Test Bank For Success in Practical Vocational Nursing From Student To Leader 6th Edition Hill Full Download

Test Bank for Success in Practical Vocational Nursing From Student to Leader, 6th Edition: H
Test Bank for Success in Practical Vocational

Nursing From Student to Leader, 6th Edition: Hill
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Test Bank
Chapter 8: Nursing Process: Your Role
MULTIPLE CHOICE
1. A student nurse asks, “If RNs use a five-step nursing process and LPN/LVNs use a
four-step process, what phase is missing?” The best response would be, “The phase of the
nursing process that is the sole responsibility of the registered nurse is
1. assessment.”
2. nursing diagnosis.”
3. planning.”
4. implementation.”
5. evaluation.”
ANS: 2
The LPN/LVN participates in all phases of the nursing process with the exception of establishing
a nursing diagnosis.
DIF: Cognitive Level: Application REF: p. 109 OBJ: 4

TOP: Nursing diagnosis: the responsibility of the RN
KEY: Nursing Process Step: Nursing Diagnosis
MSC: NCLEX: Safe, Effective Care Environment
2. The student nurse asks, “How does knowing the nursing diagnosis assist the LPN/LVN?”
The best response is based on understanding that
1. a nursing diagnosis identifies patient problems.
2. it permits the practical nurse to go beyond the scope of practice.
3. this step makes the practical nurse equal to the medical doctor.
4. knowledge of the nursing diagnosis ensures a cure for the patient.
ANS: 1
The LPN/LVN uses the nursing diagnosis to identify a patient problem.

TOP: Nursing diagnosis KEY: Nursing Process Step: Nursing Diagnosis
3. Which of the following is the primary reason that LPN/LVNs are taught to use the
nursing process?
1. diagnosing disease
2. providing reimbursement
3. resolving patient problems
4. communicating with health team members
ANS: 3
The nursing process provides a structure for nurses to identify and respond to patient needs
within the scope of nursing. Option 1 is the domain of the physician. Reimbursement is not the
primary purpose of the nursing process. Communication facilitation is not the primary purpose of
the nursing process.
DIF: Cognitive Level: Analysis REF: p. 107 OBJ: 5

TOP: Purpose of nursing process KEY: Nursing Process Step: N/A
4. During the assessment phase of the nursing process, the LPN/LVN is expected to
1. establish goals and outcome criteria.
2. collect data about the patient.
3. determine if established goals are met.
4. plan interventions to implement for the patient.
ANS: 2
Data are collected as part of the assessment phase. This is the only option that relates to
assessment.
DIF: Cognitive Level: Comprehension REF: p. 110 OBJ: 3

TOP: Assessment and data collection KEY: Nursing Process Step: Assessment
5. The nursing care plan requires the nurse to ambulate the patient twice daily. The phase of
the nursing process in which the nurse is participating is
1. assessment. 3. implementation.
2. planning. 4. evaluation.
ANS: 3
Carrying out the care plan is termed implementation. Assessment involves data collection.
Planning involves creation of the nursing care plan. Evaluation involves determining goal
attainment.

TOP: Implementation KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
6. An LPN/LVN demonstrates to a new mother how to safely bathe her infant. This is an
example of the phase of the nursing process called
1. assessment. 3. planning.
2. nursing diagnosis. 4. implementation.
ANS: 4
Initiating teaching that is within the role of the LPN/LVN and supporting teaching by the RN are
examples of implementation.

TOP: Teaching as part of the implementation phase
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance
7. When the LPN/LVN participates in the evaluation phase of the nursing process, she or he
compares the patient’s responses with the
1. nursing orders. 3. nursing diagnosis.
2. outcome criteria. 4. database.
ANS: 2
The process of determining outcome attainment involves comparing actual patient outcomes
with desired patient outcomes.
DIF: Cognitive Level: Comprehension REF: pp. 118–119 OBJ: 3

TOP: Evaluation KEY: Nursing Process Step: Evaluation
8. Which of the following are considered subjective data?

1. The patient tells the nurse that he has a headache.
2. The nursing assistant tells the nurse that the patient vomited.
3. The patient’s mother tells the nurse that the patient needs a ride to the clinic for
follow-up.
4. The physician tells the nurse that the patient needs a chest x-ray.
ANS: 1
Subjective data are based on the patient’s report or opinion. This option is the only example of
patient report.

