Updated: Mar 27
What is the Nursing Process?
The nursing process is a scientific approach that nurses employ to guarantee that patient care is of high quality. This strategy is split down into five distinct phases. Learn more about the nursing process here.
How well do you understand the Nursing Process?
Use this nurse test bank to test your knowledge. This quiz contains 30 questions with answers and rationales at the end. Good luck!
1. The nurse in charge identifies a patient's responses to actual or potential health problems during which step of the nursing process?
2. 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
3. A nurse is revising a client's care plan. During which step of the nursing process does such a revision take place?
4. Which intervention should the nurse in charge try first for a client that exhibits signs of sleep disturbance?
A. Administer sleeping medication before bedtime
B. Ask the client each morning to describe the quantity of sleep the night before
C. Teach the client relaxation techniques, such as guided imagery and progressive muscle relaxation
D. Provide the client normal sleep aids, such as pillows, back rubs, and snacks
5. A nurse is assigned to care for a postoperative male client who has diabetes mellitus. During the assessment interview, the client reports that he's impotent and says he's concerned about the effect on his marriage. In planning this client's care, the most appropriate intervention would be to:
A. Encourage the client to ask questions about personal sexuality
B. Provide time for privacy
C. Suggest referral to a sex counselor or other appropriate professional
D. Provide support for the spouse
6. Using Maslow's hierarchy of needs, a nurse assigns the highest priority to which client needs?
7. A female client who received general anesthesia returns from surgery. Postoperatively, which nursing diagnosis takes the highest priority for this client?
A. Risk for aspiration R/T anesthesia
B. Deficient fluid volume R/T blood and fluid loss from surgery
C. Impaired physical mobility R/T surgery
D. Acute pain R/T surgery
8. A male client is admitted to the hospital with blunt chest trauma after a motor vehicle accident. The first nursing priority for this client would be to:
A. Assess the client's airway
B. Provide pain relief
C. Encourage deep breathing and coughing
D. Splint the chest wall with a pillow
9. When two nursing diagnoses appear closely related, what should the nurse do first to determine which diagnosis most accurately reflects the needs of a patient?
A. Reassess the patient
B. Examine the related factors
C. Review the defining characteristics,
D. Analyze the secondary factors
10. The nurse performs an assessment of a newly admitted patient. The nurse understands that this admission assessment is conducted primarily to:
A. Diagnose if the patient is at risk for falls.
B. Identify important data
C. Establish a therapeutic relationship
D. Ensure that the patient's skin is intact
11. The guidelines for writing an appropriate nursing diagnosis include all of the following except:
A. State the diagnosis in terms of a problem, not a need
B. Use nursing terminology to describe the patient's response
C. Use statements that assist in planning independent nursing interventions
D. Use medical terminology to describe the probable cause of the patient's response
12. Independent nursing interventions commonly used for immobilized patients include all of the following except:
A. Active or passive ROM exercises, body repositioning, and ADLs as tolerated
B. Deep-breathing and coughing exercises with the change of position every 2 hours
C. Diaphragmatic and abdominal breathing exercises
D. Weight-bearing on a tilt table, total parenteral nutrition, and vitamin therapy
13. Independent nursing interventions commonly used for patients with pressure ulcers include:
A. changing the patient's position regularly to minimize pressure
B. Applying a drying agent such as an antacid to decrease moisture at the ulcer site
C. Debriding the ulcer to remove necrotic tissue, which can impede healing
D. Placing the patient in a whirlpool bath containing povidone-iodine solution as tolerated
14. While the nurse is providing the patient with personal hygiene, she observes that his skin is excessively dry. During the procedure, he tells her that he is very thirsty. An appropriate nursing diagnosis would be:
