1 of 48
Term
When the initial nursing assessment revealed that a patient had not
had a bowel movement for 2 days, the student nurse wrote the
diagnostic label "constipation." What would be the instructor's BEST
response to this student's diagnosis?
a. "Was this diagnosis derived from a cluster of significant data or a
single clue?"
b. "This early diagnosis will help us manage the problem before it
becomes more acute."
c. "Have you determined if this is an actual or a possible diagnosis?"
d. "This condition is a medical problem that should not have a
nursing diagnosis."
Give this one a try later!
a b
, c d
Don't know?
2 of 48
Term
The nurse assesses patients to determine their risk for HAIs. Which
hospitalized patient would the nurse consider most at risk for
developing this type of infection?
a. A 60-year-old patient who smokes two packs of cigarettes daily
b. A 40-year-old patient who has a white blood cell count of
6,000/mm
c. A 65-yeat-old patient who has an indwelling urinary catheter in
place
d. A 60-year-old patient who is a vegetarian and slightly
underweight
Give this one a try later!
a b
c d
Don't know?
3 of 48
Term
,The nurse is surprised to detect an elevated temperature (102°F) in a
patient scheduled for surgery. The patient has been afebrile and
shows no other signs of being febrile. What is the priority nursing
action?
a. Inform the charge nurse.
b. Inform the surgeon.
c. Validate the finding.
d. Document the finding.
Give this one a try later!
d c
a b
Don't know?
4 of 48
Term
A nurse who is caring for a patient diagnosed with HIV/AIDS incurs a
neddlestick injury when administering the patient's medications.
What would be the first action of the nurse following the exposure?
a. report the incident to the appropriate person and file an incident
report
b. wash the exposed area with warm water and soap
c. consent to PEP at appropriate time
d. Set up counseling sessions regarding safe practice to protect self
, Give this one a try later!
b d
c a
Don't know?
5 of 48
Term
The nurse records a patient's blood pressure as 148/100. What is the
priority action of the nurse when determining the significance of this
reading?
a. Compare this reading to standards
b. check the taxonomy of nursing diagnoses for a pertinent label.
c. Check a medical text for the signs and symptoms of high blood
pressure
d. Consult with colleagues
Give this one a try later!
b c
d a
Don't know?
6 of 48
Term
When the initial nursing assessment revealed that a patient had not
had a bowel movement for 2 days, the student nurse wrote the
diagnostic label "constipation." What would be the instructor's BEST
response to this student's diagnosis?
a. "Was this diagnosis derived from a cluster of significant data or a
single clue?"
b. "This early diagnosis will help us manage the problem before it
becomes more acute."
c. "Have you determined if this is an actual or a possible diagnosis?"
d. "This condition is a medical problem that should not have a
nursing diagnosis."
Give this one a try later!
a b
, c d
Don't know?
2 of 48
Term
The nurse assesses patients to determine their risk for HAIs. Which
hospitalized patient would the nurse consider most at risk for
developing this type of infection?
a. A 60-year-old patient who smokes two packs of cigarettes daily
b. A 40-year-old patient who has a white blood cell count of
6,000/mm
c. A 65-yeat-old patient who has an indwelling urinary catheter in
place
d. A 60-year-old patient who is a vegetarian and slightly
underweight
Give this one a try later!
a b
c d
Don't know?
3 of 48
Term
,The nurse is surprised to detect an elevated temperature (102°F) in a
patient scheduled for surgery. The patient has been afebrile and
shows no other signs of being febrile. What is the priority nursing
action?
a. Inform the charge nurse.
b. Inform the surgeon.
c. Validate the finding.
d. Document the finding.
Give this one a try later!
d c
a b
Don't know?
4 of 48
Term
A nurse who is caring for a patient diagnosed with HIV/AIDS incurs a
neddlestick injury when administering the patient's medications.
What would be the first action of the nurse following the exposure?
a. report the incident to the appropriate person and file an incident
report
b. wash the exposed area with warm water and soap
c. consent to PEP at appropriate time
d. Set up counseling sessions regarding safe practice to protect self
, Give this one a try later!
b d
c a
Don't know?
5 of 48
Term
The nurse records a patient's blood pressure as 148/100. What is the
priority action of the nurse when determining the significance of this
reading?
a. Compare this reading to standards
b. check the taxonomy of nursing diagnoses for a pertinent label.
c. Check a medical text for the signs and symptoms of high blood
pressure
d. Consult with colleagues
Give this one a try later!
b c
d a
Don't know?
6 of 48
