Chapter 05: Passing NCLEX-RN®
Test Bank
MULTIPLE CHOICE
- A nursing student is giving a presentation on the different organizations that support nurses. She has an adequate understanding of the American Nurses Association when she states, “The American Nurses Association:
| a. | sets the guidelines for entrance into nursing programs.” |
| b. | represents and advocates for nurses.” |
| c. | evaluates and updates licensure exams.” |
| d. | determines who is eligible to take the NCLEX exam.” |
ANS: B
The American Nurses Association represents and advocates for nurses. The National Council of State Boards of Nursing evaluates and updates licensure exams to ensure that all nurses who enter into practice meet the minimum requirement for knowledge and skills. Individual schools of nursing set the guidelines for entrance into nursing programs.
DIF: Cognitive Level: Application REF: Pages 68-69
OBJ: Discuss the development of the NCLEX-RN.
TOP: Evolution of the NCLEX-RN Exam
- A graduate nurse is submitting documentation so that she may take the NCLEX-RN within a few months. Which action shows an understanding of the content of the most updated test plan?
| a. | Spending additional study time reviewing health promotion and maintenance |
| b. | Taking a cardiology course before the exam |
| c. | Reviewing notes from previous nursing classes |
| d. | Setting aside time to study pathophysiology of the brain |
ANS: A
The graduate nurse should be aware that the most updated NCLEX-RN test plan will cover health promotion and maintenance, among other areas.
DIF: Cognitive Level: Application REF: Page 70
OBJ: Understand the evolution of the NCLEX-RN. TOP: NCLEX-RN Test Plan
- A faculty member is discussing question types found on NCLEX. The faculty member knows that students need more teaching about question types if they select which question type?
| a. | Fill-in-the-blank |
| b. | Multiple choice |
| c. | Essay |
| d. | Completing calculations |
ANS: C
Candidates will be asked to answer types of questions such as fill-in-the-blank, multiple choice, and drug calculations. Candidates will not be asked to write answers in essay format.
DIF: Cognitive Level: Application REF: Page 72 OBJ: Prepare for the NCLEX-RN.
TOP: NCLEX-RN–Style Test Items
- A student is a month into her LPN-RN program. She realizes that proper studying is key to success and passing the NCLEX-RN exam. What would be the most appropriate action for the student to take when it comes to studying?
| a. | She should begin studying at the beginning of her program. |
| b. | She should wait until she learns more about becoming an RN. |
| c. | She should begin studying after graduation, so that she retains information better. |
| d. | She does not have to study for the exam at all; she will learn everything in class. |
ANS: A
The student should begin studying for the NCLEX-RN at the beginning of her program in order to be the most prepared to take the exam on graduation. She should not wait until the end of her program to begin studying or assume that she will retain all information from class alone to pass the exam successfully.
DIF: Cognitive Level: Application REF: Pages 75-76 OBJ: Prepare for the NCLEX-RN.
TOP: Evidence-Based Strategies for Testing Success
- Every 3 years the NCSBN conducts practice analysis to determine the expectations for entry level nurses who are newly licensed. The nurse manager understands and can state that nursing care activities are analyzed in relation to all of the following except:
| a. | frequency of performance. |
| b. | time commitment. |
| c. | impact on maintaining client safety. |
| d. | client care setting where the activities are performed. |
ANS: B
Frequency of performance, impact on maintaining client safety, and client care setting where the activities are performed are analyzed by the NCSBN. The time commitment of nursing care is not one of the activities that are analyzed by the NCSBN.
DIF: Cognitive Level: Application REF: Page 69
OBJ: Discuss the development of the NCLEX-RN. TOP: Computer Adaptive Testing
- A student is studying the KATTS Framework in class. She has offered to tutor a friend who is struggling to grasp the concept of the framework. She knows that her teaching has been effective when her friend states that the KATTS Framework consists of all of the following,except:
| a. | knowledge base. |
| b. | anxiety control. |
| c. | time management skills. |
| d. | test-taking skills. |
ANS: C
The KATTS Framework focuses on knowledge base, anxiety control, and test-taking skills for success.
DIF: Cognitive Level: Application REF: Page 75
OBJ: Apply evidence-based strategies to achieve NCLEX-RN success.
