delaying
D) mobilization.
Ans: A
Feedbac
k:
Educating the client about the benefits of mobilizing, and offering to
assist combines teaching with the promotion of self-care. It is likely
premature to label the client as noncompliant, and showing him the
expected outcomes on his clinical pathway is unlikely to motivate him
if he is reluctant. It is appropriate for the nurse to educate and
encourage the client rather than simply accepting his refusal and
providing no other interventions.
Many of the homeless clients who are supposed to receive care for
HIV/AIDS miss their appointments at a clinic because it is located in a
high-rise building on a university campus. Several of the clients state
that the clinic is difficult to find and in an intimidating environment.
This demonstrates that which of the following
6. variables influencing outcome achievement is being inadequately addressed?
A) Psychosocial background of clients
B) Developmental stage of clients
C) Ethical and legal considerations
D) Resources
Ans: A
Feedbac
k:
Requiring clients to attend a clinic that is difficult to access, and located
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in a daunting environment, shows a lack of consideration for clients’
psychosocial backgrounds. Resources, development, and ethics are not
central to this lapse in care.

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 A female client 89 years of age has been admitted to the hospital with a
diagnosis of failure to thrive. She has become constipated in recent
days, in spite of maintaining a high fluid intake and taking oral stool
softeners. She admits to her nurse that the problem is rooted in the fact
that she feels mortified to attempt a bowel movement on a commode at
her bedside where staff and other clients can hear
7. her. The nurse should respond by modifying which of the following resources?
A) Environment
B) Personnel
C) Equipment
D) Patient and
visitors Ans: A
Feedback:
Providing an environment for the client that is more conducive to
privacy and, ultimately, to her elimination needs is necessary in this
case. The equipment itself (i.e., the commode) is not the problem, but
rather its proximity to others. The staff and the client herself are not
central to the client’s new problem.
8. What is the unique focus of nursing implementation?
A) Client response to health and illness
B) Client response to nursing diagnosis
C) Client compliance with treatment regimen
D) Client interview and physical
assessment Ans: A
Feedback:
In all nurse–client interactions, the nurse is concerned with the client’s
response to health and illness and the nurse’s ability to meet basic
human needs. Whereas other health care professionals focus on
selected aspects of the client’s treatment regimen, nurses are
concerned with how the client is responding to the plan of care in
general.
The researchers developing classifications for interventions are also committed to
9. developing a classification of which of the following?
A) Diagnoses
B) Outcomes
C) Goals

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D) Data
clusters Ans: B
Feedback:
The researchers involved in the development of NICs are also
committed to developing a classification of client outcomes for nursing
interventions, called Nursing Outcomes Classifications (NOCs). This
research aims to identify, label, validate, and classify nursing-sensitive
client outcomes and indicators, evaluate the validity and usefulness of
the classification in clinical field-testing, and define and test
measurement procedures for the outcomes and indicators.
10. What activity is carried out during the implementing step of the nursing process?
A) Assessments are made to identify human responses to health problems.
B) Mutual goals are established and desired client outcomes are determined.
C) Planned nursing actions (interventions) are carried out.
D) Desired outcomes are evaluated and, if necessary, the plan
is modified. Ans: C
Feedback:
During the implementing step of the nursing process, nursing actions
(interventions) planned during the planning step are carried out.
11. What role of the nurse is crucial to the prevention of fragmentation of care?
A) Advocate
B) Educator
C) Counselor
D) Coordinat
or Ans: C
Feedback:
One of nursing’s major contributions to the health care team is the role
of coordinator. Care can easily become fragmented when clients are
seen by numerous specialists—each interested in a different aspect of
the client. It is important for the nurse to make rounds with other health
care professionals and to read the results of consultations that clients
have had with specialists. They can then interpret the specialists’
findings for clients and family members, prepare clients to participate
maximally in the plan of care before and after discharge, and serve as a
liaison among the members of the health care team.

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 A nurse is changing a sterile pressure ulcer dressing based on an established protocol.
12. What does this mean?
A) The nurse is using critical thinking to implement the dressing change.
B) The client has specified how the dressing should be changed.
C) Written plans are developed that specify nursing activities for this skill.
D) The physician verbally requested specific steps of the
dressing change. Ans: C
Feedback:
Protocols (written plans that detail the nursing activities to be executed
in specific situations) are nurse-initiated interventions. They expand
the scope of nursing practice in certain clearly defined situations.
A client who was previously awake and alert suddenly becomes
unconscious. The nursing plan of care includes an order to increase oral
intake. Why would the nurse
13. review the plan of care?
A) To implement evidence-based practice
B) To ensure the order follows hospital policy
C) To be sure interventions are individualized
D) To be sure the intervention is
safe Ans: D
Feedback:
Nurses reassess the client and review the plan of care before initiating
any nursing intervention. This is done to make sure that the plan of
care is still responsive to the client’s needs, and is safe for the
particular client. In this case, the nurse would not give oral fluids to an
unconscious client.
A nurse is preparing to insert an intravenous line and begin administering
14. intravenous fluids. The client has visitors in the room. What should the nurse do?
A) Ask the visitors to leave the room.
B) Ask the client if visitors should remain in the room.
C) Tell the client to ask the visitors to leave the room.
D) Wait until the visitors leave to begin the
procedure. Ans: B

