The nurse in charge identifies a patient's responses to actual or potential health
problems during which step of the nursing process?
A. Assessing
B. Diagnosing
C. Planning
D. Evaluating
Answer: B
Rationale- The nurse identifies human responses to actual or potential health problems
during the nursing diagnoses step of the nursing process. During the assessment step,
the nurse collects data. During the planning step, the nurse develops strategies to
resolve or decrease the patient's problem. During evaluation, the nurse determines the
effectiveness of the plan of care.
A female patient is diagnosed with deep-vein thrombosis. Which nursing diagnosis
should receive the highest priority at this time?
A. Impaired gas exchange related to increased blood flow
B. Fluid volume excess related to peripheral vascular disease
C. Risk for injury related to edema
D. Altered peripheral tissue perfusion related to venous congestion
Answer: D
Rationale: This answer takes highest priority because venous inflammation and clot
formation impede blood flow in a patient with deep-vein thrombosis.
Option A is incorrect because impaired gas exchange is related to decreased, not
increased, blood flow. Option B is inappropriate because no evidence suggests that this
patient has a fluid volume excess. Option C may be warranted but is secondary to
altered tissue perfusion.
A nurse is revising a client's care plan. During which step of the nursing process does
such a revision take place?
A. Assessment
B. Planning
C. Implementation
D. Evaluation
Answer: D
Rationale: During the evaluation step of the nursing process the nurse determines
whether the goals established have been achieved, and evaluates the success of the
problems during which step of the nursing process?
A. Assessing
B. Diagnosing
C. Planning
D. Evaluating
Answer: B
Rationale- The nurse identifies human responses to actual or potential health problems
during the nursing diagnoses step of the nursing process. During the assessment step,
the nurse collects data. During the planning step, the nurse develops strategies to
resolve or decrease the patient's problem. During evaluation, the nurse determines the
effectiveness of the plan of care.
A female patient is diagnosed with deep-vein thrombosis. Which nursing diagnosis
should receive the highest priority at this time?
A. Impaired gas exchange related to increased blood flow
B. Fluid volume excess related to peripheral vascular disease
C. Risk for injury related to edema
D. Altered peripheral tissue perfusion related to venous congestion
Answer: D
Rationale: This answer takes highest priority because venous inflammation and clot
formation impede blood flow in a patient with deep-vein thrombosis.
Option A is incorrect because impaired gas exchange is related to decreased, not
increased, blood flow. Option B is inappropriate because no evidence suggests that this
patient has a fluid volume excess. Option C may be warranted but is secondary to
altered tissue perfusion.
A nurse is revising a client's care plan. During which step of the nursing process does
such a revision take place?
A. Assessment
B. Planning
C. Implementation
D. Evaluation
Answer: D
Rationale: During the evaluation step of the nursing process the nurse determines
whether the goals established have been achieved, and evaluates the success of the
