Chapter 3 Quiz

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Question #1

The nurse assesses a radial pulse rate of 48 beats per minute (bpm). Using critical thinking, what will be the best action for the nurse to take?

A Call the health care provider to get orders.

B Check the client’s previous pulse rates to validate the findings.

C Ask a fellow nurse to double-check your pulse rate assessment.

D Assess blood pressure with the client lying supine.

Question #2

The nurse is developing a care plan. At which step of the nursing process will the nurse order the primary interventions to achieve a goal?

A planning

B collaborative problems

C nursing assessment

D evaluation

Question #3

Which therapeutic communication technique may occur during the planning stage, when the client is presented with alternative ideas for consideration relative to problem solving?

A Suggesting

B Reflection

C Focusing

D Clarification

Question #4

The licensed practical nurse is caring for a client who has been admitted to the unit with a possible head injury caused by a motor vehicle accident. The LPN would contact the RN before implementing which nursing intervention?

A Encourage the client to turn, deep breathe, and cough every 2 hours.

B Check all nasal drainage for glucose.

C Limit visitors and encourage a quiet environment.

D Keep the head of the bed elevated 30°.

Question #5

The registered nurse (RN) is responsible for delegating patient care responsibilities to licensed practical nurses (LPNs) as well as ancillary personnel. What would be the most appropriate task to delegate to a nursing assistant?

A Assessing the degree of lower leg edema in a patient on bed rest

B Obtaining vital signs for a patient that has been hospitalized for 3 days

C Recording the size and appearance of a decubitus ulcer

D Measuring the circumference of a patient’s calf for edema

Question #6

A Assessing the degree of lower leg edema in a patient on bed rest

B Recording the size and appearance of a decubitus ulcer

C Measuring the circumference of a patient’s calf for edema

D Obtaining vital signs for a patient that has been hospitalized for 3 days

Question #7

Which set of nursing actions demonstrates that the nurse understands the nursing process?

A Reviewing the health record, documenting client goals, identifying the etiology of the nursing problem, and evaluating treatment outcomes

B Obtaining vital signs and pain scale rating,,documenting the nursing diagnosis as acute pain, administering analgesic, and evaluating comfort level

C Assessing for allergies, administering analgesic, obtaining baseline vital signs, and documenting the nursing diagnosis as acute pain

D Prioritizing client goals, documenting all health records precisely, conducting the health history, and documenting the nursing diagnosis

Question #8

Healthcare providers use a problem-solving approach for ethical dilemmas. Which is the last step of the ethical decision-making model?

A Survey other healthcare professionals to see if they agree with the decision.

B Evaluate the decision in terms of effects and results.

C Keep detailed documentation of the entire decision-making process.

D Follow through on the decision that has been made

Question #9

A client has just returned to the unit following abdominal surgery and is in significant pain. According to the nursing process, how frequently will the nurse perform assessments on this client?

A twice per shift

B as often as needed

C once upon arrival and 1hour later

D once upon arrival and every 2 hours afterward

Question #10

A client is to be discharged from an acute care facility after treatment for pneumonia. The nurse notes that the client’s lungs are clear and denies shortness of breath. The nurse’s actions reflect which step of the nursing process?

A Evaluation

B Assessment

C Analysis

D Data collection

Question #11

While caring for a client with a deep vein thrombosis of the leg, the nurse monitors for collaborative problems. Which action will the nurse implement while treating collaborative problems for this client?

A Assess the respiratory status every 4 hours.

B Order a heparin bolus.

C Consider discharge placement.

D Monitor intake and output every 4 hours.

Question #12

Based on the nurse’s knowledge of the increased risk for bleeding in a client undergoing chemotherapy or radiation, which of the following interventions does the nurse need to include in the client’s plan of care? Select all that apply.,,,,

A Instructing the client to use a soft toothbrush

B Increasing the patient’s injections for pain control

C Monitoring the platelet count

D Monitoring for signs of abnormal bleeding

E Instructing the client to add low-dose aspirin to daily medication regimen

Question #13

A client has been diagnosed with cardiac dysfunction and admitted to a health care center. The nurse notices that the client’s ankles and feet are swollen. Using critical thinking skills, which nursing intervention does the nurse know to perform next?,,

A Weigh client daily at the same time

B Instructing the client to use an electric razor

C Assess oxygen saturation level

D Organize activities to provide frequent rest periods

E Assess client for dependent edema

Question #14

A client has designated her daughter as a person to make healthcare decisions for the client if he is not able to do so. What type of advance directive is this considered?