TOP: KATTS Framework
- When taking an exam the student remains positive, steady, and able to handle tensions that build. The course instructor interprets the student’s behavior as:
| a. | confidence. |
| b. | control. |
| c. | common sense. |
| d. | content. |
ANS: B
Remaining positive and steady and handling tensions demonstrates control. Confidence relates to the student’s ability to believe in himself or herself. Common sense refers to listening to intuition. The content component refers to knowing the specific content that is being studied.
DIF: Cognitive Level: Analysis REF: Page 77
OBJ: Apply evidence-based strategies to achieve NCLEX-RN success.
TOP: The Five Cs
- Before beginning the exam, a student stops and reflects on the Five C’s: content, confidence, control, common sense, and comparison. Which statement made by the student indicates her understanding of confidence?
| a. | “I know I can do this.” |
| b. | “I just need to remember what I studied.” |
| c. | “I just need to narrow down the right answer.” |
| d. | “What do I think is the right answer?” |
| e. | “Relax, stay calm and focused.” |
ANS: A
When the student stops before beginning an exam and thinks, “I know I can do this,” confidence is being demonstrated. The content component refers to knowing the specific content that is being studied. Comparison refers to narrowing down to the right answer. Common sense refers to listening to intuition. Remaining positive and steady and handling tensions demonstrates control.
DIF: Cognitive Level: Application REF: Page 77
OBJ: Apply evidence-based strategies to achieve NCLEX-RN success.
TOP: The Five Cs
- It is helpful to understand the difference between school exams and the NCLEX-RN in order to ensure that you are prepared to succeed. The student demonstrates adequate understanding of the NCLEX-RN when she makes which statement?
| a. | “The exam content will test only recall and recognition of knowledge.” |
| b. | “The exam will test my critical and higher thinking skills.” |
| c. | “The exam will test my understanding of basic nursing concepts.” |
| d. | “The exam will test my knowledge of how to care for patients in the hospital setting.” |
ANS: B
The NCLEX-RN specifically tests critical and higher thinking skills, in order to ensure that candidates meet the minimum criteria needed to practice safely.
DIF: Cognitive Level: Application REF: Page 75
OBJ: Apply evidence-based strategies to achieve NCLEX-RN success.
TOP: Evidence-Based Strategies for Testing Success
- Students are applying the KATTS Framework in order to be successful in their nursing program. The instructor knows they are following the framework properly when they report which of the following?
| a. | They are studying 1 hour for every 2 to 3 hours of question drill time. |
| b. | They are studying for 2 hours for every 2 to 3 hours of question drill time. |
| c. | They are studying in group for 3 hours total. |
| d. | They are engaged in question drill time for 2 to 3 hours per study session. |
ANS: B
Students should spend 1 hour on focus content review for every 2 to 3 hours of question drill time.
DIF: Cognitive Level: Application REF: Page 76
OBJ: Apply evidence-based strategies to achieve NCLEX-RN success.
TOP: KATTS Framework
- When taking the NCLEX-RN, students may pass or fail after completing _____ or up to _____ questions.
| a. | 65; 100 |
| b. | 75; 265 |
| c. | 85; 250 |
| d. | 80; 200 |
ANS: B
Students may either pass or fail the NCLEX-RN after completing 75 or up to 265 questions.
DIF: Cognitive Level: Knowledge REF: Page 76
OBJ: Discuss the development of the NCLEX-RN. TOP: Computer Adaptive Testing
- Rigorous and ongoing testing has concluded that Computer Adaptive Testing is both _____ and _____.
| a. | reliable; valid |
| b. | difficult; tricky |
| c. | inconclusive; time-consuming |
| d. | easy; efficient |
ANS: A
Rigorous and ongoing testing continues to conclude that Computer Adaptive Testing is both reliable and valid. The NCSBN ensures this by continually evaluating tests and making changes as needed.
DIF: Cognitive Level: Knowledge REF: Page 69
OBJ: Discuss the development of the NCLEX-RN. TOP: Computer Adaptive Testing
- It is critical that students have _____ and believe that they can pass the NCLEX-RN exam.
| a. | good study habits |
| b. | a positive attitude |
| c. | a good support system |
| d. | adequate sleep |
ANS: B
Having a positive attitude and believing in oneself are critical for students preparing for the NCLEX-RN exam.
DIF: Cognitive Level: Comprehension REF: Page 76
OBJ: Apply evidence-based strategies to achieve NCLEX-RN success.