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 Feedback:
If visitors are in the client’s room, check with the client to see whether
she or he wants the visitors to stay during the procedure.
A student is ambulating a client for the first time after surgery. What would the
15. student do to anticipate and plan for an unexpected outcome?
A) Take the client’s vital signs after ambulation.
B) Ask the client’s wife to assist with ambulation.
C) Delay ambulation until the following shift.
D) Ask another student to help with
ambulation. Ans: D
Feedback:
Unexpected outcomes do occur, such as the risk of a fall for the
postoperative client who is ambulated for the first time. In anticipation,
the student caregiver could ask another student to help ambulate the
client, thus decreasing this risk.
The staff in a long-term care facility often plays loud rock music on the radio and
16. designs children’s games as exercise. What is the staff doing in this situation?
A) Considering the hearing level of older adults
B) Failing to consider visual deficits that occur with aging
C) Ignoring the developmental needs of older adults
D) Meeting needs for sensory input and
exercise Ans: C
Feedback:
Nurses must be careful not to let stereotypes about developmental
stages and tasks influence client care. Playing loud rock music and
designing children’s games ignore the older adults’ needs and is
demeaning.
A nurse administers a medication for pain but forgets to document it in the client’s
17. medical record. Legally, what does this mean?
A) Nothing, the nurse’s honesty will not be questioned.
B) The nurse can add the documentation after the client goes home.
C) The physician will verify that the nurse carried out the order.
D) In the eyes of the law, if it is not documented, it was not done.

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Ans: D
Feedbac
k:
Nurses must carefully document each intervention. The legal truth is “if
it wasn’t documented, it wasn’t done.”
A nurse delegates a specific intervention to a UAP. What implications does this have
18. for the nurse?
A) The UAP is responsible and accountable for his or her own actions.
B) Nurses do not have authority to delegate interventions.
C) The nurse transfers responsibility but is accountable for the outcome.
D) The UAP can function in an independent role for all
interventions. Ans: C
Feedback:
UAPs are trained to function in an assistive role to the RN in client
activities as delegated and supervised by the RN. Delegation is the
transfer of responsibility of an activity to another individual while
retaining accountability for the outcome.
A nurse on duty finds that a client is anxious about the results of laboratory testing.
19. Which intervention by the nurse reflects a supportive intervention?
A) Sitting with the client to encourage her to talk
B) Telling the laboratory technician to speed up the results
C) Calling the physician for an order for an anxiolytic
D) Educating the client about reducing risk
factors Ans: A
Feedback:
Supportive interventions include recognizing the need for
encouragement, unconditional acceptance of behaviors, and the
positive effects of being present for clients during stress or crisis. To
support the anxious client, the nurse should sit with her and encourage
her to talk. Telling the laboratory technician to speed up the results, or
calling the physician and taking orders for anxiolytics are inappropriate
supportive interventions. Educating the client about reducing risk
factors is an educational intervention.
Educating clients on their diabetic regimen of administering insulin is the
20. implementation of which skill?

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 A) Intrinsic
B) Technical
C) Interpersonal
D) Visual
Ans: B
Feedbac
k:
The administration of insulin is a technical skill. Technical competence
means being able to use equipment, machines, and supplies in a
particular specialty.
A registered nurse who provides care in a subacute setting is
responsible for overseeing and delegating to unlicensed assistive
personnel (UAP). Which of the following principles should the nurse
follow when delegating to UAP? Select all that
21. apply.
A) Ensure that UAPs closely follow the nursing process when providing care.