A Durable power of attorney (DPOA) for healthcare

B Living will

C Power of attorney

D Do-not-resuscitate order (DNR)

Question #15

Several times, family members have asked a nurse to share personal prescriptions when they were in need of pain medication or antibiotics. Which type of rules or standards should govern the nurse’s moral decision?

A civil law

B administrative law

C ethics

D common law

Question #16

The physician has ordered cimetidine for a client with gastric ulcers, and the nurse administers the first dose. The nurse’s actions are noted in the medical record. This notation is an example of which aspect of implementing the plan of care?

A monitoring

B intervention

C documentation

D assessment

Question #17

How is assessment defined as part of the nursing process?

A careful observation and evaluation of a client’s health status

B identification and definition of the client’s health problem(s)

C carrying out the steps in the written plan of care

D step-by-step planning of client care

Question #18

A client presents to the acute care facility with several signs and symptoms. How will the nurse determine and prioritize the client’s healthcare needs?

A contacting the physician before performing any tasks

B reading the client’s records and doing research on the client’s conditions before deciding on a course of action

C consulting with other nurses to determine the first step of care

D using a systematic method to plan and implement care to reach desired outcomes

Question #19

Which of the following is a cognitive or mental activity that nurses use in critical thinking?

A Drawing on past clinical experiences and knowledge to explain what is happening

B Setting priorities with broad time constraints

C Using bias to achieve goals

D Determining nurse-specific outcomes

Question #20

The nurse has developed a plan of care for a client who is having a surgical procedure and is at risk for the development of pneumonia. The nurse devises the outcome statement to read: “The client will have clear lungs by the third postoperative day. ” On the third postoperative day, the client has left lower lobe crackles and infiltrates on the chest x-ray. What conclusion does the nurse reach for this client?

A The outcome is not met, but progress is being made, and the plan of care is continued .

B The outcome is achieved, the problem is solved, and the nursing orders are discontinued.

C The outcome will be reassessed in 2 more days.

D The outcome is not achieved, and the plan requires critical reevaluation and revision.

Question #21

Which of the following is a true statement about critical thinking according to Alfaro-LeFevre (2010)?

A It is guided by professional standards and codes of ethics.

B It makes judgments based on conjecture.

C It considers only the client’s needs.

D It is based on the medical model.

Question #22

Several days this week, a nurse takes time after work to read to a visually impaired client who has no family close by. This behavior demonstrates that ethical values:

A are well thought out.

B concern the treatment of others.

C take priority over other values.

D are consistent.

Question #23

A client has been a resident of a long-term care facility for several years. The client’s condition has deteriorated to the point that the client is now unable to eat. The physician has recommended surgical implantation of a feeding tube. The client’s family has a legal document outlining the client’s wishes in regard to measures such as this. What is this document?

A consent form

B advance directive

C do-not-resuscitate order

D durable power of attorney

Question #24

A client reports postoperative pain near the incision site on his abdomen. He describes the pain as constantly burning and rates it at an 8/10 using the pain scale. The nurse administers morphine sulfate 2 mg IVP as ordered. Ten minutes later the nurse documents that the client now rates his pain at a 3/10 using the pain scale. The nurse’s documentation is an example of which part of the nursing process?

A Data collection

B Analysis

C Assessment

D Evaluation

Question #25

A client, 50 years old, is admitted for treatment of a gastric tumor. The client asks the nurse, “Do you think I have cancer?” Which response by the nurse would be most therapeutic?

A “You sound concerned about what the physicians will tell you.”

B “Your physician can tell you more about it.”

C “Most women your age have some kind of cancer.”