TOP: KATTS Framework
- A student is designing a study plan to prepare for NCLEX. The student analyzes testing processes and determines which goal is the best preparation process?
| a. | Review the medical surgical book 15 minutes each day for each disease process in the book. |
| b. | Answer 2500 to 3000 NCLEX-type questions before taking boards. |
| c. | Make flash cards to study lab values. |
| d. | Outline chapters for exams with a score of less than 80%. |
ANS: B
Students should complete upwards of 2500 NCLEX-RN–style questions to prepare adequately for the exam. Although reviewing the medical surgical book, making flash cards, and outlining chapters for exams with a score of less than 80% are also helpful, completing NCLEX-type questions is the best preparation process.
DIF: Cognitive Level: Application REF: Page 75
OBJ: Apply evidence-based strategies to achieve NCLEX-RN success.
TOP: Evidence-Based Strategies for Testing Success
- Studies have found that students tend to answer questions at a slower pace as they proceed through exams. With this in mind, students should be aware of _____ during school exams as practice for the NCLEX-RN.
| a. | what their classmates are doing |
| b. | the amount of time they are spending on each question |
| c. | the wording of each question |
| d. | which questions they answer first |
ANS: B
Students should be aware of time as they take exams in school so that they can practice pacing themselves before taking the NCLEX-RN.
DIF: Cognitive Level: Application REF: Page 76
OBJ: Apply evidence-based strategies to achieve NCLEX-RN success.
TOP: Evidence-Based Strategies for Testing Success
MULTIPLE RESPONSE
- The use of Computer Adaptive Technology (CAT) has drastically changed the process of licensure testing. The graduate nurse understands this process when she makes which statements? (Select all that apply.)
| a. | “The implementation of CAT allows me to choose what study material to use when testing.” |
| b. | “CAT allows me to choose a testing center that is close to my home.” |
| c. | “CAT gives me the flexibility to select a testing time and date that fits into my work schedule.” |
| d. | “CAT implementation allows me to schedule multiple testing dates, in case I cannot make one.” |
| e. | “CAT ensures easier questions than the older written tests.” |
ANS: B, C
With the implementation of Computer Adaptive Technology, students are able to make testing plans that accommodate their lifestyles. These choices include choosing a date/time to test, as well as a center that is most convenient for them. Students are not allowed to bring study material to use on the test or schedule multiple testing dates. CAT implementation does not ensure easier questions.
DIF: Cognitive Level: Application REF: Page 69
OBJ: Understand the evolution of the NCLEX-RN.
TOP: Computer Adaptive Technology
- A student is preparing to begin her final semester of nursing school. She is aware that academic and nonacademic factors can affect her ability to pass the NCLEX-RN. Which statements indicate an understanding of the nonacademic factors? (Select all that apply.)
| a. | “My self-esteem can impact my performance on the exam.” |
| b. | “Having test anxiety can prevent me from testing well.” |
| c. | “My ability to focus on studying can lead to a pass or fail.” |
| d. | “Role strain is a factor in testing success.” |
| e. | “Being good at testing would certainly help me pass.” |
ANS: A, B, D
Self-esteem, test anxiety, and role strain are all nonacademic factors that can lead to the student’s ability to pass NCLEX-RN exam.
DIF: Cognitive Level: Application REF: Page 75
OBJ: Apply evidence-based strategies to achieve NCLEX-RN success.
TOP: KATTS Framework
- Students in a nursing class have just finished an exam on the KATTS Framework. The students should know that they can do which of the following, in order to strengthen the knowledge component of the KATTS Framework? (Select all that apply.)
| a. | Complete NCLEX-RN pretests. |
| b. | Review past NCLEX-RN test plans. |
| c. | Create a study plan, and then identify knowledge deficits. |
| d. | Reread textbooks from nursing courses. |
| e. | Focus studying on strong areas of knowledge. |
ANS: A, B, C
Completing NCLEX-RN pretests is a way for students to strengthen the knowledge component of the KATTS Framework. Students should review updated NCLEX-RN test plans and assess knowledge deficits before creating a study plan.
DIF: Cognitive Level: Application REF: Page 75
OBJ: Apply evidence-based strategies to achieve NCLEX-RN success.