B) Audit the client documentation that UAPs record after they perform

interventions. Take frequent mini-reports from UAPs to ensure changes

in client status are

C) identified.
D) Know what clinical cues the UAP should be alert for and why.
E) Make frequent walking rounds to assess
clients. Ans: C, D, E
Feedback:
The nurse must take careful action to ensure that delegation results in
safe and competent client care. This necessitates such measures as
taking frequent mini- reports, identifying the clinical cues that UAPs
should be aware of, and performing rounds often. UAPs are not
normally educated to follow the nursing process nor to perform
documentation.
Which of the following statements accurately describes a recommended guideline for
22. implementatio
n? Select all
that apply.
A)
When
implementing
B) nursing care,
remember to
C) act
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ind t to determine whether the action is still needed.
ep
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 Consult colleagues and the nursing and related literature to see if other approaches
D) might be more successful.
Reduce your repertoire of skilled nursing interventions to ensure a greater likelihood
E) of success.
Ans: B, D
Feedback:
When implementing nursing care, the nurse should act in partnership
with the client/family and reassess the client to determine if the
nursing action is still needed. The nurse should always question that
the nursing intervention selected is the best of all possible alternatives.
The nurse should consult colleagues and related nursing literature to
see if other approaches might be more successful. The nurse should
develop a repertoire of skilled nursing interventions, and check to
make sure that the ones selected are consistent with standards of
care and within legal/ethical guidelines to practice.
Which example reflects client variables that influence outcome achievement? Select
23. all that apply.
A) The client was born with cystic fibrosis.
B) The nurse works at a hospital in a diverse community.
C) Nursing interventions are consistent with standards of care.
D) The client is a college graduate and is employed.
E) The client engages in activities associated with
Ramadan. Ans: A, D, E
Feedback:
Important client variables that influence outcome achievement include
the physical health of the client, level of education attained, and
cultural practices that impact life and health practices. Nurse
variables, such as working in a diverse community, and standards of
practice also influence client outcome achievement.
The nurse is trying to determine factors influencing a client who is not
following the plan of care. Which client statement identifies a potential
factor interfering with
24. following the plan of care? Select all that apply.
A) I don’t drive so I was unable to fill my prescription.
B) I consult the list of low sodium foods when preparing meals.
C) My social security check does not come until next week.
D) I dropped the strips for my finger-stick blood glucose testing in the bath water.
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 “My daughter helps me with my range of motion exercises every morning and
E) afternoon.”
Ans: A, C, D
Feedback:
Common factors that contribute to a client not following the plan of
care include inability to afford treatment (social security check) and
limited access to treatment (doesn’t drive; damaged testing strips).
The nurse is caring for a client with a diagnosis of end-stage renal
disease. The client has expressed the desire to be kept comfortable and
to not continue further treatment. The daughter arrives from out of
town and is demanding to have further testing done to determine the
best treatment option for the client. What is
25. the best action for the nurse to take at this time?
A) Explain to the daughter the wishes of the client.
B) Arrange a meeting between the physician and daughter.
C) Contact the imaging center to schedule the testing.
D) Persuade the client to agree to the daughter’s
request. Ans: A
Feedback:
The priority is for the nurse to explain to the daughter the wishes of the
client and support the client’s decision. As an advocate, the nurse
implements actions to protect the rights of the client. The other options
do not support the client’s decision.

26. Which is a responsibility of the nurse in the nurse-client-family team

relationship? Provide creative leadership to make the nursing unit a

satisfying and challenging

A) place to work.
B) Support the nursing care given by other nursing and non-nursing personnel.

C) Educate the family to be informed and assertive consumers of

health care. Coordinate the inputs of the multidisciplinary team into

a comprehensive plan of
D) care.
Ans: C
Feedbac
k:
Educating the family to be informed and assertive consumers of health
care is a role responsibility in the nurse-client-family relationship.
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Responsibilities of the nurse in

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 the nurse-health care team relationship include coordinating the
inputs of the multidisciplinary team into a comprehensive plan of care.
In the nurse-nurse relationship, the nurse provides creative leadership
to make the nursing unit a satisfying and challenging place to work,
and supports the nursing care given by other nursing personnel.
The nurse is caring for a client with a diagnosis of colon disease. The
client has expressed to various members of the health care team the
desire to be kept comfortable and to not continue further treatment.
The client asks the nurse to be present when the client discusses the
decision with other family members. In which
27. professional nursing relationship is the nurse participating?
A) Nurse-client
B) Nurse-nurse
C) Nurse-client-family
D) Nurse-health care
team Ans: C
Feedback:
The nurse is fulfilling role responsibilities of the nurse-client-family
relationship when being present for a discussion of the matter by the
client and family.
The nurse is delegating to the unlicensed assistive personnel (UAP). What is the
28. best instruction by the nurse?
A) Notify me right away if the client’s systolic blood pressure is 170 or greater.
B) Let me know if the client’s blood pressure becomes elevated.
C) If the client’s blood pressure falls outside normal limits, come get me.
D) I need to know if the client’s blood pressure changes from his
normal baseline. Ans: A
Feedback:
When delegating tasks, it is essential for the nurse to give clear
instructions to the person to whom the task is being delegated. The
statement, which includes specific parameters for the systolic blood
pressure, clearly identifies what the UAP should be alerted to and the
subsequent action to take. The other three options are vague and do
not provide adequate direction for the UAP.
The nursing student is caring for a Native American client who is admitted for deep
29. vein thrombosis. The nursing student speaks with a nurse regarding the client’s lack

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 of eye contact with the student. The nurse responds that Native
Americans view eye contact as an invasion of privacy. Which error did
the nursing student make?
A) Failure to act in partnership with the client.
B) Failure to approach the client caringly.
C) Failure to seek the client’s input in the plan of care.
D) Failure to provide culturally
sensitive care. Ans: D
Feedback:
The nursing student failed to provide culturally sensitive care by
expecting the client to engage in eye contact. There is no information
to suggest the nursing student failed to act in partnership with the
client, approach the client caringly, or seek the client’s input in the plan
of care.
The nurse is preparing to implement plans of care with several clients. Which action
30. would be inappropriate for the nurse to perform?

