1. A patient tells the nurse, "I C
have had this dull ache in my
side now for 4 days; it real- Back-channeling gives positive comments
ly hurts when I bend over." such as "all right," "go on," or "uh-huh" to the
The nurse responds, "All speaker, thus indicating that you heard what
right, go on." The nurse's re- the patient is saying and are interested in hear-
sponse is an example of: ing the full story.
A. inference.
B. a cue.
C. back-channeling.
D. open-ended question.
2. The nurse prepares to ad- A
minister care to a patient by
first positioning him more Insertion of a urinary catheter is the only de-
comfortably. She inspects pendent intervention, which requires an order
his surgical wound and re- from a health care provider.
inforces the dressing with
extra tape. She explains
the procedure that she will
use for insertion of a uri-
nary catheter. She prepares
the patient and inserts the
catheter. Which of the fol-
lowing steps is a dependent
nursing intervention?
A. Insertion of the urinary
catheter
B. Reinforcement of dress-
ing with tape
C. Instruction about the pro-
cedure for insertion of the
urinary catheter
D. Positioning the patient for
comfort
3.
, A patient has a pressure B
ulcer resulting from urine
incontinence and sustained The intent of the therapy is to promote wound
pressure over her coccyx. healing. Therefore the objective evaluative
The nursing plan of care measure for attainment of the goal is to mea-
includes a goal of "Pres- sure the size of the wound.
sure ulcer heals in 3 weeks."
Which of the following is an
evaluative measure for this
goal?
A. Turn patient every 90 min-
utes.
B. Measure the diameter of
the ulcer.
C. Measure the color of pa-
tient's urine.
D. Determine patient's re-
port of discomfort during
turning.
4. A nurse has been inter- B
viewing a newly assigned
patient. The cues from the This is an error in data collection. In this case
assessment suggest that the nurse did not completely collect the data.
the patient has a problem The nurse should have done a physical ex-
breathing. The nurse does amination on the patient's respiratory system
not validate the findings by to identify objective causes for the patient's
doing a physical examina- breathing difficulties.
tion. This is an example of
which type of error?
A. Error in data clustering
B. Error in data collection
C. Error in diagnostic state-
ment
D. Error in interpretation and
analysis
, 5. A nursing student is report- C
ing off at the end of her
shift to the RN. The student The only outcome measure was the pain level.
tells the RN that her patient Administration of the analgesic and the use
has a priority nursing diag- of distraction were interventions. Observation
nosis of Pain. She tells the of the patient grimacing was an unreported
RN that the last time the or- nursing observation.
dered analgesic was given
was 2 hours ago. The patient
continues to report pain at a
level of 4. The student also
tried repositioning and dis-
traction to reduce the pa-
tient's discomfort. She ob-
served her patient grimace
while turning. Which expect-
ed outcome measure did the
student report to the RN?
A. Administration of the
analgesic as ordered
B. The use of distraction as
a pain-relief measure
C. The reported pain level of
4 on a scale of 0 to 10
D. Observation of the patient
grimacing during turning
6. A nurse completes a res- C
piratory assessment on a
patient who had abdominal Goals are broad statements that describe de-
surgery 1 day ago. During sired changes in a patient's condition or be-
the assessment she auscul- havior. Patient's pulse oximetry is a measur-
tates crackles in both low- able outcome, not a goal. Instructing patient to
er lobes, and the patient deep breathe and cough every 2 hours is an
coughs, producing light yel- intervention, not a goal. "Patient will be able to
low sputum. The patient's sleep through the night" does not address the
body temperature is 37.0° C patient's nursing diagnosis of Impaired Gas
(98.6° F), pulse is 110, respi- Exchange.
have had this dull ache in my
side now for 4 days; it real- Back-channeling gives positive comments
ly hurts when I bend over." such as "all right," "go on," or "uh-huh" to the
The nurse responds, "All speaker, thus indicating that you heard what
right, go on." The nurse's re- the patient is saying and are interested in hear-
sponse is an example of: ing the full story.
A. inference.
B. a cue.
C. back-channeling.
D. open-ended question.
2. The nurse prepares to ad- A
minister care to a patient by
first positioning him more Insertion of a urinary catheter is the only de-
comfortably. She inspects pendent intervention, which requires an order
his surgical wound and re- from a health care provider.
inforces the dressing with
extra tape. She explains
the procedure that she will
use for insertion of a uri-
nary catheter. She prepares
the patient and inserts the
catheter. Which of the fol-
lowing steps is a dependent
nursing intervention?
A. Insertion of the urinary
catheter
B. Reinforcement of dress-
ing with tape
C. Instruction about the pro-
cedure for insertion of the
urinary catheter
D. Positioning the patient for
comfort
3.
, A patient has a pressure B
ulcer resulting from urine
incontinence and sustained The intent of the therapy is to promote wound
pressure over her coccyx. healing. Therefore the objective evaluative
The nursing plan of care measure for attainment of the goal is to mea-
includes a goal of "Pres- sure the size of the wound.
sure ulcer heals in 3 weeks."
Which of the following is an
evaluative measure for this
goal?
A. Turn patient every 90 min-
utes.
B. Measure the diameter of
the ulcer.
C. Measure the color of pa-
tient's urine.
D. Determine patient's re-
port of discomfort during
turning.
4. A nurse has been inter- B
viewing a newly assigned
patient. The cues from the This is an error in data collection. In this case
assessment suggest that the nurse did not completely collect the data.
the patient has a problem The nurse should have done a physical ex-
breathing. The nurse does amination on the patient's respiratory system
not validate the findings by to identify objective causes for the patient's
doing a physical examina- breathing difficulties.
tion. This is an example of
which type of error?
A. Error in data clustering
B. Error in data collection
C. Error in diagnostic state-
ment
D. Error in interpretation and
analysis
, 5. A nursing student is report- C
ing off at the end of her
shift to the RN. The student The only outcome measure was the pain level.
tells the RN that her patient Administration of the analgesic and the use
has a priority nursing diag- of distraction were interventions. Observation
nosis of Pain. She tells the of the patient grimacing was an unreported
RN that the last time the or- nursing observation.
dered analgesic was given
was 2 hours ago. The patient
continues to report pain at a
level of 4. The student also
tried repositioning and dis-
traction to reduce the pa-
tient's discomfort. She ob-
served her patient grimace
while turning. Which expect-
ed outcome measure did the
student report to the RN?
A. Administration of the
analgesic as ordered
B. The use of distraction as
a pain-relief measure
C. The reported pain level of
4 on a scale of 0 to 10
D. Observation of the patient
grimacing during turning
6. A nurse completes a res- C
piratory assessment on a
patient who had abdominal Goals are broad statements that describe de-
surgery 1 day ago. During sired changes in a patient's condition or be-
the assessment she auscul- havior. Patient's pulse oximetry is a measur-
tates crackles in both low- able outcome, not a goal. Instructing patient to
er lobes, and the patient deep breathe and cough every 2 hours is an
coughs, producing light yel- intervention, not a goal. "Patient will be able to
low sputum. The patient's sleep through the night" does not address the
body temperature is 37.0° C patient's nursing diagnosis of Impaired Gas
(98.6° F), pulse is 110, respi- Exchange.
