NP exam 3 Questions and Answers Graded A+

NP exam 3 Questions and Answers Graded A+ The nurse in charge identifies a patient's responses to actual or potential health problems during which step of the nursing process? A. Assessing B. Diagnosing C. Planning D. Evaluating Answer: B Rationale- The nurse identifies human responses to actual or potential health problems during the nursing diagnoses step of the nursing process. During the assessment step, the nurse collects data. During the planning step, the nurse develops strategies to resolve or decrease the patient's problem. During evaluation, the nurse determines the effectiveness of the plan of care. A female patient is diagnosed with deep-vein thrombosis. Which nursing diagnosis should receive the highest priority at this time? A. Impaired gas exchange related to increased blood flow B. Fluid volume excess related to peripheral vascular disease C. Risk for injury related to edema D. Altered peripheral tissue perfusion related to venous congestion Answer: D Rationale: This answer takes highest priority because venous inflammation and clot formation impede blood flow in a patient with deep-vein thrombosis. Option A is incorrect because impaired gas exchange is related to decreased, not increased, blood flow. Option B is inappropriate because no evidence suggests that this patient has a fluid volume excess. Option C may be warranted but is secondary to altered tissue perfusion A nurse is revising a client's care plan. During which step of the nursing process does such a revision take place? A. Assessment B. Planning C. Implementation D. Evaluation Answer: D Rationale: During the evaluation step of the nursing process the nurse determines whether the goals established have been achieved, and evaluates the success of the plan. Answer A involves data collection. Answer B involves setting priorities, and Answer C is the actual intervention. Which intervention should the nurse in charge try first for a client that exhibits signs of sleep disturbance? A. Administer sleeping medication before bedtime B. Ask the client each morning to describe the quantity of sleep the night before C. Teach the client relaxation techniques, such as guided imagery and progressive muscle relaxation D. Provide the client normal sleep aids, such as pillows, back rubs, and snacks Answer: D Rationale: You should begin with the simplest interventions. Answer A is incorrect because medications should be avoided whenever possible. Answer B would be a thorough sleep assessment, and should be done only after common sense interventions fail. Answer C would be appropriate only after common sense interventions fail. Using Maslow's hierarchy of needs, a nurse assigns the highest priority to which client need? A. Elimination B. Security C. Safety D. Belonging Answer- A Rationale - According to Maslow, elimination is a first-level or physiological need. Security and safety are second-level needs, and belonging is a third-level need. A female client who received general anesthesia returns from surgery. Postoperatively, which nursing diagnosis takes highest priority for this client? A. Acute pain R/T surgery B. Deficient fluid volume R/T blood and fluid loss from surgery C. Impaired physical mobility R/T surgery D. Risk for aspiration R/T anesthesia Answer: D Rationale- Risk for aspiration takes priority because general anesthesia may impair gag and swallow reflexes. The other options, although important, are secondary to this. A male client is admitted to the hospital with blunt chest trauma after a motor vehicle accident. The first nursing priority for this client would be to: A. Assess the client's airway B. Provide pain relief C. Encourage deep breathing and coughing D. Splint the chest wall with a pillow Answer: A Rationale- The first priority is to evaluate airway patency. Pain management and splinting are important for client comfort, but come after an airway assessment. Coughing and deep breathing may be contraindicated if the client has internal bleeding and other injuries. When two nursing diagnoses appear closely related, what should the nurse do first to determine which diagnosis most accurately reflects the needs of a patient? A. Reassess the patient B. Examine the related to factors C. Analyze the secondary to factors D. Review the defining characteristics Answer: D Rationale- The first thing a nurse should do to differentiate is to compare the data collected to the major and minor defining characteristics of each of the nursing diagnoses being considered. The nurse performs an assessment of a newly admitted patient. The nurse understands that this admission assessment is conducted primarily to: A. Diagnose if the patient is at risk for falls. B. Ensure that the patient's skin is intact C. Establish a therapeutic relationship D. Identify important data Answer: D Rationale- This is the primary purpose of a nursing admission assessment. The guidelines for writing an appropriate nursing diagnosis include all of the following except: A. State the diagnosis in terms of a problem, not a need B. Use nursing terminology to describe the patient's response C. Use statements that assist in planning independent nursing interventions D. Use medical terminology to describe the probable cause of the patient's response Answer- D Rationale- A nursing diagnosis is a statement about a patient's actual or potential health problem that is within the scope of independent nursing intervention. Medical terminology is never part of the nursing