Ask the English-as-a-Second-Language (ESOL) client to state in his or

A) her own words what it means to be NPO.
Seek input from the family of how the client with aphasia normally
B) communicates at home.
Respond to the postoperative client’s question that baths are given
C) only in the morning.
Request that family members provide ethnic/cultural foods of the
D) African client’s liking.
Ans: C
Feedbac
k:
Guidelines for implementing indicate that the nurse implements care
that is culturally sensitive and individualized for the client. The nurse
forms a partnership with the client and family when implementing care.
The response by the nurse indicating a set time for baths is not
reflective of being open to individualizing client care. The other options
are consistent with the guidelines for implementing.
Nursing students need to learn to nurse themselves in order to prepare
to be professional nurses. Which activities would fail to prepare nursing
students for the
31. delivery of nursing care?
A) Time management, communication, and establishing a support system.
B) Establishing a support system, a sense of humor, and self-awareness.
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C) Self-awareness, preparation for crisis, and stress management.
D) A sense of humor, anticipation of loss, and developing negative
body image. Ans: D
Feedback:
Activities that would prepare nursing students for the delivery of
nursing care include time management, communication, establishing
a support system, self- awareness, stress management, a sense of
humor, and preparation for crisis and loss. Negative body image is not
desired.
The nurse is assessing a client with a diagnosis of hypertension. The
client’s blood pressure is 178/88, an increase from 134/78 at the
previous clinic visit. The nurse asks the client what has changed from
the previous visit. Which client statement
32. identifies a potential factor interfering with the plan of care?
A) My husband has been ill and I don’t have anyone to help me care for him.
B) I have learned to prepare foods differently so they are low in fat.
C) My neighbor walks with me around the neighborhood every morning.
D) I have been taking my hydrochlorothiazide (HydroDIURIL)
every day. Ans: A
Feedback:
Common factors that contribute to a client not following the plan of care
include lack of family support, inability to afford treatment, limited
access to treatment, and adverse physical or emotional effects of
treatment. The burden of caring for her husband may be placing stress
on the client, and causing her blood pressure to be elevated despite
engaging in health promotion and blood pressure-lowering activities.
The nurse overhears two nursing students talking about nursing
interventions. Which statement by one of the nursing students
indicates further education is
33. required?

Nursing interventions must be consistent with standards of care and

A) research findings.
B) Nursing interventions must be culturally sensitive and individualized

for the client. Nursing interventions must be compatible with other

therapies planned for the

C) client.
D) Nursing interventions must be approved by other members of the
health care team. Ans: D

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 Feedback:
Nursing interventions should be based on the etiology in the nursing
diagnosis, be compatible with other planned therapies, be consistent
with standards of care and research, and individualized for the client.
Nursing interventions can be independent, dependent, and
interdependent. Independent nursing interventions are nurse- initiated
interventions directed at the etiology of the client problem; they do not
require approval from other members of the health care team.
Each time a nurse administers an insulin injection to a client with
diabetes, she tells the client what she is doing and demonstrates each
step of preparing and giving the
34. injection. What is the nurse promoting in the client?
A) Self-care
B) Dependence
C) Competence
D) Discipline
Ans: A
Feedbac
k:
The plan of nursing care should include specific instructions for
education/learning needs of the client to promote self-care and
independence. Competency pertains to the nurse’s ability (knowledge,
skills, and attitudes) to provide safe and effective care. The nurse’s role
includes education, counseling, and advocating, but not providing
discipline to clients.
What characteristic of a competent nurse practitioner enables nurses to be role
35. models for clients?
A) Sense of humor
B) Writing ability
C) Organizational skills
D) Good personal
health Ans: D
Feedback:
Good personal health enables nurses not only to practice more
efficiently, but also to be a health model for clients and their families.
Nurses can help clients to imitate good health behaviors, and
eventually integrate them into their daily life through the process of
identification.

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Set 10

Upon evaluation of the client’s plan of care, the nurse determines that the expected
1. outcomes have been achieved. Based upon this response, the nurse will do what?
A) Terminate the plan of care.
B) Modify the plan of care.
C) Continue the plan of care.
D) Re-evaluate the plan of
care. Ans: A
Feedback:
The nurse will terminate the plan of care when each expected outcome
has been achieved. Modifying the plan of care is necessary if there are
difficulties in achieving the outcomes. Re-evaluating each step of the
nursing process is a step in the modification of a plan of care.
Continuing the plan of care occurs if more time is needed to achieve
the outcomes.
Nursing care and client outcomes may be evaluated by use of a
retrospective evaluation process. Which of the following is an example
of a retrospective evaluation
2. process?
A) Postdischarge questionnaire.
B) Direct observation of nursing care.
C) Client interview during hospitalization.
D) Review of client’s chart during
hospitalization. Ans: A
Feedback:

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 Retrospective evaluation may use postdischarge questionnaires and
client interviews, or chart reviews after the client has been discharged.
Concurrent evaluation occurs while the client is receiving care and may
include the following: direct observation of nursing care and client
interviews; and direct observation of chart reviews during
hospitalization.
An older adult client has lost significant muscle mass during her
recovery from a systemic infection. As a result, she has not yet met the
outcomes for mobility and activities of daily living that are specified in
her nursing plan of care. How should her
3. nurses best respond to this situation?
A) Continue the plan of care with the aim of helping the client achieve the outcomes.
B) Terminate the plan of care since it does not accurately reflect the client’s abilities.
C) Modify the plan of care to better reflect the client’s current functional ability.
D) Replace the client’s individualized plan of care with a
clinical pathway. Ans: A
Feedback:
Nurses regularly evaluate clients’ progression toward the achievement
of outcomes that are specified in plans of care. When clients need more
time to achieve desired outcomes, it is appropriate to continue with the
existing plan of care. It is not necessary to terminate the plan of care
and modification may be premature.
Abandoning the plan and replacing it with a clinical pathway is
counterproductive to the continuity of care.
The nurse has responded to a client’s request to view her medical chart
by arranging a meeting between the client, the clinical nurse leader,
and her primary care physician. The nurse is exemplifying which of the
following characteristics of quality
4. health care?
A) Information
B) Science
C) Cooperation
D) Individualizati
on Ans: A
Feedback:
The Institute of Medicine’s Committee on Quality Health Care in
America has identified aspects of care that clients can reasonably
expect. One of these expectations is information, which is manifested
by allowing clients access to their medical records. Other
characteristics that clients can expect are knowledge-based