TOP: Data collection
KEY: Nursing Process Step: Assessment (Data Collection) MSC: NCLEX: N/A
9. “I feel like I can’t catch my breath” is an example of

1. effective data. 3. subjective data.
2. objective data. 4. evaluative data.
ANS: 3
Subjective data are based on patient report or opinion. Objective data are data the nurse can
verify. Effective data and evaluative data are not used as data classifications.

TOP: Subjective data
KEY: Nursing Process Step: Assessment (Data Collection)
10. Blood pressure 110/70 at 8 PM is most accurately described as an example of

1. planning data. 3. objective data.
2. subjective data. 4. reassessment data.
ANS: 3
Objective data are sometimes called signs. Objective data can be verified. Subjective data are
based on patient report. Planning data and reassessment data are not used as data classifications.
TOP: Objective data
11. When a nurse uses Maslow’s Hierarchy of Needs to prioritize patient problems, which
problem would be considered the highest priority? The patient
1. is unsteady and may become injured.
2. is experiencing marital difficulties.
3. has deficient knowledge about the condition.
4. is acutely short of breath.
ANS: 4
The priority problem is one that is potentially life-threatening: shortness of breath. Physiologic or
survival needs take priority over higher-level needs. The problems mentioned in the other
options do not threaten survival.

TOP: Priority setting KEY: Nursing Process Step: Planning
12. Which of the following statements regarding short-term goals is accurate? Short-term
goals
1. are broad rather than specific.
2. can be accomplished within days or hours.
3. must be accomplished while the patient is hospitalized.
4. are less realistic than long-term goals.
ANS: 2
Short-term goals can usually be accomplished within hours or days, whereas long-term goals
may take weeks.

TOP: Goals KEY: Nursing Process Step: Planning
13. The patient problem has been identified as insufficient intake of oral fluids. The best
outcome statement is that the
1. patient will ingest 1500 ml oral fluids during each 24-hour period.
2. patient will request fluids when thirsty.
3. nurse will encourage fluid intake by the patient.
4. nurse will provide the patient with 100 ml of fluid hourly.
ANS: 1
An outcome may be attained by stating the problem in positive terms. It is always a statement of
what the patient will do. Option 2 may not result in the desired intake. Options 3 and 4 are
nurse-centered.

TOP: Outcomes KEY: Nursing Process Step: Planning
14. A student nurse asks, “What’s the primary purpose of the evaluation phase of the nursing
process?” The best response is,
1. “To establish a timeframe for completion of goals.”
2. “To determine if the nurse completed all nursing interventions.”
3. “To determine which nurses are eligible for raises or promotion.”
4. “To compare actual patient outcomes with desired outcomes.”
ANS: 4
Data collection with comparison of actual and desired patient outcomes is the focus of the
evaluation phase of the nursing process. Option 1 is initially part of the planning phase.
Timeframes for goal attainment may be revised during the evaluation phase, but this is not the
primary purpose of evaluation. In options 2 and 3, evaluation is patient-centered.
DIF: Cognitive Level: Application REF: pp. 118–119 OBJ: 3

TOP: Evaluation KEY: Nursing Process Step: Evaluation
15. How does the LPN/LVN use nursing diagnosis in patient care?
1. set patient-centered goals
2. convert nursing diagnoses to patient problems
3. implement independent nursing interventions
4. justify participating in data collection
ANS: 2
The LPN/LVN uses nursing diagnosis as the reference point to identify patient problems that
require intervention. Nursing diagnosis is not required by the LPN/LVN to set goals and
outcomes, implement nursing interventions, or participate in data collection.

TOP: Nursing diagnosis KEY: Nursing Process Step: Nursing Diagnosis
16. The phases of the nursing process in which the LPN/LVN participates with the greatest
degree of independence are
1. goal setting and evaluation. 3. data collection and implementation.
2. planning and implementation. 4. evaluation and data collection.
ANS: 3
The LPN/LVN curriculum trains graduates to collect data and implement a variety of nursing
interventions, making a high degree of independence possible in these areas. Option 1 requires a
greater degree of interdependence with the RN. Planning requires greater interdependence with
the RN, making option 2 incorrect. Evaluation requires greater interdependence with the RN,
making option 3 incorrect.

