NURS 406 UNIT 4 QUIZ 1 | QUESTIONS
AND ANSWERS | 2026 UPDATE | WITH
COMPLETE SOLUTIONS.
You are writing a care plan for an 85-year-old patient who has community-acquired pneumonia and you note
decreased breath sounds to bilateral lung bases on auscultation. What is the most appropriate nursing diagnosis for
this patient?
A) Ineffective airway clearance related to tracheobronchial secretions
B) Pneumonia related to progression of disease process
C) Poor ventilation related to acute lung infection
D) Immobility related to fatigue - ANSWER>Ans: A
Feedback: Nursing diagnoses are not medical diagnoses or treatments. The most appropriate nursing diagnosis for
this patient is ineffective airway clearance related to copious tracheobronchial secretions. Pneumonia and poor
ventilation are not nursing diagnoses. Immobility is likely, but is less directly related to the patients admitting
medical diagnosis and the nurses assessment finding.
You are providing care for a patient who has a diagnosis of pneumonia attributed to Streptopoppus pneumonia
infection. Which of the following aspects of nursing care would constitute part of the planning phase of the nursing
process?
A) Achieve SaO2 92% at all times.
B) Auscultate chest q4h.
C) Administer oral fluids q1h and PRN.
D) Avoid overexertion at all times. - ANSWER>Ans: A
Feedback: The planning phase entails specifying the immediate, intermediate, and long-term goals of nursing
action, such as maintaining a certain level of oxygen saturation in a patient with pneumonia. Providing fluids and
avoiding overexertion are parts of the implementation phase of the nursing process. Chest auscultation is an
assessment.
,You are the nurse who is caring for a patient with a newly diagnosed allergy to peanuts. Which of the following is
an immediate goal that is most relevant to a nursing diagnosis of deficient knowledge related to appropriate use of
an EpiPen?
A) The patient will demonstrate correct injection technique with todays teaching session.
B) The patient will closely observe the nurse demonstrating the injection.
C) The nurse will teach the patients family member to administer the injection.
D) The patient will return to the clinic within 2 weeks to demonstrate the injection. - ANSWER>Ans: A
Feedback: Immediate goals are those that can be reached in a short period of time. An appropriate immediate goal
for this patient is that the patient will demonstrate correct administration of the medication today. The goal should
specify that the patient administer the EpiPen. A 2-week time frame is inconsistent with an immediate goal.
A recent nursing graduate is aware of the differences between nursing actions that are independent and nursing
actions that are interdependent. A nurse performs an interdependent nursing intervention when performing which
of the following actions?
A) Auscultating a patients apical heart rate during an admission assessment
B) Providing mouth care to a patient who is unconscious following a cerebrovascular accident
C) Administering an IV bolus of normal saline to a patient with hypotension
D) Providing discharge teaching to a postsurgical patient about the rationale for a course of oral antibiotics -
ANSWER>Ans: C
Feedback: Although many nursing actions are independent, others are interdependent, such as carrying out
prescribed treatments, administering medications and therapies, and collaborating with other health care team
members to accomplish specific, expected outcomes and to monitor and manage potential complications. Irrigating
a wound, administering pain medication, and administering IV fluids are interdependent nursing actions and
require a physicians order. An independent nursing action occurs when the nurse assesses a patients heart rate,
provides discharge education, or provides mouth care.
A nurse has been using the nursing process as a framework for planning and providing patient care. What action
would the nurse do during the evaluation phase of the nursing process?
A) Have a patient provide input on the quality of care received.
B) Remove a patients surgical staples on the scheduled postoperative day.
C) Provide information on a follow-up appointment for a postoperative patient.
, D) Document a patients improved air entry with incentive spirometric use. - ANSWER>Ans: D
Feedback: During the evaluation phase of the nursing process, the nurse determines the patients response to
nursing interventions. An example of this is when the nurse documents whether the patients spirometry use has
improved his or her condition. A patient does not do the evaluation. Removing staples and providing information
on follow-up appointments are interventions, not evaluations.
An audit of a large, university medical center reveals that four patients in the hospital have current orders for
restraints. You know that restraints are an intervention of last resort, and that it is inappropriate to apply restraints
to which of the following patients?
A) A postlaryngectomy patient who is attempting to pull out his tracheostomy tube
B) A patient in hypovolemic shock trying to remove the dressing over his central venous catheter
C) A patient with urosepsis who is ringing the call bell incessantly to use the bedside commode
D) A patient with depression who has just tried to commit suicide and whose medications are not achieving
adequate symptom control - ANSWER>Ans: C
Feedback: Restraints should never be applied for staff convenience. The patient with urosepsis who is frequently
ringing the call bell is requesting assistance to the bedside commode; this is appropriate behavior that will not
result in patient harm. The other described situations could plausibly result in patient harm; therefore, it is more
likely appropriate to apply restraints in these instances.
A patient has been diagnosed with small-cell lung cancer. He has met with the oncologist and is now weighing the
relative risks and benefits of chemotherapy and radiotherapy as his treatment. This patient is demonstrating which
ethical principle in making his decision?
A) Beneficence
B) Confidentiality
C) Autonomy
D) Justice - ANSWER>Ans: C
Feedback: Autonomy entails the ability to make a choice free from external constraints. Beneficence is the duty to
do good and the active promotion of benevolent acts. Confidentiality relates to the concept of privacy. Justice
states that cases should be treated equitably.