D “We don’t know for sure until you undergo more tests.”

Question #26

The nurse and patient establish a goal to stand at the bedside for 5 minutes prior to the end of her shift at 2300. Earlier that day the patient had a total knee replacement. This is an example of which type of goal?

A Independent goal

B Intermediate goal

C Long-term goal

D Immediate goal

Question #27

Which communication technique is helpful in health teaching about relevant aspects of a client’s well-being and self-care?

A Humor

B Informing

C Silence

D Reflection

Question #28

A client has been admitted to the hospital with a large sacral pressure ulcer. The physician orders the wound care protocol to be performed twice a day. What would be a statement on the plan of care that would address the implementation phase of the nursing process for this client?

A A 6 cm x 4 cm wound with malodorous, yellow exudate

B The client’s wound has healed by 0.5 cm on day 3 of wound care.

C The client’s wound will heal by 1 cm by the end of 5 days.

D Turn the client every 2 hours.

Question #29

A Data collection

B Assessment

C Analysis

D Evaluation

Question #30

Patient health education provided by the nurse

A must focus on wellness issues.

B must be approved by the physician.

C is an independent function of nursing practice.

D requires a physician’s order.

Question #31

The nurse is preparing a client for a colonoscopy at the hospital. Who does the nurse understand is responsible for obtaining the informed consent from this client?

A The healt care provider’s office nurse

B The health care provider

C The nurse manager

D The nurse

Question #32

Assessment, the first of five steps in the nursing process, begins with initial patient contact. What activities by the nurse are included in this component of the nursing process? (Select all that apply.),,

A Collecting and analyzing data

B Interviewing and obtaining a nursing history

C Observing for altered symptomatology

D Developing outcome criteria

E Evaluation of the patient’s response to a medication

Question #33

Which situation would require the nurse to use critical thinking and decision-making skills in providing genetics-related nursing care?

A Providing education related to growth and development to a blended family with children of different ages

B Providing education related to lead poisoning to a single parent of a 4-year-old child

C Providing family counseling to a same-sex couple that just adopted a 5-year-old with attention deficit hyperactivity disorder (ADHD)

D Providing fertility counseling to a young family with a 2-year-old child with cystic fibrosis

Question #34

The nurse is administering a medication to a client for the treatment of his constipation. The client states that he prefers not to take the medication today. The nurse respects the client’s right and informs him if he needs it later, just let the nurse know. What professional value is the nurse displaying?

A Beneficence

B Autonomy

C Fidelity

D Nonmaleficence

Question #35

The nurse is to administer a potassium supplement to the client. The nurse does not check the potassium level prior to administering the medication and later finds that the potassium level was at a critical high. What principle has this nurse violated?

A Autonomy

B Fidelity

C Beneficence

D Nonmaleficence

Question #36

The RN develops an outcome standard of “client will ambulate with an assistive device 60 feet with assistance twice a day” for a client who had a hip replacement. What part of the nursing process is involved with this outcome statement?

A Assessment

B Implementation

C Evaluation

D Planning

Question #37

A Evaluation

B Assessment

C Analysis

D Data collection

Question #38

A client has a nursing diagnosis of “Feeding self-care deficit related to right-sided weakness. Which of the following would be the most appropriate expected outcome for this client?

A The client will demonstrate an ability to feed himself with a spoon at the morning meal.

B The client will not lose any weight throughout the hospital stay.

C The client will demonstrate an interest in eating during the evening snack.

D The client will have a staff member open all packages prior to all meals.

Question #39

Which critical thinking skill involves identification of client problems indicated by data?

A Inference

B Interpretation

C Analysis

D Explanation

Question #40

Healthcare providers use a problem-solving approach for ethical dilemmas. Which is the last step of the ethical decision-making model?

A Evaluate the decision in terms of effects and results.

B Survey other healthcare professionals to see if they agree with the decision.

C Follow through on the decision that has been made.

D Keep detailed documentation of the entire decision-making process.

Question #41

An ER nurse must quickly assess two clients who were in a car accident and determine whose needs take priority. In this situation, critical thinking allows the nurse to:

A delegate tasks to other ER staff, thereby freeing up more time to care for clients presenting with true emergencies.