TOP: LPN/LVN relative independence/interdependence KEY: Nursing Process Step: N/A
17. The RN head nurse is having a busy day. When the LPN/LVN reports data she has
collected, the RN states “Incorporate that into the nursing care plan and write down the
intervention you’d use. I’ll co-sign the entry.” The LPN/LVN should
1. do as requested.
2. ask the advice of the shift supervisor later in the shift.
3. tell the RN that this action is not within the LPN/LVN scope of practice.
4. write a letter to the state board of nursing to report the RN’s unprofessional
conduct.
ANS: 3
The RN is responsible for determining the nursing care plan. The LPN/LVN collects data that the
RN may use to modify the plan, but may not independently modify the plan. If the LPN/LVN
functions outside the identified scope of practice (as in option 1), she would be breaking the law.
Options 2 and 4 do not directly address the problem at the time it occurs.

TOP: Scope of practice KEY: Nursing Process Step: Planning
18. The LPN/LVN learns at report that a patient’s priority problems are pain and inability to
ambulate associated with arthritis. During the patient’s bath he becomes short of breath. The
LPN/LVN should implement interventions based on
1. the priorities given at the report.
2. the patient’s identified strengths.
3. the patient’s changing status.
4. information obtained from the Nursing Outcomes Classification (NOC) project.
ANS: 3
Status changes are a priority. Priorities may change rapidly, depending on the patient’s condition.
This change challenges survival and assumes priority over the other identified problems.

TOP: Priorities KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiologic Integrity
19. Identify the outcome that would be appropriate to include in the nursing care plan of a
patient who has undergone total knee replacement.
1. The patient will be stronger by (date).
2. The patient will transfer from the bed to a chair with the assistance of a walker and
one staff member by the third postoperative day.
3. The nurse will help the patient ambulate the length of the hall twice daily.
4. The nurse will evaluate the patient’s strength based on his ability to ambulate in
the hall on the first postoperative day.
ANS: 2
Option 2 contains the elements necessary for a well-written outcome. It must be patient-centered,
realistic, measurable, and time-referenced. Option 1 is not measurable. Options 3 and 4 are
nurse-centered.

TOP: Outcomes KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiologic Integrity
20. A nurse expresses difficulty deciding which nursing interventions to suggest for a patient
with arthritic pain during an upcoming patient-centered conference. A peer suggests referring to
the Nursing Interventions Classification (NIC) taxonomy. This would provide the nurse with
information on
1. how to provide basic care to patients.
2. identification of nursing measures to help patients progress toward goals.
3. a language for measuring patients’ response to nursing interventions.
4. how to translate nursing diagnoses into nursing problems.
ANS: 2
NIC standardizes, defines, and assists nurses in choosing the appropriate nursing interventions. It
includes physical and psychosocial interventions, health promotion, illness treatment, and
independent and collaborative interventions. NIC is not a basic text. NIC does not provide a
measurement language. NIC does not give information about translating nursing diagnoses into
nursing problems.

TOP: NIC KEY: Nursing Process Step: Planning
MSC: NCLEX: Safe, Effective, Care Environment
21. The patient’s nursing diagnosis is pain associated with walking related to knee injury.
The LPN/LVN should accurately identify the patient problem as
1. arthritis. 3. need for knee brace.
2. unwillingness to exercise. 4. knee pain.
ANS: 4
Knee pain is the best translation given for the nursing diagnosis. Option 1 is a medical diagnosis.
Option 2 assumes information not given in the scenario. Option 3 prescribes a treatment.

TOP: Translating nursing diagnosis to patient problem
KEY: Nursing Process Step: Planning MSC: NCLEX: Physiologic Integrity
22. A beginning nurse asks an experienced nurse, “When should I focus on data collection?”
Which statement provides the best description for when a nurse should collect patient-centered
data?
1. following report when coming on duty
2. within 1 hour of reporting off duty
3. while assisting patient with hygiene
4. during each patient contact
ANS: 4
Data is collected whenever the nurse and patient interact. The other options limit data collection.

