Adult Care 1 Exam 1 Questions With Complete Solutions
1. The nurse is writing a nursing diagnosis for a plan of care for
a patient who has been newly diagnosed with type 2 diabetes.
Which statement reflects the correct format for a nursing
diagnosis?
a. Anxiety
b. Anxiety related to new drug therapy
c. Anxiety related to anxious feelings about drug therapy, as
evidenced by statements such as "I'm upset about having to test
my blood sugars."
d. Anxiety related to new drug therapy, as evidenced by
statements such as "I'm upset about having to test my blood
sugars." Correct Answers ANS: D
Formulation of nursing diagnoses is usually a three-step process.
"Anxiety" is missing the "related to" and "as evidenced by"
portions of defining characteristics. "Anxiety related to new
drug therapy" is missing the "as evidenced by" portion of
defining characteristics. The statement beginning "Anxiety
related to anxious feelings" is incorrect because the "related to"
section is simply a restatement of the problem "anxiety," not a
separate factor related to the response.
DIF: COGNITIVE LEVEL: Understanding (Comprehension)
REF: p. 7
TOP: NURSING PROCESS: Nursing Diagnosis
1. The nurse teaches a student nurse about how to apply the
nursing process when providing patient care. Which statement,
if made by the student nurse, indicates that teaching was
successful?
,a. The nursing process is a scientific-based method of
diagnosing the patients health care problems.
b. The nursing process is a problem-solving tool used to identify
and treat patients health care needs.
c. The nursing process is based on nursing theory that
incorporates the biopsychosocial nature of humans.
d. The nursing process is used primarily to explain nursing
interventions to other health care professionals. Correct Answers
ANS: B
The nursing process is a problem-solving approach to the
identification and treatment of patients problems. Diagnosis is
only one phase of the nursing process. The primary use of the
nursing process is in patient care, not to establish nursing theory
or explain nursing interventions to other health care
professionals.
DIF: Cognitive Level: Understand (comprehension) REF: 7
TOP: Nursing Process: Implementation MSC:
1. The nurse uses the Situation-Background-Assessment-
Recommendation (SBAR) format to communicate a change in
patient status to a health care provider. In which order should the
nurse make the following statements? (Put a comma and a space
between each answer choice [A, B, C, D].)
,a. The patient needs to be evaluated immediately and may need
intubation and mechanical ventilation.
b. The patient was admitted yesterday with heart failure and has
been receiving furosemide (Lasix) for diuresis but urine output
has been low.
c. The patient has crackles audible throughout the posterior chest
and the most recent oxygen saturation is 89%. Her condition is
very unstable.
d. This is the nurse on the surgical unit. After assessing the
patient, I am very concerned about increased shortness of breath
over the past hour. Correct Answers ANS:
D, B, C, A
The order of the nurses statements follows the SBAR format.
DIF: Cognitive Level: Apply (application) REF: 15
OBJ: Special Questions: Prioritization TOP: Nursing Process:
Implementation MSC:
1. When giving medications, the nurse will follow the rights of
medication administration. The rights include the right
documentation, the right reason, the right response, and the
patient's right to refuse. Which of these are additional rights?
(Select all that apply.)
a. Right drug
b. Right route
c. Right dose
d. Right diagnosis
, e. Right time
f. Right patient Correct Answers ANS: A, B, C, E, F
Additional rights of medication administration must always
include the right drug, right dose, right time, right route, and
right patient. The right diagnosis is incorrect.
DIF: COGNITIVE LEVEL: Remembering (Knowledge) REF:
p. 9
TOP: NURSING PROCESS: Implementation
1. Which information will the nurse consider when deciding
what nursing actions to delegate to a licensed
practical/vocational nurse (LPN/LVN) who is working on a
medical-surgical unit (select all that apply)?
a. Institutional policies
b. Stability of the patient
c. State nurse practice act
d. LPN/LVN teaching abilities
e. Experience of the LPN/LVN Correct Answers ANS: A, B, C,
E
The nurse should assess the experience of LPN/LVNs when
delegating. In addition, state nurse practice acts and institutional
policies must be considered. In general, LPN/LVN scope of
practice includes caring for patients who are stable, while
registered nurses should provide most of the care for unstable
patients. Since LPN/LVN scope of practice does not include
patient education, this will not be part of the delegation process.
