Chapter 18 Planning Nursing Care Fundamentals of Nursing 11th Edition (Potter & Perry) 50 NCLEX-Style Exam Questions with Detailed Rationales

1. A nurse is developing a care plan for a patient with chronic heart failure. Which of the following is the best example of a correctly written goal? A. The patient will increase physical activity. B. The patient will walk 50 feet using a walker within three days. C. The patient should try to feel better within the week. D. The nurse will assist the patient with mobility exercises. Answer: B. The patient will walk 50 feet using a walker within three days. Rationale: This goal is specific, measurable, attainable, realistic, and time-bound (SMART), making it an effective nursing goal. ________________________________________ 2. During the planning phase of the nursing process, what is the primary purpose of setting priorities among nursing diagnoses? A. To improve nurse satisfaction and workflow B. To establish which nurse is responsible for care C. To determine which problems require the most immediate attention D. To reduce the length of hospital stay Answer: C. To determine which problems require the most immediate attention Rationale: Prioritizing diagnoses helps ensure that life-threatening or urgent issues are addressed first. ________________________________________ 3. A nurse is working with a patient who has just undergone abdominal surgery. Which of the following is a correctly formulated short-term goal? A. Patient will be pain-free. B. Patient will resume regular diet. C. Patient will verbalize pain level below 3 on a scale of 0–10 within 24 hours. D. Patient will feel better soon. Answer: C. Patient will verbalize pain level below 3 on a scale of 0–10 within 24 hours. Rationale: This goal is measurable and time-specific, meeting SMART criteria. ________________________________________ 4. Which of the following is a correctly written nursing intervention? A. Encourage deep breathing. B. Help patient with exercises. C. Assist the patient to ambulate 10 feet with walker three times daily. D. Watch the patient carefully. Answer: C. Assist the patient to ambulate 10 feet with walker three times daily. Rationale: Nursing interventions should be specific, detailed, and measurable to guide care effectively. ________________________________________ 5. A patient with diabetes needs to learn self-injection of insulin. What type of goal would be most appropriate? A. Psychomotor B. Cognitive C. Affective D. Collaborative Answer: A. Psychomotor Rationale: Psychomotor goals involve the development of new skills such as administering insulin. ________________________________________ 6. The nurse prioritizes a patient’s nursing diagnoses using Maslow’s hierarchy of needs. Which diagnosis would receive the highest priority? A. Risk for impaired skin integrity B. Anxiety related to hospitalization C. Impaired gas exchange D. Ineffective coping Answer: C. Impaired gas exchange Rationale: Physiological needs like oxygenation are the highest priority in Maslow’s hierarchy. ________________________________________ 7. Which of the following goals best reflects an affective outcome? A. Patient will correctly perform wound care. B. Patient will describe three signs of infection. C. Patient will express acceptance of body image changes within one week. D. Patient will walk 100 feet independently. Answer: C. Patient will express acceptance of body image changes within one week. Rationale: Affective outcomes involve feelings, values, and attitudes. ________________________________________ 8. A nurse develops a care plan including a collaborative intervention. Which of the following is an example? A. Monitor urine output. B. Administer pain medication as prescribed. C. Teach patient about low-sodium diet. D. Elevate legs to reduce swelling. Answer: B. Administer pain medication as prescribed. Rationale: Collaborative interventions involve physician-initiated orders carried out by the nurse. ________________________________________ 9. What is the benefit of using standardized nursing interventions such as those found in NIC (Nursing Interventions Classification)? A. Limits nurse autonomy B. Reduces time spent on documentation C. Promotes consistent and evidence-based care D. Eliminates the need for critical thinking Answer: C. Promotes consistent and evidence-based care Rationale: NIC provides standardized language and interventions that improve communication and quality. ________________________________________ 10. Which statement is true regarding planning care for a group of patients? A. Address all patient problems simultaneously. B. Delegate all care to the nursing assistant. C. Prioritize based on patient preferences only. D. Use critical thinking to prioritize interventions. Answer: D. Use critical thinking to prioritize interventions. Rationale: Planning requires critical thinking to prioritize care based on safety, urgency, and patient needs. ________________________________________ 11. When writing nursing goals, what should the nurse include to make them measurable? A. A vague time frame B. Patient’s emotional response C. A specific, observable behavior D. Nurse’s plan of action Answer: C. A specific, observable behavior Rationale: Goals should describe observable patient actions to measure progress effectively. ________________________________________ 12. Which nursing diagnosis is most appropriate to address first in a patient with multiple needs? A. Risk for falls B. Anxiety C. Acute pain D. Knowledge deficit Answer: C. Acute pain Rationale: Immediate physical needs like pain management take precedence over other concerns. ________________________________________ 13. A nurse sets a long-term goal for a stroke patient. Which of the following is an example? A. Patient will walk 20 feet with a cane by the end of the shift. B. Patient will verbalize decreased anxiety within 30 minutes. C. Patient will independently perform ADLs within 6 weeks. D. Patient will eat 50% of meal within 24 hours. Answer: C. Patient will independently perform ADLs within 6 weeks. Rationale: Long-term goals are typically set for extended periods, often after discharge. ________________________________________ 14. Which action reflects the nurse’s role in establishing expected outcomes? A. Delegating goal setting to the physician B. Using the medical diagnosis to guide interventions C. Collaborating with the patient to set realistic goals D. Allowing family to determine priorities Answer: C. Collaborating with the patient to set realistic goals Rationale: Patient involvement ensures that goals are meaningful and achievable. ________________________________________ 15. Which of the following is the best example of a nursing-sensitive outcome? A. Blood glucose level within normal limits B. Decreased anxiety reported by the patient C. Wound healing after surgical intervention D. Reduced hospital length of stay Answer: B. Decreased anxiety reported by the patient Rationale: Nursing-sensitive outcomes are directly influenced by nursing care. ________________________________________