A. Potential for impaired skin integrity R/T altered gland function
B. Potential for impaired skin integrity R/T dehydration
C. Impaired skin integrity R/T dehydration
D. Impaired skin integrity R/T altered circulation
15. The most important nursing intervention to correct skin dryness is:
A. avoid bathing until the condition is remedied and notify the physician
B. ask the physician to refer the patient to a dermatologist
C. Consult the dietitian about increasing fat intake, and taking necessary measures to prevent infection
D. encourage the patient to increase fluid intake, use nonirritating soap, and apply lotion to involved areas
16. Which of the following is an appropriately written nursing diagnosis?
A. Pain related to insufficient use of medication
B. Pain related to difficulty ambulating
C. Anxiety related to the cardiac monitor
D. Bedpan required frequently as a result of altered elimination pattern
17. Accountability is a critical aspect of nursing care. An example of accountability is demonstrated by:
A. Selecting the medication schedule for the client
B. Implementing discharge teaching plans that meet individual needs
C. Evaluating the client's outcomes after implementation of care
D. Promoting participation of all staff members in unit meetings
18. The nurse is working with a client who is being prepared for a diagnostic test this afternoon. The client tells the nurse she wants to have her hair shampooed. How would the nurse prioritize this client's need?
A. Immediate priority
B. Low priority
C. Intermediate priority
D. High priority
19. Nursing interventions should be documented according to specific criteria so they are clearly understood by other members of the nursing team. The most appropriate of the following intervention statements is:
A. Offer fluids to the client q 2 hours
B. Observe the client's respirations
C. Change the client's dressing daily
D. Irrigate the nasogastric tube q 2 hours with 30 mL normal saline
20. A nurse who specializes in the care of clients with ostomies shows a client's significant other how to assist with the manipulation of ostomy equipment. The nurse demonstrating the technique to the client is using what type of nursing skill?
21. During an interview, the nurse needs to obtain specific information about the signs and symptoms of a health problem. To obtain these data most efficiently, the nurse should use:
A. Active listening
B. Open-ended questions
C. Closed-ended questions
D. Seeking clarification
22. Which of the following is classified as subjective data?
A. Client appears sleepy
B. No distress noted
C. Abdomen soft and non-tender
D. States feels anxious and tense
23. The nurse uses a variety of skills in the application of the nursing process. An example of a cognitive nursing skill is:
A. Providing a soothing bed bath
B. Communicating with the client and family
C. Giving an injection to the client per physician's orders
D. Recognizing the potential complications of a blood transfusion
24. Which of the following is an appropriate etiology for a nursing diagnosis?
A. Incisional pain
B. Poor hygienic practices
C. Needs bedpan frequently
D. Inadequate prescription of medication by the physician
25. Nursing interventions should be documented according to specific criteria so they are clearly understood by other members of the nursing team. The intervention statement "Nurse will apply warm, wet soaks to the client's leg while the client is awake" lacks which of the following components?
D. Qualifications of the person who will perform the task
26. Of the following statements, which one is an example of an appropriately written nursing diagnosis?
A. Acute pain related to left mastectomy
B. Impaired gas exchange related to altered blood gases
C. Deficient knowledge related to the need for cardiac catheterization
D. Need for high protein diet related to alteration in nutrition
27. The nurse notes a narcotic is to be administered per epidural cath. The nurse, however, does not know how to perform this procedure. Which aspects of the implementation process should be followed?
A. Seek assistance
B. Reassess the client
C. Use interpersonal skills
D. Critical decision making
28. A client comes to the walk-in clinic with reports of abdominal pain and diarrhea. While taking the client's vital signs, the nurse is implementing which phase of the nursing process?
29. The nurse is measuring the client's urine output and straining the urine to assess for stones. Which of the following should the nurse record as objective data?
A. The client reports abdominal pain
B. The client's urine output was 450 mL
C. The client states, "I didn't see any stones in my urine."
D. The client states, "I feel like I have passed a stone."
30. When evaluating an elderly client's blood pressure (BP) of 146/78 mmHg, the nurse does which of the following before determining whether the BP is normal or represents hypertension?
A. Compare this reading against defined standards
B. Compare the reading with one taken in the opposite arm
C. Determine gaps in the vital signs in the client record
D. Compare the current measurement with previous ones
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 an evaluation, the nurse determines the effectiveness of the plan of care.
This answer takes the highest priority because venous inflammation and clot formation impede blood flow in a patient with deep-vein thrombosis.
During the evaluation step of the nursing process, the nurse determines whether the goals established have been achieved, and evaluates the success of the plan. Answer A involves data collection. Answer B involves setting priorities, and Answer C is the actual intervention.