23. The nursing process consists of collecting data (assessment), nursing diagnosis, planning,
implementation, and evaluating nursing care. Which step of the nursing process is the sole
responsibility of the registered nurse?
1. planning 3. implementation
2. assessment 4. nursing diagnosis
ANS: 4
The nursing process consists of collecting data (assessment), nursing diagnosis (which is the RN
responsibility), planning, implementation, and evaluating nursing care. Nursing diagnosis is
within the RN’s legal role, but LPN/LVNs have an important role in assisting the RN in the other
steps of the nursing process.

TOP: Nursing process
KEY: Nursing Process Step: Assessment, Diagnosis, Planning, Implementation, Evaluation
MSC: NCLEX: N/A
24. A nurse is gathering and reviewing information about a patient. The nurse is participating
in which step of the nursing process?
1. planning 3. data collection
2. evaluation 4. implementation
ANS: 3
The nursing process consists of collecting data (assessment), nursing diagnosis (which is the
RN’s responsibility), planning, implementation, and evaluating nursing care. Data collection is a
systematic gathering and review of information about the patient, which is communicated to
appropriate members of the health team.

TOP: Nursing process
25. An LPN/LVN is assisting the RN in the development of goals and interventions for a
patient’s plan of care. The LPN/LVN is participating in which step of the nursing process?
ANS: 1
RN’s responsibility), planning, implementation, and evaluating nursing care. Planning involves
assisting the RN in the development of nursing diagnosis, goals, and interventions for a patient’s
plan of care and maintaining patient safety.

TOP: Nursing process KEY: Nursing Process Step: Planning
MSC: NCLEX: N/A
26. A nurse is comparing a patient’s outcomes of nursing care to the expected outcomes. The
nurse then communicates these findings to members of the health care team. The nurse is
participating in which step of the nursing process?
ANS: 2
RN’s responsibility), planning, implementation, and evaluating nursing care. Evaluation
compares the actual outcomes of nursing care to the expected outcomes, which are then
communicated to members of the health care team.

TOP: Nursing process KEY: Nursing Process Step: Evaluation
MSC: NCLEX: N/A
27. A nurse reviews a patient’s care plan and finds a goal for the patient to ambulate at least
three times a day. The nurse assists the patient to accomplish this goal. The nurse is participating
in which step of the nursing process?
ANS: 4
RN’s responsibility), planning, implementation, and evaluating nursing care. Implementation is
the provision of required nursing care to accomplish established patient goals.

TOP: Nursing process KEY: Nursing Process Step: Implementation
MSC: NCLEX: N/A
28. A nurse is gathering data about a patient. The nurse determines that which of the
following information are subjective data?
1. The patient complains of excruciating crushing chest pain.
2. The patient is short of breath and coughs up green sputum.
3. The patient has gained 1 lb of weight within the past 24 hours.
4. The patient is experiencing sinus tachycardia and peripheral edema.
ANS: 1
Subjective information is based on the patient’s opinion. Some refer to subjective information as
symptoms. This usually includes feelings of physical discomfort, anxiety, and mental stress that
are more difficult to measure. The nurse cannot experience subjective symptoms. Objective
information includes data that the nurse can verify; also known as “signs.” A physical
assessment provides objective data. The terms check, observe, monitor, weigh, measure, and
smell are cues that this may be objective data collection. Obtaining initial data, such as vital
signs, height, and weight, is often assigned to the LPN/LVN. Objective information helps
support or cast doubt on subjective information. Option 1 is the only option that is subjective.
Options 2, 3, and 4 are all examples of objective data.

following information are subjective data?
1. The patient complains of feeling anxious about their upcoming surgery.
2. The patient is short of breath and has an oxygen saturation level of 86%.
3. The patient has a heart rate of 85 beats per minute and has a sinus rhythm.
4. The patient has consumed 60% of breakfast, 45% of lunch, and 50% of dinner.
ANS: 1
support or cast doubt on subjective information. Option 1 is the only option that is subjective.
Options 2, 3 and 4 are all examples of objective data.

following information are objective data?
1. The patient complains of phantom pain after receiving a left below-the-knee
amputation.
2. The patient complains of crushing chest pain and states, “I feel like there is an
elephant sitting on my chest.”
3. The patient complains of feeling anxious about being hospitalized, and states, “I
feel like I’m going to die.”
4. The patient has a heart rate of 99 beats per minute, respirations of 20 per minute,
and a temperature of 99.2° F.
ANS: 4
support or cast doubt on subjective information. Option 4 is the only option that is objective.
Options 1, 2, and 3 are all examples of subjective data.