1. The nurse is writing a nursing diagnosis for a plan of care for
a patient who has been newly diagnosed with type 2 diabetes.
Which statement reflects the correct format for a nursing
diagnosis?
a. Anxiety
b. Anxiety related to new drug therapy
c. Anxiety related to anxious feelings about drug therapy, as
evidenced by statements such as "I'm upset about having to test
my blood sugars."
d. Anxiety related to new drug therapy, as evidenced by
statements such as "I'm upset about having to test my blood
sugars." Correct Answers ANS: D
Formulation of nursing diagnoses is usually a three-step process.
"Anxiety" is missing the "related to" and "as evidenced by"
portions of defining characteristics. "Anxiety related to new
drug therapy" is missing the "as evidenced by" portion of
defining characteristics. The statement beginning "Anxiety
related to anxious feelings" is incorrect because the "related to"
section is simply a restatement of the problem "anxiety," not a
separate factor related to the response.
DIF: COGNITIVE LEVEL: Understanding (Comprehension)
REF: p. 7
TOP: NURSING PROCESS: Nursing Diagnosis
1. The nurse teaches a student nurse about how to apply the
nursing process when providing patient care. Which statement,
if made by the student nurse, indicates that teaching was
successful?
,a. The nursing process is a scientific-based method of
diagnosing the patients health care problems.
b. The nursing process is a problem-solving tool used to identify
and treat patients health care needs.
c. The nursing process is based on nursing theory that
incorporates the biopsychosocial nature of humans.
d. The nursing process is used primarily to explain nursing
interventions to other health care professionals. Correct Answers
ANS: B
The nursing process is a problem-solving approach to the
identification and treatment of patients problems. Diagnosis is
only one phase of the nursing process. The primary use of the
nursing process is in patient care, not to establish nursing theory
or explain nursing interventions to other health care
professionals.
DIF: Cognitive Level: Understand (comprehension) REF: 7
TOP: Nursing Process: Implementation MSC:
1. The nurse uses the Situation-Background-Assessment-
Recommendation (SBAR) format to communicate a change in
patient status to a health care provider. In which order should the
nurse make the following statements? (Put a comma and a space
between each answer choice [A, B, C, D].)
,a. The patient needs to be evaluated immediately and may need
intubation and mechanical ventilation.
b. The patient was admitted yesterday with heart failure and has
been receiving furosemide (Lasix) for diuresis but urine output
has been low.
c. The patient has crackles audible throughout the posterior chest
and the most recent oxygen saturation is 89%. Her condition is
very unstable.
d. This is the nurse on the surgical unit. After assessing the
patient, I am very concerned about increased shortness of breath
over the past hour. Correct Answers ANS:
D, B, C, A
The order of the nurses statements follows the SBAR format.
DIF: Cognitive Level: Apply (application) REF: 15
OBJ: Special Questions: Prioritization TOP: Nursing Process:
Implementation MSC:
1. When giving medications, the nurse will follow the rights of
medication administration. The rights include the right
documentation, the right reason, the right response, and the
patient's right to refuse. Which of these are additional rights?
(Select all that apply.)
a. Right drug
b. Right route
c. Right dose
d. Right diagnosis
, e. Right time
f. Right patient Correct Answers ANS: A, B, C, E, F
Additional rights of medication administration must always
include the right drug, right dose, right time, right route, and
right patient. The right diagnosis is incorrect.
DIF: COGNITIVE LEVEL: Remembering (Knowledge) REF:
p. 9
TOP: NURSING PROCESS: Implementation
1. Which information will the nurse consider when deciding
what nursing actions to delegate to a licensed
practical/vocational nurse (LPN/LVN) who is working on a
medical-surgical unit (select all that apply)?
a. Institutional policies
b. Stability of the patient
c. State nurse practice act
d. LPN/LVN teaching abilities
e. Experience of the LPN/LVN Correct Answers ANS: A, B, C,
E
The nurse should assess the experience of LPN/LVNs when
delegating. In addition, state nurse practice acts and institutional
policies must be considered. In general, LPN/LVN scope of
practice includes caring for patients who are stable, while
registered nurses should provide most of the care for unstable
patients. Since LPN/LVN scope of practice does not include
patient education, this will not be part of the delegation process.
