,
,100%Pass
6. A patient with a bacterial infection has a nursing diagnosis of deficient fluid volume related to
excessive diaphoresis. Which outcome would the nurse recognize as appropriate for this
patient?
a. Patient has a balanced intake and output.
b. Patient’s bedding is changed when it becomes damp.
c. Patient understands the need for increased fluid intake.
d. Patient’s skin remains cool and dry throughout hospitalization.
ANS: A
This statement gives measurable data showing resolution of the problem of deficient fluid
volume that was identified in the nursing diagnosis statement. The other statements would not
indicate that the problem of deficient fluid volume was resolved.
DIF: Cognitive Level: Apply (application) REF: 7
TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
7. A nurse asks the patient if pain was relieved after receiving medication. What is the purpose
of the evaluation phase of the nursing process?
a. To determine if interventions have been effective in meeting patient outcomes
b. To document the nursing care plan in the progress notes of the medical record
c. To decide whether the patient’s health problems have been completely resolved
d. To establish if the patient agrees that the nursing care provided was satisfactory
ANS: A
Evaluation consists of determining whether the desired patient outcomes have been met and
whether the nursing interventions were appropriate. The other responses do not describe the
evaluation phase.
DIF: Cognitive Level: Understand (comprehension) REF: 5
TOP: Nursing Process: Evaluation MSC: NCLEX: Safe and Effective Care Environment
8. The nurse interviews a patient while completing the health history and physical examination.
What is the purpose of the assessment phase of the nursing process?
a. To teach interventions that relieve health problems
b. To use patient data to evaluate patient care outcomes
c. To obtain data with which to diagnose patient problems
d. To help the patient identify realistic outcomes for health problems
ANS: C
During the assessment phase, the nurse gathers information about the patient to diagnose
patient problems. The other responses are examples of the planning, intervention, and
evaluation phases of the nursing process.
DIF: Cognitive Level: Understand (comprehension) REF: 5
TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment
9. Which nursing diagnosis statement is written correctly?
a. Altered tissue perfusion related to heart failure
b. Risk for impaired tissue integrity related to sacral redness
c. Ineffective coping related to response to biopsy test results
d. Altered urinary elimination related to urinary tract infection
, 100%Pass
ANS: C
This diagnosis statement includes a NANDA nursing diagnosis and an etiology that describes
a patient’s response to a health problem that can be treated by nursing. The use of a medical
diagnosis as an etiology (as in the responses beginning “Altered tissue perfusion” and
“Altered urinary elimination”) is not appropriate. The response beginning “Risk for impaired
tissue integrity” uses the defining characteristic as the etiology.
DIF: Cognitive Level: Understand (comprehension) REF: 7
TOP: Nursing Process: Diagnosis MSC: NCLEX: Safe and Effective Care Environment
10. The nurse admits a patient to the hospital and develops a plan of care. What components
should the nurse include in the nursing diagnosis statement?
a. The problem and the suggested patient goals or outcomes
b. The problem with possible causes and the planned interventions
c. The problem, its cause, and objective data that support the problem
d. The problem with an etiology and the signs and symptoms of the problem
ANS: D
When writing nursing diagnoses, this format should be used: problem, etiology, and signs and
symptoms. The subjective, as well as objective, data should be included in the defining
characteristics. Interventions and outcomes are not included in the nursing diagnosis
statement.
DIF: Cognitive Level: Remember (knowledge) REF: 7
TOP: Nursing Process: Diagnosis MSC: NCLEX: Safe and Effective Care Environment
11. A nurse is caring for a patient with heart failure. Which task is appropriate for the nurse to
delegate to experienced unlicensed assistive personnel (UAP)?
a. Monitor for shortness of breath or fatigue after ambulation.
b. Instruct the patient about the need to alternate activity and rest.
c. Obtain the patient’s blood pressure and pulse rate after ambulation.
d. Determine whether the patient is ready to increase the activity level.
ANS: C
UAP education includes accurate vital sign measurement. Assessment and patient teaching
require registered nurse education and scope of practice and cannot be delegated.
DIF: Cognitive Level: Apply (application) REF: 11
OBJ: Special Questions: Delegation TOP: Nursing Process: Planning
MSC: NCLEX: Safe and Effective Care Environment
12. A nurse is caring for a group of patients on the medical-surgical unit with the help of one float
registered nurse (RN), one unlicensed assistive personnel (UAP), and one licensed
practical/vocational nurse (LPN/LVN). Which assignment, if delegated by the nurse, would
be inappropriate?
a. Measurement of a patient’s urine output by UAP
b. Administration of oral medications by LPN/LVN
c. Check for the presence of bowel sounds and flatulence by UAP
d. Care of a patient with diabetes by RN who usually works on the pediatric unit
ANS: C
,100%Pass
6. A patient with a bacterial infection has a nursing diagnosis of deficient fluid volume related to
excessive diaphoresis. Which outcome would the nurse recognize as appropriate for this
patient?
a. Patient has a balanced intake and output.
b. Patient’s bedding is changed when it becomes damp.
c. Patient understands the need for increased fluid intake.
d. Patient’s skin remains cool and dry throughout hospitalization.
