When delivering patient care, which intervention does the nurse perform as part of the evaluation
process?
Recognizes unmet outcomes
Which type of problem is a high priority?
One related to life-threatening needs of the patients
Which patient problem would be a high priority?
Chest pain
Which problem would the nurse add to the care plan after evaluating a diabetic patient who had a
problem with glucose control but is now restless and asking many questions about an upcoming
procedure on the big toe?
Anxiety
Which level of prevention describes a nurse administering a vaccine to an infant?
Primary prevention.
Setting a time frame for outcomes of care determines which purpose?
When the patient is expected to respond in the desired manner
Which action would a student nurse take when asked to perform a procedure that the student nurse has
been trained in but has not performed in the hospital? Select all that apply. One, some, or all responses
may be correct.
Check the hospital’s procedure manual to obtain more information
Ask an experienced nurse for supervision and guidance during the procedure.
Verbalize the steps of the procedure with an instructor before performing it.
,Which response would the nurse make for a patient who expresses confusion about how to manage a
leg wound after discharge?
Explain and demonstrate the necessary action to the patient
Which outcome is correctly written and would the nurse add to the plan of care about the patient’s
apical pulse?
The patient’s apical pulse will be at least 70 beats per minute.
Which action demonstrates nursing competency when evaluating a patient? Select all that apply. One,
some, or all responses may be correct.
Reflect on the situation.
Understand a patient situation.
Recognize errors or omissions.
Examine the results of care according to clinical data collected.
Compare achieved effects with goals and expected outcome
Which action describes an independent nursing intervention? Select all that apply. One, some, or all
responses may be correct.
Offering counseling for coping
Initiating early mobility protocols
Instructing patients on side effects of medications
Positioning patients to prevent pressure injury formation
Which feature is true about standing orders?
Allow a quick response to a rapidly changing clinical situation
Which expected outcome is written in measurable terms?
,1
Patient will be pain free.
2
Patient will have less pain.
3
Patient will take pain medication every 4 hours.
Correct4
Patient will report pain acuity less than 4 on a scale of 0 to 10.
Using a scale for the patient’s report of pain acuity is measurable because it is the only outcome
statement that allows the nurse to obtain an actual measure of the patient’s pain. "Patient will be pain
free" is a goal, not an expected outcome. "Patient will have less pain" is vague and not measurable.
"Patient will take pain medication every 4 hours" is an intervention, not an expected outcome.
Which intervention performed by the nurse is an independent nursing intervention? Select all that
apply. One, some, or all responses may be correct.
Correct1
Teaching the patient about deep-breathing exercises
2
Starting an intravenous (IV) infusion
3
Administering analgesic medications
Correct4
Assisting the patient in taking a bed bath
Correct5
Repositioning a patient for relief from pain
Teaching the patient about deep-breathing exercises, assisting the patient with a bed bath, and
repositioning the patient can be performed independently by the nurse. Independent nursing
interventions are activities that do not need an order from another health care provider. Starting an IV
infusion and administering analgesic medications require an order from a health care provider, making
these interventions dependent, not independent.
, STUDY TIP: The following are crucial requisites for doing well on the National Council Licensure
Examinations (NCLEX®): (1) A sound understanding of the subject, (2) the ability to follow the
directions given at the beginning of the test, (3) the ability to comprehend what is read, (4) the
patience to read each question and set of options carefully before deciding how to answer the
question, (5) the ability to use the computer correctly to record answers, (6) the determination to do
well, and (7) a degree of confidence.
Which intervention performed by the nurse would require an order from a health care provider?
Select all that apply. One, some, or all responses may be correct.
Correct1
Getting an x-ray of the chest to rule out pulmonary complications
Correct2
Administering an antibiotic to prevent infection
Correct3
Starting an intravenous (IV) infusion of normal saline
4
Instructing the patient to splint the incision when coughing
5
Teaching the patient about the side effects of the medication
These include getting an x-ray, administering an antibiotic, and starting an IV infusion. Health care
provider–initiated interventions are dependent nursing interventions or actions that require an order
from a physician or other health care providers. Instructing the patient to splint the incision when
coughing and teaching the patient about the side effects of the medication do not require an order
from a health care provider.
Test-Taking Tip: When using this program, be sure to note if you guess at an answer. This will permit
you to identify areas that need further review. In addition, it will help you to see how correct your
guessing can be.
Which interpretation would the nurse make regarding a patient with pneumonia whose cough
decreased and respiratory rate decreased from 33 to 25 breaths/min after nebulization treatments?