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 care (science), coordination between professionals (cooperation), and
respect for client choices and preferences (individualization).
Nurses have identified the following outcome in the care of a client who
is recovering from a stroke: “Client will ambulate 100 feet without the
use of mobility aids by 12/12/2011.” Several nurses have evaluated the
client’s progression towards this outcome at various points during her
care. Which of the following evaluative
5. statements is most appropriate?
“12/12/2011 – Outcome partially met. Patient ambulated 75 feet without the use
A) of mobility aids”
B) “12/12/2011 – Outcome unmet. Patient’s ambulation remains inadequate.”
C) “12/10/2011 Outcome met, but with the use of a quad cane to assist ambulation.”
D) “12/14/2011 Outcome
met.” Ans: A
Feedback:
An evaluative statement should include both the decision about how
well the outcome was met along with data that support this decision.
Characterizing the client’s ambulation as “inadequate” is not
sufficiently precise. Stating that this outcome was met with the use of
a cane contradicts the original terms of the outcome.
The nurse witnessed a more senior nurse make six unsuccessful
attempts at starting an intravenous (IV) line on a client. The senior
nurse persisted, stating, “I refuse to admit defeat.” This resulted in
unnecessary pain for the client. How should
6. the first nurse best respond to this colleague’s incompetent practice?
A) Report the nurse’s practice and have the nurse manager address the matter.
B) Encourage the nurse to attend an in-service on IV starts.
Reassure the nurse that this is a difficult skill and give her feedback on her
C) performance.
D) Document an unmet outcome in the client’s
plan of care. Ans: A
Feedback:
According to the study Silence Kills: The Seven Crucial Conversations
for Healthcare (Maxfield, Grenny, Patterson, McMillan, & Switzler,
2005), an appropriate response to incompetence is to report the
matter and enlist the manager to conduct follow-up. Reassuring the
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 not sufficient responses to incompetence. This action does not
constitute an unmet outcome on the part of the client.
The manager of a medical unit regularly reviews the incident reports
that result from errors and near misses that occur on the unit. How
should the manager best
7. respond to these incident reports?
A) Use them to inform improvements and education on the unit.
B) Use them to identify deficient workers for removal or demotion.
C) Cross-reference them with client satisfaction reports from the unit.
D) Use them to identify individuals who would benefit from
probationary measures. Ans: A
Feedback:
It is most beneficial for the manager to frame incident reports as
sources of improvement, which can improve both client care and the
work environment. Punitive follow-up by demotion, probation, or
removal is likely to create reluctance among staff to complete incident
reports. Cross-referencing incident reports with client satisfaction
reports is unlikely to result in substantial improvements to the unit’s
care and culture.
What cognitive processes must the nurse use to measure client achievement of
8. outcomes during evaluation?
A) Intuitive thinking
B) Critical thinking
C) Traditional knowing
D) Rote
memory Ans: B
Feedback:
Each element of evaluation requires the nurse to use critical thinking
about how best to evaluate the client’s progress toward valued
outcomes.
A nurse is evaluating the outcomes of a plan of care to teach an obese client about
9. the calorie content of foods. What type of outcome is this?
A) Psychomotor
B) Affective
C) Physiologic

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D) Cognitive
Ans: D
Feedbac
k:
Cognitive goals involve increasing client knowledge. These goals may
be evaluated by asking clients to repeat information or to apply new
knowledge in their everyday lives.
A nurse is educating a client on how to administer insulin, with the
expected outcome that the client will be able to self-administer the
insulin injection. How would this
10. outcome be evaluated?
A) Asking the client to verbally repeat the steps of the injection
B) Asking the client to demonstrate self-injection of insulin
C) Asking family members how much trouble the client is having with injections
D) Asking the client how comfortable he or she is with
injections Ans: B
Feedback:
Psychomotor outcomes describe the client’s achievement of new skills
and are evaluated by asking the client to demonstrate the new skill.
A nurse in a community health center has been having regular
meetings with a woman who wants to stop smoking. Which of the
following outcome decision options
11. would the nurse document if the woman has not smoked for three months?
A) Outcome met
B) Outcome partially met
C) Outcome not met
D) Outcome
inappropriate Ans: A
Feedback:
After data have been collected and interpreted to determine client
outcome achievement, the nurse makes and documents a judgment
summarizing the findings. The three decision options are met, partially
met, and not met. In this case, the nurse’s judgment is that the client
has met the expected outcome of smoking cessation.