B minimize the time spent with each client, so the overall operations of the ER will be more efficient.

C consider all factors, interpret the information, and make decisions relevant to each client’s care.

D communicate each client’s status more efficiently to the attending physician.

Question #42

A longterm care facility’s newest client refuses to attend group activities or social events offered by the facility. Which level of Maslow’s hierarchy do social events address?

A third: love and belonging needs

B fourth: esteem and self-esteem needs

C fifth: self-actualization needs

D second: safety and security needs

Question #43

A client with newly diagnosed diabetes requests information about how to give an injection. What is the best communication technique the nurse can use with the client?

A reflecting the client’s feelings about his question

B demonstrating the proper injection technique

C providing a URL for a website that demonstrates proper injection technique

D informing about the proper injection technique

Question #44

Analyzing information for patterns, maintaining a flexible attitude, and making decisions reflecting creativity are all what type of components necessary for nurses?

A Critical thinking

B Rationalism

C Utilitarianism

D Moral thinking

Question #45

The nurse is caring for a group of clients. What priority nursing intervention illustrates planned nursing care prioritized according to Maslow’s hierarchy of needs?

A Discourage a terminally ill client from participating in a plan of care, to minimize fears about death.

B Help a client walk to the shower because the shower area is vacant at this time.

C Administer pain medication to a client before transportation to physical therapy for crutch-walking exercises.

D Interrupt a family’s visit with client with depression to assess blood pressure measurement.

Question #46

What statement does the nurse determine is a medical diagnosis rather than a nursing diagnosis?

A Sleep-pattern disturbances

B Risk for falls

C Fever of unknown origin

D Fluid volume excess

Question #47

The nurse prepares to administer medication to the patient. The patient states, “I would prefer not to take that medication until I speak with my physician.” The nurse honors the patient’s desire to make decisions, following which common ethical principle?

A Fidelity

B Beneficence

C Autonomy

D Paternalism

Question #48

The nurse is attending a client with chronic renal failure. The client is experiencing a loss of appetite and reports feeling like everyday situations have become more stressful. The client reports feeling disappointed and frustrated with the condition, and says the family is not getting any help. What is the most important nursing intervention that the nurse needs to carry out at this point?

A administer immunosuppressant

B schedule a family meeting

C coordinate with resources for client support

D offer nutritional counseling

Question #49

Which term is defined as a formal systematic study of moral beliefs?

A Ethics

B Fidelity

C Morality

D Veracity

Question #50

A client jumped out of a window on the second floor of the hospital and sustained a spinal cord injury that resulted in the inability to have upper and lower extremity sensation. What type of documentation by the nurse would be appropriate in this situation?

A “Client observed standing on the window ledge; asked client to come down and proceeded to enter the room, and client jumped through the glass.”

B “The client must have been depressed and wanted to commit suicide.”

C “I saw the client get ready to jump and was unable to get to him fast enough.”

D “The previous shift should have notified the physician that the client was suicidal.”

Question #51

A client has designated her daughter as a person to make healthcare decisions for the client if he is not able to do so. What type of advance directive is this considered?

A Do-not-resuscitate order (DNR)

B Living will

C Durable power of attorney (DPOA) for healthcare

D Power of attorney

Question #52

Which of the following is the highest level of human need according to Maslow (1968)?

A Self-actualization

B Love and belonging

C Esteem and self-esteem

D Physiologic

Question #53

Which type of nursing diagnosis identifies an existing condition that the client is experiencing?

A health promotion

B syndrome

C risk

D problem-focused

Question #54

The use of patient restraints limits which ethical principle?

A Autonomy

B Beneficence

C Trust

D Justice

Question #55

Developing a written plan of nursing care takes place during which step of the nursing process?

A Planning

B Implementation

C Diagnosis

D Assessment

Question #56

Which element is involved in the planning phase of the nursing process?

A Identify measurable outcomes

B Complete health history

C Identify collaborative problems

D Carry out the nursing orders

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