Fundamentals of Nursing NCLEX RN Exam Practice Q&A Set 5

Fundamentals of Nursing NCLEX RN Exam Practice Q&A Set 5 | 75 Questions 1. 1. Question Once a nurse assesses a client’s condition and identifies appropriate nursing diagnoses, a: o A. Plan is developed for nursing care. o B. Physical assessment begins. o C. List of priorities is determined. o D. Review of the assessment is conducted with other team members. Incorrect Correct Answer: A. Plan is developed for nursing care. The planning stage is where goals and outcomes are formulated that directly impact patient care based on EDP guidelines. These patient-specific goals and the attainment of such assist in ensuring a positive outcome. Nursing care plans are essential in this phase of goal setting. • Option B: Assessment is the first step and involves critical thinking skills and data collection; subjective and objective. Subjective data involves verbal statements from the patient or caregiver. Objective data is measurable, tangible data such as vital signs, intake and output, and height and weight. • Option C: A nursing diagnosis encompasses Maslow’s Hierarchy of Needs and helps to prioritize and plan care based on patient-centered outcomes. In 1943, Abraham Maslow developed a hierarchy based on basic fundamental needs innate for all individuals. • Option D: Data may come from the patient directly or from primary caregivers who may or may not be direct relation family members. Friends can play a role in data collection. Electronic health records may populate data and assist in assessment. 2. 2. Question Planning is a category of nursing behaviors in which: • A. The nurse determines the health care needed for the client. • B. The physician determines the plan of care for the client. • C. Client-centered goals and expected outcomes are established. • D. The client determines the care needed. Incorrect Correct Answer: C. Client-centered goals and expected outcomes are established. The planning stage is where goals and outcomes are formulated that directly impact patient care based on EDP guidelines. These patient-specific goals and the attainment of such assist in ensuring a positive outcome. • Option A: Nursing care plans are essential in this phase of goal setting. Care plans provide a course of direction for personalized care tailored to an individual’s unique needs. Overall condition and comorbid conditions play a role in the construction of a care plan. • Option B: As explored by Salmond and Echevarria, healthcare is changing, and the traditional roles of nurses are transforming to meet the demands of this new healthcare environment. Nurses are in a position to promote change and impact patient delivery care models in the future. • Option D: Care plans enhance communication, documentation, reimbursement, and continuity of care across the healthcare continuum. Critical thinking skills will play a vital role as nurses develop plans of care for these patient populations with multiple comorbidities and embrace this challenging healthcare arena. 3. 3. Question 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: • A. Physician • B. Non-Emergent, non-life-threatening needs • C. Future well-being. • D. Urgency of problems Incorrect Correct Answer: D. Urgency of problems Triage of patients involves looking for signs of serious illness or injury. These emergency signs are connected to the Airway – Breathing – Circulation/Consciousness – Dehydration and are easily remembered as ABCD. If the client does not have any emergency signs, the health worker proceeds to assess the client for priority conditions. This should not take more than a few seconds. Some of these signs will have been noticed during the ABCD triage and others need to be rechecked. • Option A: All clinical staff involved in the care of the sick should be prepared to carry out a rapid assessment to identify the few clients who are severely ill and require emergency treatment. • Option B: Triage is the process of rapidly examining sick children when they first arrive in order to place them in one of the following categories: those with EMERGENCY SIGNS who require immediate emergency treatment; those with PRIORITY SIGNS who should be given priority in the queue so they can be rapidly assessed and treated without delay; and those who have no emergency or priority signs and are NON-URGENT cases. These clients can wait their turn in the queue for assessment and treatment. The majority of sick clients will be non-urgent and will not require emergency treatment. • Option C: Ideally, all clients should be checked on their arrival by a person who is trained to assess how ill they are. This person decides whether the client will be seen immediately and receive life-saving treatment, or will be seen soon, or can safely wait for his or her turn to be examined. 4. 4. Question A client-centered goal is a specific and measurable behavior or response that reflects a client’s: • A. Desire for specific health care interventions. • B. Highest possible level of wellness and independence in function. • C. Physician’s goal for the specific client. • D. Response when compared to another client with a similar problem. Incorrect Correct Answer: B. Highest possible level of wellness and independence in function. Client-centered practices facilitate the development of strong therapeutic relationships and enable care providers to understand how to maximize clients’ strengths and minimize challenges in achieving treatment and recovery goals. • Option A: Care providers negotiate between clients’ decisions and ongoing risk assessments. The care plan reflects safe practices and promotes interventions that minimize or reduce potential harms to the client. • Option C: Client-centred care empowers clients, promoting autonomy, rights, voice, and self-determination in the treatment planning and recovery process and supports care plans that are developed in collaboration with clients, and allows clients to express their self-identified needs and choices. • Option D: Client-centred care is about treating clients as they want to be treated, with knowledge about and respect for their values and personal priorities. Health care providers who take the time to get to know their clients can provide care that better addresses the needs of clients and improves their quality of care. 5. 5. Question For clients to participate in goal setting, they should be: • A. Alert and have some degree of independence. • B. Ambulatory and mobile. • C. Able to speak and write. • D. Able to read and write. Incorrect Correct Answer: A. Alert and have some degree of independence. Goal setting in nursing provides direction for planning nursing interventions and evaluating patient progress. The purpose of goal setting in nursing is to enable the patient and nurse to determine when the problem has been resolved and help motivate the patient and the nurse by providing a sense of achievement. • Option B: In light of the potential benefits of patient participation in goal setting, a study by Baker, Rice, Zimmerman, Marshak, et. al. believes the following are needed: (1) patient and therapist education regarding the potential advantages of participation, (2) the enhancement of patient readiness to assume greater responsibility in their care, and (3) the development of models for use in achieving patient participation. • Option C: Patient and therapist education is needed regarding methods for patient participation during initial goal-setting activities. In a study by Baker, Rice, Zimmerman, Marshak, et. al., the therapists stated that they believed that it is important to include patients in goal-setting activities and that outcomes will be improved if patients participate. Patients also indicated that participation is important to them. • Option D: Patient participation in goal setting is emphasized in order to enhance patient management and the effectiveness of treatment. Participation should improve outcomes and could be used to identify benefits that may result from the treatment. These benefits include greater goal attainment, increased patient satisfaction, gains in function, better adherence to treatment regimens, decreased depression in patients, and reduced burnout rates among physical therapists. 6. 6. Question The nurse writes an expected outcome statement in measurable terms. An example is: • A. Client will have less pain. • B. Client will be pain-free. • C. Client will report pain acuity less than 4 on a scale of 0-10. • D. Client will take pain medication every 4 hours around the clock. Incorrect Correct Answer: C. Client will report pain acuity less than 4 on a scale of 0-10. When developing goals for patients, the nurse needs to look at several factors. Think back to the SMART goal criteria. In order to be specific, nurses focus on questions like ‘What is the problem? What is the response desired?’ To make it measurable, ‘How will the client look or behave if the healthy response is achieve