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 A nurse is interested in improving client care on the unit through performance
12. improvement. What is the first step in this process?
A) Discover the problem.
B) Plan a strategy.
C) Implement a change.
D) Assess the
change. Ans: A
Feedback:
Each nurse must decide how to respond when he or she perceives that
client care is being compromised. The four steps listed are all
components of the process of performance improvement, with
discovering the problem being the first step.
A nurse forgets to raise the bed railings of a client who is confused after
taking pain medications. The client attempts to get out of bed, and
suffers a minor fall. The nurse asks a colleague who witnessed the fall
not to mention it to anyone because the client only had minor bruises.
What would be the appropriate action of the
13. colleague?
A) No other steps need to be taken, since the client was not seriously injured.
The colleague should inform the nurse that a full report of the incident needs to be
B) made.
C) The colleague should monitor the client closely for any adverse effects of the fall.
D) The colleague should report the incident in a peer review of
the nurse. Ans: B
Feedback:
The colleague should tell the nurse that a full report needs to be made.
If appropriate, the colleague could help the nurse identify what
contributed to her not raising the bed railings in an effort to prevent it
from happening in the future.
A nurse is evaluating and revising a plan of care for a client with cardiac
catheterization. Which of the following actions should the nurse
perform before
14. revising a plan of care?
A) Discuss any lack of progress with the client.
B) Collect information on abnormal functions.
C) Identify the client’s health-related problems.

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D) Select appropriate nursing
interventions. Ans: A
Feedback:
The nurse should discuss any lack of progress with the client so that
both the client and the nurse can speculate on what activities need to
be discontinued, added, or changed. Collecting information on
abnormal functions and risk factors is done during the assessment.
Identification of the client’s health-related problems is done during
diagnosis. Nurses select appropriate nursing interventions and
document the plan of care in the planning stage of the nursing process,
not during evaluation.
When a charge nurse evaluates the need for additional staff nurses and
additional monitoring equipment to meet the client’s needs, the charge
nurse is performing an
15. evaluation termed …
A) process evaluation
B) structure evaluation
C) outcome evaluation
D) summary
evaluation Ans: B
Feedback:
Structure evaluation focuses on the attributes of the setting or
surroundings where health care is provided.
When a nursing supervisor evaluates the staff nurse’s performance
with a group of clients to whom the staff nurse has provided nursing
care, the supervisor is
16. performing which type of evaluation?
A) Outcome evaluation
B) Summary evaluation
C) Structure evaluation
D) Process
evaluation Ans: D
Feedback:
Process evaluation focuses on the nurse’s performance and whether
the nursing care provided was appropriate and competent.

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 A nurse working in a hospital setting discovers problems with the
delivery of nursing care on the pediatric unit. Which of the following
suggestions from the Institute of Medicine’s Committee on Quality of
Health Care in America (Kohn, Corrigan, &
17. Donaldson, 2000) could help redesign and improve care? Select all that apply.
A) Base care on continuous healing relationships.
B) Customize care based on available resources.
C) Keep the nurse as the source of control.
D) Share knowledge and allow for free flow of information.
E) Practice evidence-based decision
making. Ans: A, D, E
Feedback:
The Institute of Medicine’s Committee on Quality of Health Care in
America (Kohn, Corrigan, & Donaldson, 2000) suggests 10 new rules to
redesign and improve care:
(1) care based on continuous healing relationships, (2) customization
based on client needs and values, (3) the client as the source of control,
(4) shared knowledge and the free flow of information, (5) evidence-
based decision making, (6) safety as a system property, (7) the need
for transparency, (8) anticipation of needs, (9) continuous decrease in
waste, and (10) cooperation among clinicians.
A nurse is counseling a novice nurse who gives 150% effort at all times
and is becoming frustrated with a health care system that provides
substandard care to clients. Which of the following advice would be
appropriate in this situation? Select
18. all that apply.

Tell the new nurse to help other nurses perform their jobs, thus
ensuring quality client care is being delivered.
A)
Encourage the new nurse to leave her problems at work behind, instead of
rehashing them at home.
B)
After establishing a reputation for delivering quality nursing care, have
her seek creative solutions for nursing problems.
C)
Tell her to view nursing care concerns as challenges rather than
overwhelming obstacles, and seek help for solutions.
D)
State that if resources do not permit quality care, it is not the role of
the new nurse to explore change strategies within the institution.
E)
Ans: B, C, D
Feedback:

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 The following items are good advice for nurses experiencing burnout:
Learn to give quality care during designated work period; leave on
time; avoid the temptation to do the work of others; and leave work
concerns at work. After establishing a reputation for delivering quality
nursing care, seek creative solutions for nursing problems (strategies
to increase nursing resources, motivation, morale) and try them —
hopefully with a support network. View concerns as challenges rather
than overwhelming obstacles. Develop a realistic sense of how much
nursing care (and of what quality) can be delivered with existing
resources. If resources do not permit quality care, explore change
strategies within the institution. If administration is not supportive,
explore other practice settings.
Which activity does the nurse perform during the evaluating stage? Select all that
19. apply.
A) Validates with the client the problem of constipation.
Collects data to determine the number of catheter-associated infections on the
B) nursing unit.
C) Increases the frequency of repositioning from every two hours to every one hour.
D) Sets a goal of ambulating from bed to room door and back to bed.
E) Identifies smoking and sedentary lifestyle as risk factors for
hypertension. Ans: B, C
Feedback:
During the evaluation stage, the nurse modifies the plan of care if
desired outcomes are not achieved (increased frequency of
repositioning) and collects data, such as number of infections, to
monitor quality and effectiveness of nursing practice. During the
diagnosis stage, the nurse identifies factors contributing to the client’s
health problem, such as smoking and sedentary lifestyle, and validates
the identified health problems (such as constipation) with the clients.
The nurse establishes plan priorities and sets goals with the client and
family during the outcome identification and planning.
20. Which activity does the nurse engage in during evaluation? Select all that apply.
A) Collect data to determine whether desired outcomes are met.
B) Assess the effectiveness of planned strategies.
C) Adjust the time frame to achieve the desired outcomes.
D) Involve the client and family in formulating desired outcomes.
E) Initiate activities to achieve the desired
outcomes. Ans: A, B, C