ANS: A
This statement gives measurable data showing resolution of the problem of deficient fluid
volume that was identified in the nursing diagnosis statement. The other statements would not
indicate that the problem of deficient fluid volume was resolved.
DIF: Cognitive Level: Apply (application) REF: 7
TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
7. A nurse asks the patient if pain was relieved after receiving medication. What is the purpose
of the evaluation phase of the nursing process?
a. To determine if interventions have been effective in meeting patient outcomes
b. To document the nursing care plan in the progress notes of the medical record
c. To decide whether the patient’s health problems have been completely resolved
d. To establish if the patient agrees that the nursing care provided was satisfactory
ANS: A
Evaluation consists of determining whether the desired patient outcomes have been met and
whether the nursing interventions were appropriate. The other responses do not describe the
evaluation phase.
DIF: Cognitive Level: Understand (comprehension) REF: 5
TOP: Nursing Process: Evaluation MSC: NCLEX: Safe and Effective Care Environment
8. The nurse interviews a patient while completing the health history and physical examination.
What is the purpose of the assessment phase of the nursing process?
a. To teach interventions that relieve health problems
b. To use patient data to evaluate patient care outcomes
c. To obtain data with which to diagnose patient problems
d. To help the patient identify realistic outcomes for health problems
ANS: C
During the assessment phase, the nurse gathers information about the patient to diagnose
patient problems. The other responses are examples of the planning, intervention, and
evaluation phases of the nursing process.
DIF: Cognitive Level: Understand (comprehension) REF: 5
TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment
9. Which nursing diagnosis statement is written correctly?
a. Altered tissue perfusion related to heart failure
b. Risk for impaired tissue integrity related to sacral redness
c. Ineffective coping related to response to biopsy test results
d. Altered urinary elimination related to urinary tract infection
, 100%Pass
ANS: C
This diagnosis statement includes a NANDA nursing diagnosis and an etiology that describes
a patient’s response to a health problem that can be treated by nursing. The use of a medical
diagnosis as an etiology (as in the responses beginning “Altered tissue perfusion” and
“Altered urinary elimination”) is not appropriate. The response beginning “Risk for impaired
tissue integrity” uses the defining characteristic as the etiology.
DIF: Cognitive Level: Understand (comprehension) REF: 7
TOP: Nursing Process: Diagnosis MSC: NCLEX: Safe and Effective Care Environment
10. The nurse admits a patient to the hospital and develops a plan of care. What components
should the nurse include in the nursing diagnosis statement?
a. The problem and the suggested patient goals or outcomes
b. The problem with possible causes and the planned interventions
c. The problem, its cause, and objective data that support the problem
d. The problem with an etiology and the signs and symptoms of the problem
ANS: D
When writing nursing diagnoses, this format should be used: problem, etiology, and signs and
symptoms. The subjective, as well as objective, data should be included in the defining
characteristics. Interventions and outcomes are not included in the nursing diagnosis
statement.
DIF: Cognitive Level: Remember (knowledge) REF: 7
TOP: Nursing Process: Diagnosis MSC: NCLEX: Safe and Effective Care Environment
11. A nurse is caring for a patient with heart failure. Which task is appropriate for the nurse to
delegate to experienced unlicensed assistive personnel (UAP)?
a. Monitor for shortness of breath or fatigue after ambulation.
b. Instruct the patient about the need to alternate activity and rest.
c. Obtain the patient’s blood pressure and pulse rate after ambulation.
d. Determine whether the patient is ready to increase the activity level.
ANS: C
UAP education includes accurate vital sign measurement. Assessment and patient teaching
require registered nurse education and scope of practice and cannot be delegated.
DIF: Cognitive Level: Apply (application) REF: 11
OBJ: Special Questions: Delegation TOP: Nursing Process: Planning
MSC: NCLEX: Safe and Effective Care Environment
12. A nurse is caring for a group of patients on the medical-surgical unit with the help of one float
registered nurse (RN), one unlicensed assistive personnel (UAP), and one licensed
practical/vocational nurse (LPN/LVN). Which assignment, if delegated by the nurse, would
be inappropriate?
a. Measurement of a patient’s urine output by UAP
b. Administration of oral medications by LPN/LVN
c. Check for the presence of bowel sounds and flatulence by UAP
d. Care of a patient with diabetes by RN who usually works on the pediatric unit
ANS: C