TOP: Objective data
COMPLETION
31. A patient states, “I’m feeling left-sided chest pain that radiates to my left arm.” This is an
example of ____________________ data.
ANS:
subjective
support or cast doubt on subjective information.

32. A nurse notes that a patient is experiencing increased peripheral edema and has urinated
20 cc of urine in the past hour. This is an example of ____________________ data.
ANS:
objective
support or cast doubt on subjective information.
TOP: Objective data
MULTIPLE RESPONSE
33. The LPN/LVN should be alert to possible barriers to data collection such as (select all
that apply)
1. inadequate assessment skills.
2. presence of distractions.
3. respectful distancing.
4. insufficient time.
5. inability to speak the language.
6. patient labeling.
ANS: 1, 2, 4, 5, 6
Each of the options except option 3 may create a barrier to data collection. Option 3, respectful
distancing, suggests calling the patient by title and surname and avoiding overly familiar
approaches.

TOP: Barriers to data collection
34. Select strategies that will facilitate patient data collection. (Select all that apply.)
1. Ensure that the patient knows who you are and what you are going to do.
2. Address the patient with familiarity, using terms of endearment.
3. Repeat questions the patient has previously answered.
4. Clarify what you do not understand with the patient.
5. Judge patient behaviors and attitudes.
ANS: 1, 4
Use of good communication strategies facilitates data collection. Orienting the patient to your
role and purpose of the interaction and clarifying what is not understood will facilitate data
collection. Option 2 is disrespectful and creates a barrier to communication. Option 3 suggests to
the patient that no one listens to what has already been revealed. Option 5, being judgmental,
results in labeling patients and making judgmental statements to the patient.

MSC: NCLEX: Psychosocial Integrity
35. Reasons the nursing process and critical thinking are included in the LPN/LVN
curriculum include (select all that apply)
1. Both are needed to identify patient problems, issues, and risks.
2. They foster making evidence-based judgments.
3. Clearer communication between RN and LPN can take place.
4. Job stress and burnout are diminished.
5. Patient safety is adversely affected.
ANS: 1, 2, 3
The nursing process provides a reasoning model for use in planning and implementing care. This
model requires use of critical thinking skills. Option 4 is incorrect. Job stress and burnout have
not been directly associated with use of the nursing process or critical thinking. Option 5 is
incorrect. The aim of both the nursing process and critical thinking is to promote patient safety.
DIF: Cognitive Level: Analysis REF: pp. 107–109 OBJ: 5

TOP: Inclusion of nursing process and critical thinking in LPN/LVN curriculum
KEY: Nursing Process Step: Planning MSC: NCLEX: Safe, Effective Care Environment
36. Select the statements that accurately describe the role of the LPN/LVN in relation to use
of the nursing process. (Select all that apply.)
1. LPN/LVNs have an interdependent relationship with other health team members.
2. LPN/LVNs act in a more dependent role when participating in the planning and
evaluation phases.
3. LPN/LVNs act more independently when participating in data collection and
implementation phases.
4. LPN/LVNs are able to use the NANDA list to make nursing diagnoses.
5. LPN/LVN basic education enables them to perform patient interviews and
assessment of body systems.
ANS: 1, 2, 3
LPN/LVNs implement orders for treatments and medication written by physicians, dentists,
nurse practitioners, physician assistants, etc. The LPN/LVN contributes by collecting and sharing
data that are used by the RN to plan and evaluate care. The LPN/LVN is skillful in data
collection and providing planned nursing interventions. Nursing diagnosis is the domain of the
RN. LPN/LVN basic education does not teach interview skills and physical assessment of body
systems.