TOP: KATTS Framework
- A group of nursing students is planning to utilize the KATTS Framework for their group study this week. In order to complete a drill set effectively, they should do which of the following? (Select all that apply.)
| a. | Complete a minimum of 50 questions within 1 hour, and work up to 100 questions in 2 hours. |
| b. | Create a study plan for gaps in knowledge. |
| c. | Understand the rationale for the both the correct and incorrect answers. |
| d. | Analyze the results of the drill set, and look for gaps in knowledge. |
| e. | Complete a minimum of 100 questions in 1 hour, and work up to 200 questions in 2 hours. |
ANS: A, B, C, D
The steps for completing a drill set include completing a minimum of 50 questions in 1 hour and working up to 100 questions in 2 hours, analyzing the results of the drill set and looking for gaps in knowledge, understanding the rationale for the correct and incorrect answers, and creating a study plan for gaps in knowledge.
DIF: Cognitive Level: Application REF: Page 76
OBJ: Apply evidence-based strategies to achieve NCLEX-RN success.
TOP: KATTS Framework
- A graduate nurse is preparing to take the NCLEX-RN exam. She knows that which self-care activities that will help her pass the exam? (Select all that apply.)
| a. | Getting adequate sleep at night |
| b. | Eating a balanced diet |
| c. | Studying all night before the exam |
| d. | Consuming energy drinks to stay awake and focused |
ANS: A, B
The graduate nurse should focus on self-care activities that will help her reach her goal of passing the NCLEX-RN exam. These include getting adequate sleep at night and eating a balanced diet. Staying up studying the night before the exam would be counterproductive, and consuming energy drinks is not a healthy self-care activity.
DIF: Cognitive Level: Application REF: Page 76
OBJ: Apply evidence-based strategies to achieve NCLEX-RN success.
TOP: KATTS Framework
Chapter 07: The Nurses, Ideas, and Forces That Define the Profession
Test Bank
MULTIPLE CHOICE
- It has been said that Florence Nightingale revolutionized nursing. Which example supports this statement?
| a. | She encouraged men to become nurses. |
| b. | She encouraged nurses to serve physicians in order to learn from them. |
| c. | She instituted changes that affected patient survival rates. |
| d. | She organized nursing in America. |
ANS: C
When she learned of the lack of medical and nursing care for British troops during the Crimean War (1853-1856), Nightingale organized a group of 38 nurses to travel to the Crimea in southern Russia. Despite societal opposition, she and her team reached the Crimean battlefields in 1854. They found overcrowding in the hospitals, no medical supplies, and limited space for the sick and injured. Using her own funds, Nightingale obtained supplies, cleaned up the unsanitary conditions, and established laundries to wash linens. At the end of 6 months, Nightingale and her nurses had decreased the death rate from 42% to 2%.
DIF: Cognitive Level: Application REF: Page 100
OBJ: Discuss historical contributions to modern nursing. TOP: History of Nursing
- A student is studying the history of nursing. Which statement made by the student would be correct if she had an adequate understanding of America’s first trained nurse?
| a. | “America’s first trained nurse reduced student nurses’ working hours.” |
| b. | “As America’s first trained nurse, Isabel Hampton Robb promoted licensure exams.” |
| c. | “America’s first trained nurse worked to create associate degree programs.” |
| d. | “America’s first trained nurse was Linda Richards.” |
ANS: D
Linda Richards is known as America’s first trained nurse. Isabel Hampton Robb reduced student nurse working hours and promoted licensure exams. Mildred Montag worked to create associate degree programs as a shorter route into nursing.
DIF: Cognitive Level: Application REF: Page 104
OBJ: Discuss historical contributions to modern nursing. TOP: History of Nursing
- Which is the dominant focus of patient care in the current health care environment?
| a. | To increase cost to increase profit |
| b. | To contain rising costs |
| c. | To ignore rising costs |
| d. | To manage care according to cost |
ANS: B
The dominant focus of patient care in the current health care environment is to contain rising costs. Hospitals, faced with financial difficulties, are merging into large health care systems. Managed care, an insurance-based approach to reducing costs, has invaded patient care in every setting. Nurses are challenged to deliver quality nursing care in an environment that limits consumers’ options.
DIF: Cognitive Level: Evaluation REF: Page 107
OBJ: Describe the effect of managed care and merging health care services on the nursing profession. TOP: Nursing in the Current Health Care Environment
- What is the function of Continuous Quality Improvement?
| a. | To improve staff compliance with training |
| b. | To assist staff in building on nursing skills |
| c. | To assess patient care, from admission to discharge |
| d. | To improve collaboration of staff |
ANS: C
Continuous Quality Improvement involves assessing patient care, beginning with point-of- entry into the health system through discharge or transitional care.