1
process?
Recognizes unmet outcomes
Which type of problem is a high priority?
One related to life-threatening needs of the patients
Which patient problem would be a high priority?
Chest pain
Which problem would the nurse add to the care plan after evaluating a diabetic patient who had a
problem with glucose control but is now restless and asking many questions about an upcoming
procedure on the big toe?
Anxiety
Which level of prevention describes a nurse administering a vaccine to an infant?
Primary prevention.
Setting a time frame for outcomes of care determines which purpose?
When the patient is expected to respond in the desired manner
Which action would a student nurse take when asked to perform a procedure that the student nurse has
been trained in but has not performed in the hospital? Select all that apply. One, some, or all responses
may be correct.
Check the hospital’s procedure manual to obtain more information
Ask an experienced nurse for supervision and guidance during the procedure.
Verbalize the steps of the procedure with an instructor before performing it.
,Which response would the nurse make for a patient who expresses confusion about how to manage a
leg wound after discharge?
Explain and demonstrate the necessary action to the patient
Which outcome is correctly written and would the nurse add to the plan of care about the patient’s
apical pulse?
The patient’s apical pulse will be at least 70 beats per minute.
Which action demonstrates nursing competency when evaluating a patient? Select all that apply. One,
some, or all responses may be correct.
Reflect on the situation.
Understand a patient situation.
Recognize errors or omissions.
Examine the results of care according to clinical data collected.
Compare achieved effects with goals and expected outcome
Which action describes an independent nursing intervention? Select all that apply. One, some, or all
responses may be correct.
Offering counseling for coping
Initiating early mobility protocols
Instructing patients on side effects of medications
Positioning patients to prevent pressure injury formation
Which feature is true about standing orders?
Allow a quick response to a rapidly changing clinical situation
Which expected outcome is written in measurable terms?
,1
Patient will be pain free.
2
Patient will have less pain.
3
Patient will take pain medication every 4 hours.
Correct4
Patient will report pain acuity less than 4 on a scale of 0 to 10.
Using a scale for the patient’s report of pain acuity is measurable because it is the only outcome
statement that allows the nurse to obtain an actual measure of the patient’s pain. "Patient will be pain
free" is a goal, not an expected outcome. "Patient will have less pain" is vague and not measurable.
"Patient will take pain medication every 4 hours" is an intervention, not an expected outcome.
Which intervention performed by the nurse is an independent nursing intervention? Select all that
apply. One, some, or all responses may be correct.
Correct1
Teaching the patient about deep-breathing exercises
2
Starting an intravenous (IV) infusion
3
Administering analgesic medications
Correct4
Assisting the patient in taking a bed bath
Correct5
Repositioning a patient for relief from pain
Teaching the patient about deep-breathing exercises, assisting the patient with a bed bath, and
repositioning the patient can be performed independently by the nurse. Independent nursing
interventions are activities that do not need an order from another health care provider. Starting an IV
infusion and administering analgesic medications require an order from a health care provider, making
these interventions dependent, not independent.
, STUDY TIP: The following are crucial requisites for doing well on the National Council Licensure
Examinations (NCLEX®): (1) A sound understanding of the subject, (2) the ability to follow the
directions given at the beginning of the test, (3) the ability to comprehend what is read, (4) the
patience to read each question and set of options carefully before deciding how to answer the
question, (5) the ability to use the computer correctly to record answers, (6) the determination to do
well, and (7) a degree of confidence.
Which intervention performed by the nurse would require an order from a health care provider?
Select all that apply. One, some, or all responses may be correct.
Correct1
Getting an x-ray of the chest to rule out pulmonary complications
Correct2
Administering an antibiotic to prevent infection
Correct3
Starting an intravenous (IV) infusion of normal saline
4
Instructing the patient to splint the incision when coughing
5
Teaching the patient about the side effects of the medication
These include getting an x-ray, administering an antibiotic, and starting an IV infusion. Health care
provider–initiated interventions are dependent nursing interventions or actions that require an order
from a physician or other health care providers. Instructing the patient to splint the incision when
coughing and teaching the patient about the side effects of the medication do not require an order
from a health care provider.
Test-Taking Tip: When using this program, be sure to note if you guess at an answer. This will permit
you to identify areas that need further review. In addition, it will help you to see how correct your
guessing can be.
Which interpretation would the nurse make regarding a patient with pneumonia whose cough
decreased and respiratory rate decreased from 33 to 25 breaths/min after nebulization treatments?
1