diagnosis. Independent nursing interventions commonly used for immobilized patients include all of the following except: A. Active or passive ROM exercises, body repositioning, and ADLs as tolerated B. Deep-breathing and coughing exercises with change of position every 2 hours C. Diaphragmatic and abdominal breathing exercises D. Weight bearing on a tilt table, total parenteral nutrition, and vitamin therapy Answer: D Rationale- A, B, & C are incorrect. These are not independent nursing interventions because they require a physician's order. Independent nursing interventions commonly used for patients with pressure ulcers include: A. changing the patient's position regularly to minimize pressure B. Applying a drying agent such as an antacid to decrease moisture at the ulcer site C. Debriding the ulcer to remove necrotic tissue, which can impede healing D. Placing the patient in a whirlpool bath containing povidone-iodine solution as tolerated Answer: A Rationale- Independent nursing interventions for a patient with pressure ulcers commonly include changing positions. B, C, & D all require a physician's order. Additionally, a drying agent (answer B) would be contraindicated because the wound needs moisture to heal. While the nurse is providing a patient personal hygiene, she observes that his skin is excessively dry. During the procedure, he tells her that he is very thirsty. An appropriate nursing diagnosis would be: A. Potential for impaired skin integrity R/T altered gland function B. Potential for impaired skin integrity R/T dehydration C. Impaired skin integrity R/T dehydration D. Impaired skin integrity R/T altered circulation Answer: C Rationale- The appropriate diagnosis for a patient with excessively dry skin is impaired skin integrity - actual not potential. R/T dehydration is appropriate because the patient complained of thirst. The most important nursing intervention to correct skin dryness is: A. avoid bathing until the condition is remedied and notify physician B. ask physician to refer the patient to a dermatologist C. Consult the dietitian about increasing fat intake, and take necessary measures to prevent infection D. encourage the patient to increase fluid intake, use nonirritating soap, and apply lotion to involved areas Answer: D Rationale- Preventative measures, such as these, will prevent the skin from cracking, which would make the client more prone to infection. The other 3 answers are options, however NOT the best choice for this particular situation. Once a nurse assesses a client's condition and identifies appropriate nursing diagnoses, a: A.Plan is developed for nursing care. B.Physical assessment begins C.List of priorities is determined. D.Review of the assessment is conducted with other team members. A.Plan is developed for nursing care. Priorities are established to help the nurse anticipate and sequence nursing interventions when a client has multiple problems or alterations. Priorities are determined by the client's: 1.Physician 2.Nonemergent, non-life threatening needs 3.Future well-being. 4.Urgency of problems 4.Urgency of problems A client centered goal is a specific and measurable behavior or response that reflects a client's: 1.Desire for specific health care interventions 2.Highest possible level of wellness and independence in function. 3.Physician's goal for the specific client. 4.Response when compared to another client with a like problem. 2.Highest possible level of wellness and independence in function. For clients to participate in goal setting, they should be: 1.Alert and have some degree of independence. 2.Ambulatory and mobile. 3.Able to speak and write. 4.Able to read and write. 1.Alert and have some degree of independence. The nurse writes an expected outcome statement in measurable terms. An example is: 1.Client will have less pain. 2.Client will be pain free. 3.Client will report pain acuity less than 4 on a scale of 0-10. 4.Client will take pain medication every 4 hours around the clock. 3.Client will report pain acuity less than 4 on a scale of 0-10. As goals, outcomes, and interventions are developed, the nurse must: 1.Be in charge of all care and planning for the client. 2.Be aware of and committed to accepted standards of practice from nursing and other disciples. 3.Not change the plan of care for the client. 4.Be in control of all interventions for the client. 2.Be aware of and committed to accepted standards of practice from nursing and other disciples. When establishing realistic goals, the nurse: 1.Bases the goals on the nurse's personal knowledge. 2.Knows the resources of the health care facility, family, and the client. 3.Must have a client who is physically and emotionally stable. 4.Must have the client's cooperation. 2.Knows the resources of the health care facility, family, and the client. To initiate an intervention the nurse must be competent in three areas, which include: 1.A.Knowledge, function, and specific skills B.Experience, advanced education, and skills. C.Skills, finances, and leadership. D.Leadership, autonomy, and skills. 1.A.Knowledge, function, and specific skills Collaborative interventions are therapies that require: 1.Physician and nurse interventions. 2.Nurse and client interventions. 3.Client and Physician intervention. 4.Multiple health care professionals. 4.Multiple health care professionals. Well formulated, client-centered goals should: 1.Meet immediate client needs. 2.Include preventative health care. 3.Include rehabilitation needs. 4.All of the above. 4.All of the above.