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 Feedback:
The nurse establishes desired outcomes with the client and family
during the outcome identification and planning stage. The nurse
initiates activities to achieve the desired outcomes during the
implementation stage. During the evaluation stage, the nurse collects
data to determine whether desired outcomes are met, assesses the
effectiveness of planned strategies, and adjusts the time frame to
achieve the desired outcomes.
21. Which client outcome is a physiologic outcome? Select all that apply.
A) The client’s HA1c is 7.4%.
B) The client’s blood pressure is 118/74.
C) The client rates his or her pain rating as 6.
D) The client self-administers insulin subcutaneously.
E) The client describes manifestations of wound
infection. Ans: A, B, C
Feedback:
Physiologic outcomes are physical changes in the client, such as pain
ratings and blood pressure and HA1c measurements. Psychomotor
outcomes describe the client’s achievement of new skills, such as
insulin administration. Cognitive outcomes demonstrate gains in client
knowledge, such as manifestations of infection.
22. Which activity is a possible solution for inadequate nursing staffing?
A) Identify the kind and amount of nursing services required.
B) Learn to give quality care during designated work period.
C) Use a team conference to develop a consistent plan of care.
D) Educate the client to become an assertive health care
consumer. Ans: A
Feedback:
A possible solution for inadequate staffing is to identify the kind and
amount of nursing services required. Using a team conference to
develop a consistent plan of care is a possible solution for the client
who refused to cooperate with the therapeutic regimen. Educating the
client to become an assertive health care consumer is a possible
solution for the client who quietly accepts whatever care is delivered
or not delivered. A possible solution for the nurse who is a candidate
for burnout is to learn to give quality care during the designated work
period.

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 The nurse assesses urine output following administration of a diuretic. Which step of
23. the nursing process does this nursing action reflect?
A) Assessment
B) Outcome identification
C) Implementation
D) Evaluati
on Ans: D
Feedback:
Assessing the client’s response to a diuretic medication is an example
of evaluation. During assessment, the nurse collects and synthesizes
data to identify patterns. The nurse establishes desired outcomes with
the client and family during the outcome identification and planning
stage. The nurse initiates activities to achieve the desired outcomes
during the implementation stage.
The nurse participates in a quality assurance program. Data from the
previous year indicates a 2% reduction in the number of repeat
admissions for clients who underwent hip replacement surgery. The
nurse recognizes this is which type of
24. evaluation?
A) Design evaluation
B) Process evaluation
C) Outcome evaluation
D) Structure
evaluation Ans: C
Feedback:
Quality assurance programs focus on three types of evaluation:
structure, process, and outcome. Outcome evaluation focuses on
measurable changes in the health status of clients, such as a 2%
reduction in the number of repeat admissions for clients who
underwent hip replacement surgery. Structure evaluation focuses on
the environment in which care is provided, whereas process evaluation
focuses on the nature and sequence of activities carried out by
implementing the nursing process.
There is no design evaluation.
The nurse participates in a quality assurance program and reviews
evaluation data for the previous month. Which of the following does the
nurse recognize as an
25. example of process evaluation?
A) A 10% reduction in the number of ventilator-associated pneumonia

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B) A 5% increase in the number of nosocomial catheter-related urinary tract infections