You should begin with the simplest interventions. Answer A is incorrect because medications should be avoided whenever possible. Answer B would be a thorough sleep assessment and should be done only after common-sense interventions fail. Answer C would be appropriate only after common-sense interventions fail.
Making appropriate referrals is a valid part of planning the client's care. The nurse normally does not provide sex counseling. While providing time for privacy and providing support for the spouse is important, it is not as important as referring the client to a sex counselor/appropriate professional.
6. A According to Maslow, elimination is a first-level or physiological need. Security and safety are second-level needs, and belonging is a third-level need.
Risk for aspiration takes priority because general anesthesia may impair gag and swallow reflexes. The other options, although important, are secondary to this.
The first priority is to evaluate airway patency. Pain management and splinting are important for client comfort but come after an airway assessment. Coughing and deep breathing may be contraindicated if the client has internal bleeding and other injuries.
The first thing a nurse should do to differentiate is to compare the data collected to the major and minor defining characteristics of each of the nursing diagnoses being considered.
This is the primary purpose of a nursing admission assessment.
A nursing diagnosis is a statement about a patient's actual or potential health problem that is within the scope of independent nursing intervention. Medical terminology is never part of the nursing diagnosis.
A, B, & C are incorrect. These are not independent nursing interventions because they require a physician's order.
Independent nursing interventions for a patient with pressure ulcers commonly include changing positions. B, C, & D all require a physician's order. Additionally, a drying agent, answer B would be contraindicated because the wound needs moisture to heal.
The appropriate diagnosis for a patient with excessively dry skin is impaired skin integrity - actual not potential. R/T dehydration is appropriate because the patient complained of thirst.
Preventative measures, such as these, will prevent the skin from cracking, which would make the client more prone to infection. The other 3 answers are options, however NOT the best choice for this particular situation.
This is an example of an appropriately written nursing diagnosis. It consists of a diagnostic label and the associated etiology. Nursing interventions can be directed at treating or managing the behavior of insufficient medication use. note: for purposes of this example there are no signs and symptoms listed. In an actual diagnosis, the S/S would need to be listed as well.
Accountability refers to individuals being answerable for their actions. It involves follow-up and a reflective analysis of one's decisions to evaluate their effectiveness.
The client's request would be of low priority because it is not directly related to a specific illness or prognosis.
This is the most appropriate intervention statement. It includes the action, frequency, quantity, and method.
Psychomotor skills involve the integration of cognitive and motor activities, such as in providing ostomy care.
Using closed-ended questions helps the nurse to acquire specific information about health problems such as symptoms, precipitating factors, or relief measures in an efficient manner.
Subjective data are clients' perceptions about their health problems. Feeling anxious and tense is information that only the client can provide.
Cognitive skills involve the application of nursing knowledge. Understanding normal and abnormal physiological and psychological responses is a cognitive skill, as in recognizing the potential complications of a blood transfusion.
Incisional pain is an appropriate etiology for a nursing diagnosis. It is a condition that identifies the cause of a client's response to a health problem that a nurse can treat or manage.
The intervention statement does not include how frequently the warm soaks should be applied.
This nursing diagnosis is written correctly. It defines a problem and its possible cause; in this case, the problem is the client's response to a diagnostic test.
If a nurse does not know how to perform a procedure, he or she should seek assistance. Information about the procedure is obtained from the literature and the agency's procedure book. All equipment necessary for the procedure is collected. Finally, another nurse who has completed the procedure correctly and safely provides assistance and guidance.
The first step in the nursing process is assessment, the process of collecting data. All subsequent phases of the nursing process (options 2, 3, and 4) rely on accurate and complete data.
Objective data is measurable data that can be seen, heard, or verified by the nurse. The objective data is the measurement of the urine output. A client's statements and reports of symptoms are documented as subjective data, such as the data found in options 1, 3, and 4.
Analysis of the client's BP requires knowledge of the normal BP range for an older adult. The nurse compares the client's data against identified standards to determine whether this reading is normal or abnormal. Measuring the BP in the other arm (option 2) and comparing the reading to previous ones (option 4) will give additional client data, but the comparison alone will not determine whether the BP is normal. Gaps in the record (option 3) will not aid in interpreting the current measurement.
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