A patient with migraines does not know whether she is receiving a placebo for pain management or the new drug
that is undergoing clinical trials. Upon discussing the patients distress, it becomes evident to the nurse that the
AND ANSWERS | 2026 UPDATE | WITH
COMPLETE SOLUTIONS.
You are writing a care plan for an 85-year-old patient who has community-acquired pneumonia and you note
decreased breath sounds to bilateral lung bases on auscultation. What is the most appropriate nursing diagnosis for
this patient?
A) Ineffective airway clearance related to tracheobronchial secretions
B) Pneumonia related to progression of disease process
C) Poor ventilation related to acute lung infection
D) Immobility related to fatigue - ANSWER>Ans: A
Feedback: Nursing diagnoses are not medical diagnoses or treatments. The most appropriate nursing diagnosis for
this patient is ineffective airway clearance related to copious tracheobronchial secretions. Pneumonia and poor
ventilation are not nursing diagnoses. Immobility is likely, but is less directly related to the patients admitting
medical diagnosis and the nurses assessment finding.
You are providing care for a patient who has a diagnosis of pneumonia attributed to Streptopoppus pneumonia
infection. Which of the following aspects of nursing care would constitute part of the planning phase of the nursing
process?
A) Achieve SaO2 92% at all times.
B) Auscultate chest q4h.
C) Administer oral fluids q1h and PRN.
D) Avoid overexertion at all times. - ANSWER>Ans: A
Feedback: The planning phase entails specifying the immediate, intermediate, and long-term goals of nursing
action, such as maintaining a certain level of oxygen saturation in a patient with pneumonia. Providing fluids and
avoiding overexertion are parts of the implementation phase of the nursing process. Chest auscultation is an
assessment.
,You are the nurse who is caring for a patient with a newly diagnosed allergy to peanuts. Which of the following is
an immediate goal that is most relevant to a nursing diagnosis of deficient knowledge related to appropriate use of
an EpiPen?
A) The patient will demonstrate correct injection technique with todays teaching session.
B) The patient will closely observe the nurse demonstrating the injection.
C) The nurse will teach the patients family member to administer the injection.
D) The patient will return to the clinic within 2 weeks to demonstrate the injection. - ANSWER>Ans: A
Feedback: Immediate goals are those that can be reached in a short period of time. An appropriate immediate goal
for this patient is that the patient will demonstrate correct administration of the medication today. The goal should
specify that the patient administer the EpiPen. A 2-week time frame is inconsistent with an immediate goal.
A recent nursing graduate is aware of the differences between nursing actions that are independent and nursing
actions that are interdependent. A nurse performs an interdependent nursing intervention when performing which
of the following actions?
A) Auscultating a patients apical heart rate during an admission assessment
B) Providing mouth care to a patient who is unconscious following a cerebrovascular accident
C) Administering an IV bolus of normal saline to a patient with hypotension
D) Providing discharge teaching to a postsurgical patient about the rationale for a course of oral antibiotics -
ANSWER>Ans: C
Feedback: Although many nursing actions are independent, others are interdependent, such as carrying out
prescribed treatments, administering medications and therapies, and collaborating with other health care team
members to accomplish specific, expected outcomes and to monitor and manage potential complications. Irrigating
a wound, administering pain medication, and administering IV fluids are interdependent nursing actions and
require a physicians order. An independent nursing action occurs when the nurse assesses a patients heart rate,
provides discharge education, or provides mouth care.
A nurse has been using the nursing process as a framework for planning and providing patient care. What action
would the nurse do during the evaluation phase of the nursing process?
A) Have a patient provide input on the quality of care received.
B) Remove a patients surgical staples on the scheduled postoperative day.
C) Provide information on a follow-up appointment for a postoperative patient.
, D) Document a patients improved air entry with incentive spirometric use. - ANSWER>Ans: D
Feedback: During the evaluation phase of the nursing process, the nurse determines the patients response to
nursing interventions. An example of this is when the nurse documents whether the patients spirometry use has
improved his or her condition. A patient does not do the evaluation. Removing staples and providing information
on follow-up appointments are interventions, not evaluations.
An audit of a large, university medical center reveals that four patients in the hospital have current orders for
restraints. You know that restraints are an intervention of last resort, and that it is inappropriate to apply restraints
to which of the following patients?
A) A postlaryngectomy patient who is attempting to pull out his tracheostomy tube
B) A patient in hypovolemic shock trying to remove the dressing over his central venous catheter
C) A patient with urosepsis who is ringing the call bell incessantly to use the bedside commode
D) A patient with depression who has just tried to commit suicide and whose medications are not achieving
adequate symptom control - ANSWER>Ans: C
Feedback: Restraints should never be applied for staff convenience. The patient with urosepsis who is frequently
ringing the call bell is requesting assistance to the bedside commode; this is appropriate behavior that will not
result in patient harm. The other described situations could plausibly result in patient harm; therefore, it is more
likely appropriate to apply restraints in these instances.
A patient has been diagnosed with small-cell lung cancer. He has met with the oncologist and is now weighing the
relative risks and benefits of chemotherapy and radiotherapy as his treatment. This patient is demonstrating which
ethical principle in making his decision?
A) Beneficence
B) Confidentiality
C) Autonomy
D) Justice - ANSWER>Ans: C
Feedback: Autonomy entails the ability to make a choice free from external constraints. Beneficence is the duty to
do good and the active promotion of benevolent acts. Confidentiality relates to the concept of privacy. Justice
states that cases should be treated equitably.
A patient with migraines does not know whether she is receiving a placebo for pain management or the new drug
that is undergoing clinical trials. Upon discussing the patients distress, it becomes evident to the nurse that the