C) 40% of all client rooms in the facility are private and equipped with a

computer A nursing care plan was developed within the eight hours of

admission for 97% of

D) all admissions.
Ans: D
Feedbac
k:
Process evaluation focuses on the nature and sequence of activities
carried out by nurses implementing the nursing process, such as the
timing of nursing care plan creation. Quality assurance programs focus
on three types of evaluation: structure, process, and outcome.
Outcome evaluation focuses on measurable changes in the health
status of clients, such as the number of ventilator-associated
pneumonia and nosocomial catheter-related urinary tract infections.
Structure evaluation focuses on the environment in which care is
provided, such as the number of private rooms equipped with a
computer.
The client’s expected outcome is The client will maintain skin integrity by discharge.
26. Which of the following measures is best in evaluating the outcome?
A) The client’s ability to reposition self in bed.
B) Pressure-relieving mattress on the bed.
C) Percent intake of a diet high in protein.
D) Condition of the skin over bony
prominences. Ans: D
Feedback:
During evaluation, the nurse collects data and makes a judgment
summarizing the findings. In making a decision about how well the
outcome was met, the nurse examines client data or behaviors that
validate whether the outcome is met. The condition of the skin,
especially over bony prominences, provides the best measure of
whether skin integrity has been maintained.
An expected client outcome is, The client will remain free of infection by
discharge. When evaluating the client’s progress, the nurse notes the
client’s vital signs are within normal limits, the white blood cell count is
12,000, and the client’s abdominal wound has a half-inch gap at the
lower end with yellow-green discharge. Which
27. statement would be an appropriate evaluation statement?
A) Goal partially met; client identified fever and presence of wound discharge.
B) Client understands the signs and symptoms of infection.
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C) Goal partially met; client able to perform activities of daily living.
Goal not met; white blood cell count elevated, presence of yellow-green discharge
D) from wound.
Ans: D
Feedbac
k:
During evaluation, the nurse collects data and makes a judgment
summarizing the findings. In making a decision about how well the
outcome was met, the nurse has three options: met, partially met, or
not met. An elevated white blood cell count and the presence of yellow-
green wound discharge are clinical manifestations consistent with an
infectious process, so the outcome has not been met.
The nurse is caring for a client who is experiencing an asthma attack.
Ten minutes after administering an inhaled bronchodilator to the client,
the nurse returns to ask if the client’s breathing is easier. The nurse is
engaging in which phase of the
28. nursing process?
A) Assessment
B) Diagnosing
C) Planning
D) Implementing
E) Evaluatin
g Ans: E
Feedback:
The nurse is collecting evaluative data to determine whether or not the
client is achieving the therapeutic response to the bronchodilator.
The nurse is preparing to mail a client satisfaction questionnaire to a
client who was discharged from the hospital four days ago. Which type
of evaluation is the nurse
29. conducting?
A) Retrospective evaluation
B) Peer review
C) Nursing audit
D) Concurrent
evaluation Ans: A
Feedback:

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 A retrospective audit uses post-discharge questionnaires to collect data.
A nursing audit is a method of evaluating nursing care that involves
reviewing client records to assess the outcomes of nursing care (or the
process by which these outcomes were achieved). Concurrent
evaluation involves direct observations of nursing care, client
interviews, and chart review to determine whether the specified
evaluative criteria are met. Peer review involves the evaluation of one
staff member by another staff member on the same level in the
hierarchy of the organization. This is done for the purpose of
professional performance improvement.
The nurse is caring for the client with pneumonia. An expected client
outcome is, The client will maintain adequate oxygenation by
discharge. Which outcome criterion
30. indicates the goal is met?
A) Client taking antibiotic as ordered.
B) Client identifies signs and symptoms of recurrence of infection.
C) Client coughing and deep breathing every one hour.
D) Client no longer requires
oxygen. Ans: D
Feedback:
The client who is maintaining adequate oxygenation would not require
oxygen. The client could be able to do the other three options and still
have problems with oxygenation.
The client reports participating in water aerobics for 60 minutes three times each
31. week. This is an example of what type of outcome?
A) Affective outcome
B) Psychomotor outcome
C) Physiologic outcome
D) Cognitive
outcome Ans: A
Feedback:
An affective outcome involves changes in the client’s values, beliefs,
and attitude, such as participating in water aerobics. Cognitive
outcomes demonstrate increases in client knowledge. Physiologic
outcomes are physical changes in the client. Psychomotor outcomes
describe the client’s achievement of new skills.
The client’s pulse oximetry reading is 97% on room air 30 minutes after removal of
32. a nasal cannula. This is an example of what type of outcome?

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A) Affective outcome
B) Psychomotor outcome
C) Physiologic outcome
D) Cognitive
outcome Ans: C
Feedback:
Physiologic outcomes are physical changes in the client, such as pulse
oximetry. An affective outcome involves changes in the client’s values,
beliefs, and attitude.
Cognitive outcomes demonstrate increases in client knowledge.
Psychomotor outcomes describe the client’s achievement of new skills.
The nurse is giving a shift report to the oncoming nurse who will be
caring for a client with a portacath access device. The oncoming
nurse states, I have never taken care of a client with a portacath.
Would you give me the basics, so I know what to do? Which standard
for establishing and sustaining healthy work
33. environments is the oncoming nurse breaching?
A) Appropriate staffing
B) Effective decision making
C) True collaboration
D) Skilled
communication Ans:
A
Feedback:
Appropriate staffing ensures that client needs are effectively matched
with nurse competencies. In this scenario, the nurse is ill-prepared to
care for the client. The nurse needs structured training to learn about
the nursing care of portacaths.
Skilled communication requires health team members to communicate
in a respectful, non-intimidating manner with colleagues. True
collaboration involves skilled communication, mutual respect, shared
responsibility, and decision making among nurses, and between nurses
and other health team members. Effective decision making ensures
nurses are valued and active partners in making policy, directing and
evaluating clinical care, and leading organizational operations.
The correct sequence of steps for performance improvement is:

1. Discover a problem.

2. Plan a strategy using indicators.

34.

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 3. Implement a change.

4. Assess the change.

A) 1, 2, 3, 4
B) 1, 4, 2, 3
C) 4, 1, 2, 3
D) 1, 2, 4, 3
E) 1, 3, 2, 4
Ans: A
Feedbac
k:
The correct sequence of steps for performance improvement is (1)
discover a problem; (2) plan a strategy using indicators; (3) implement
a change; and (4) assess the change; if the change is not met, plan a
new strategy.

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