TOP: Role in the nursing process KEY: Nursing Process Step: N/A
37. Which of the following are examples of subjective data? (Select all that apply.)
1. A patient has an offensive body odor.
2. A patient complains of feeling stressed.
3. A patient complains of feeling anxious.
4. A patient complains of substernal chest pain.
5. A patient falls when ambulating to the bathroom.
6. A patient states, “I feel a sense of impending doom.”
ANS: 2, 3, 4, 6
Test Bank for Success in Practical Vocational Nursing From Student to Leader, 6th Edition: H
support or cast doubt on subjective information. Options 2, 3, 4, and 6 are the only options that
are subjective. Options 1 and 5 are examples of objective data.

38. Which of the following are examples of objective data? (Select all that apply).
1. A patient has an offensive body odor.
2. A patient complains of feeling stressed.
3. A patient complains of feeling anxious.
4. A patient complains of substernal chest pain.
5. A patient falls when ambulating to the bathroom.
6. A patient states, “I feel a sense of impending doom.”
ANS: 1, 5
support or cast doubt on subjective information. Options 1 and 5 are examples of objective data.
Options 2, 3, 4, and 6 are examples of subjective data.

TOP: Objective data
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Chapter 8: Nursing Process: Your Role

DIF: Cognitive Level: Application REF: p. 109 OBJ: 4

DIF: Cognitive Level: Application REF: p. 109 OBJ: 5

DIF: Cognitive Level: Analysis REF: p. 107 OBJ: 5

DIF: Cognitive Level: Comprehension REF: p. 110 OBJ: 3

DIF: Cognitive Level: Application REF: p. 117 OBJ: 3

DIF: Cognitive Level: Application REF: p. 117 OBJ: 3

DIF: Cognitive Level: Comprehension REF: pp. 118–119 OBJ: 3

8. Which of the following are considered subjective data?

DIF: Cognitive Level: Analysis REF: p. 110 OBJ: 3

9. “I feel like I can’t catch my breath” is an example of

DIF: Cognitive Level: Application REF: p. 110 OBJ: 3

10. Blood pressure 110/70 at 8 PM is most accurately described as an example of

DIF: Cognitive Level: Application REF: p. 113 OBJ: 2

DIF: Cognitive Level: Comprehension REF: p. 115 OBJ: 3

DIF: Cognitive Level: Application REF: p. 115 OBJ: 3

DIF: Cognitive Level: Application REF: pp. 118–119 OBJ: 3

DIF: Cognitive Level: Comprehension REF: p. 109 OBJ: 4

DIF: Cognitive Level: Analysis REF: p. 109 OBJ: 3

DIF: Cognitive Level: Application REF: p. 118 OBJ: 3

DIF: Cognitive Level: Application REF: p. 109 OBJ: 3

DIF: Cognitive Level: Analysis REF: p. 109 OBJ: 3

DIF: Cognitive Level: Comprehension REF: p. 119 OBJ: 3

DIF: Cognitive Level: Application REF: p. 109 OBJ: 3

DIF: Cognitive Level: Application REF: p. 109 OBJ: 3

DIF: Cognitive Level: Comprehension REF: p. 108 OBJ: 4

DIF: Cognitive Level: Comprehension REF: p. 109 OBJ: 3

DIF: Cognitive Level: Comprehension REF: p. 109 OBJ: 3

DIF: Cognitive Level: Comprehension REF: p. 109 OBJ: 3

DIF: Cognitive Level: Comprehension REF: p. 109 OBJ: 3

DIF: Cognitive Level: Analysis REF: p. 110 OBJ: 3

DIF: Cognitive Level: Analysis REF: p. 110 OBJ: 3

DIF: Cognitive Level: Analysis REF: p. 110 OBJ: 3

DIF: Cognitive Level: Analysis REF: p. 110 OBJ: 3

DIF: Cognitive Level: Analysis REF: p. 112 OBJ: 1

DIF: Cognitive Level: Analysis REF: p. 112 OBJ: 3

DIF: Cognitive Level: Analysis REF: pp. 107–109 OBJ: 5

DIF: Cognitive Level: Analysis REF: p. 109 OBJ: 2

DIF: Cognitive Level: Analysis REF: p. 110 OBJ: 3

DIF: Cognitive Level: Analysis REF: p. 110 OBJ: 3

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