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The Nursing Process Quiz

I. Choose the best answer from the letter choices succeeding each numbered item.

Ms. Cabacungan complains of pain in her chest, difficulty of breathing and cough. The
nurse would be correct if she documents these data as :

Objective data c. Subjective data


Observable data d. General information

Which of the following assessment findings would be documented as objective data?

Leg pain and calf tenderness c. Dizziness and headache in PM


Redness and swelling on arm d. Weakness and nausea

A nurse is performing a physical assessment, which of the following would indicate a


problem?

Clear bilateral lung sounds 4. Apical heart rate – 112 bpm


Jaundice 5. Afebrile
Erythema of lower extremities 6. Cyanosis on fingers

7. Respiratory rate – 19 breaths/min

1,3,4 and 5 c. 3,4,5,2 and 1


2,3,4 and 6 d. 3,2,4,6 and 1

4. The nurse is organizing the assessment data elicited from her patient and groups
related
information together. The nurse is doing what phase of the Nursing process?

a. Evaluation c. Outcome identification


b. Assessment d. Implementation

5. Which of the following is not an activity of the nurse during evaluation?

a. Measuring goal attainment c. Collection of data


b. Revising the care plan d. Performing Nursing orders

6. Which of the following is Incorrect regarding the establishment of priorities in


patient?

a. Airway should always be given Highest priority


b. Clients with unstable condition should be given priority over those who are
stable
c. Attend to equipment and apparatus like IV fluids, IFCs and drainage tubes first
d. Actual problems take precedence over potential problems

7. Bella Flores has just undergone surgery on her right lower leg. During the night, she
required an analgesic to help her sleep. She doesn’t have appetite to eat but is able
to take in liquids without nausea. Which of the following nursing diagnosis should be
given highest priority?

a. Impaired tissue perfusion: peripheral


b. Imbalanced nutrition: Less than body requirement
c. Pain
d. Impaired physical mobility

8. A patient is being positioned by the nurse because of complaints of difficulty of


breathing.
The action of the nurse indicates what phase of the nursing process?

a. Implementation c. Assessment
b. Evaluation d. Outcome Identification

9. The first component of a nursing diagnosis statement consists of :

a. Etiology c. Problem
b. Signs and symptoms d. Related factors

10. In the Nursing diagnosis “Impaired physical mobility related to joint stiffness as
evidenced by limited range of motion and difficulty turning”, the etiology of the
problem
is:

a. Limited range of motion c. physical mobility


b. Joint stiffness d. Difficulty turning

11. Which of the following is included in a client’s plan of care?

a. Doctor’s orders, demographic data, medication administration and rationales


b. Client’s assessment data, medical treatments with rationales, diagnostic results
and
significance
c. Collected documentation of all team members providing care for the client
d. Client’s nursing diagnosis, goals, expected outcomes and nursing interventions

12. When establishing priorities for a client’s plan of care, the nurse should rank which
of the
following as the lowest priority?

a. Client’s needs regarding referrals


b. Safety-related needs
c. Needs of family members involved in the plan of care
d. Client’s social, love and belongingness needs

13. Which of the following are the essential components for outcome identification?

a. Target date, nursing action, measurement criteria and desired client behavior
b. Client behavior, measurement criteria, conditions under which the behavior
occurs
and target date
c. Client behavior, target date and conditions under which the behavior occurs
d. Target date, nursing action, measurement criteria and desired client behavior

14. As an intervention for controlling pain of a postoperative client, a nurse administers


analgesic. This activity of the nurse is an example of a/an:

a. independent nursing action c. collaborative nursing action


b. dependent nursing action d. legal nursing action

15. As a nurse taking the next shift, which of the following patient conditions should
the you
prioritize?

a. A 29 y/o post operative patient complaining of thirst


b. A 17 y/o patient with left arm fracture secondary to mauling complaining of
severe
QApain
c. A 58 y/o post stroke victim with left-sided paralysis with bluish discoloration of
nails
d. A neonate with respiratory rate of 32 breaths per minute

16. Which of the following nursing diagnoses should be dealt with immediately?

a. High risk for infection c. Impaired physical mobility


b. Anxiety/ fear d. High risk for fluid volume deficit

17. On assessment, the nurse obtains the following findings : BP-130/90 mmHg; PR-
108bpm; RR-20; T- 37.4 C; with complaints DOB, headache, diziness and
o

expressed
worries about her 17 y/o son left at home. Which of the possible problems
would be of
least priority?

a. BP- 130/90 c. Difficulty of breathing


b. Worries on her son d. headache and dizziness

18. Using the P-E-R-S-O-N-S format in data clustering, where would you include the
assessment finding “non-pitting edema at Right forearm site of previous IV”?
a. Elimination c. Safety and security
b. Nutrition d. Oxygenation

19. Which of the following patients should be prioritized according to Maslow’s Theory?

a. Angelina, a post appendectomy patient who is complaining of pain


b. Yaya, such a loser, with Alzheimer’s who will be institutionalized
c. Ogie, a diabetic patient who awaits instructions for self-injection
d. Bitoy, a newly admitted patient, anxious about his scheduled endoscopy

20. In the diagnostic statement “Fluid volume excess r/t decreased venous return as
manifested by edema on lower extremity”, the etiology of the problem is:

a. Edema c. Excess fluid volume


b. Decreased venous return d. Impaired circulation

21. Nursing diagnoses must meet specific criteria to reflect both the client's problem
and the
possible etiology involved. 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 cardiac monitor
d. Bedpan required frequently as a result of altered elimination pattern

22. After visiting with the client the nurse documents the assessment data. Both
objective and
subjective information has been obtained during the assessment. 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. 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?

a. Method
b. Quantity
c. Frequency
d. Qualifications of the person who will perform the task
24. Nursing diagnoses meet specific criteria so they accurately reflect both the client's
problem
and the possible etiology involved. 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 need for cardiac catherization
d. Need for high protein diet related to alteration in nutrition

25. 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

II. Identify whether the following are Subjective or Objective data.

1. Skin with blemishes


2. Dizziness
3. PR-110bpm
4. Complaints of boredom
5. Feels rested upon awakening
6. Muscle tone
7. Last menstrual period
8. Cyanosis
9. Foul smelling breath
10. Tingling sensation and numbness
11. Dirty finger nails
12. Temp-38.1oC
13. Stomachache
14. Profuse sweating(diaphoresis)
15. Rashes