DIF: Cognitive Level: Analysis REF: Pages 108-109
OBJ: Discuss the role of nursing in quality improvement of patient care.
TOP: Quality Improvement in Nursing
- Florence Nightingale contributed to nursing in many different ways. The student nurse has an understanding of the history of nursing when she does which of the following?
| a. | Educates another student about the efforts of Florence Nightingale to promote research |
| b. | States that Nightingale is responsible for minor contributions to the early education of nurses |
| c. | Believes that Nightingale was not involved in the theory of nursing |
| d. | States that Nightingale did not assist in the development of the nursing process |
ANS: A
The student shows an understanding of the history of nursing when he or she educates another student on the research efforts of Nightingale. Nightingale is responsible for major contributions to education of nurses, began the development of the nursing process, and served a large role in the development of nursing theory.
DIF: Cognitive Level: Application REF: Page 104
OBJ: Discuss historical contributions to modern nursing. TOP: History of Nursing
- A student understands the contributions of Clara Barton when she states, “Clara Barton
| a. | is known as the Lady with the Lamp.” |
| b. | fought for women’s rights.” |
| c. | is known as the Angel of the Battlefield.” |
| d. | was America’s first trained nurse.” |
ANS: C
Clara Barton is known as the Angel of the Battlefield, Lavinia Dock fought for women’s rights, Florence Nightingale is known as the Lady with the Lamp, and Linda Richards was America’s first trained nurse.
DIF: Cognitive Level: Application REF: Page 104
OBJ: Discuss historical contributions to modern nursing. TOP: History of Nursing
- Which action by the nurse shows the use of the nursing process?
| a. | The nurse works with the health care team to set outcomes and plan interventions for the patient. |
| b. | The same nurse admits the patient and then discharges him the next day. |
| c. | The nurse works with the patient to set outcomes and plan interventions. |
| d. | The nurse sends the provider in for an immediate assessment of the patient. |
ANS: C
In the nursing process, nurses work with patients to set expected outcomes and plan interventions to meet these outcomes.
DIF: Cognitive Level: Application REF: Page 107
OBJ: Understand concept of the nursing process.
TOP: Health Maintenance and Disease Prevention
- What is the major social factor that has developed the role of nursing to what it is today?
| a. | Society’s attitude toward the role of women |
| b. | Society’s lack of qualified health providers |
| c. | Society’s lack of resources to pay for health care |
| d. | Society’s lack of education about health care |
ANS: A
Society’s attitude toward the role of women is a major social factor that has developed the role of nursing.
DIF: Cognitive Level: Application REF: Page 102
OBJ: Discuss historical contributions to modern nursing. TOP: History of Nursing
- _____ defined nursing as “that care which puts a person in the best possible condition for nature to restore or to preserve health, and to prevent or to cure disease or injury.”
| a. | Barton |
| b. | Nightingale |
| c. | Breckenridge |
| d. | Dix |
ANS: B
This definition is as quoted form Nightingale’s Notes on Nursing, written in 1860.
DIF: Cognitive Level: Knowledge REF: Page 104
OBJ: Discuss historical contributions to modern nursing. TOP: History of Nursing
- The nurse responsible for promotion of associate degree programs is:
| a. | Lavinia Dock. |
| b. | Mildred Montag. |
| c. | Linda Richards. |
| d. | Lillian Wald. |
ANS: B
Mildred Montag promoted associate degrees as a way for nurses to enter the field of nursing in a shorter time period. Lavinia Dock fought for women’s rights and the right to vote. Linda Richards, America’s first trained nurse, improved nursing education. Lillian Wald cared for tenement families by establishing a visiting nurse service.
DIF: Cognitive Level: Knowledge REF: Page 104
OBJ: Discuss historical contributions to modern nursing. TOP: History of Nursing
MULTIPLE RESPONSE
- Based on what you know, what events would you select to show the contributions that Isabel Hampton Robb made to nursing? (Select all that apply.)
| a. | Established a visiting nurse service |
| b. | Reduced student working hours |
| c. | Wrote a book on the history of nursing |
| d. | Promoted licensure exams |
| e. | Fought for women’s rights and the right to vote |
ANS: B, D
Isabel Hampton Robb reduced student working hours and promoted licensure exams. Mary Adelaide Nutting wrote a book on the history of nursing, Lillian Wald established a visiting nurse service, and Lavinia Dock fought for women’s rights and the right to vote.
DIF: Cognitive Level: Evaluation REF: Page 104
OBJ: Discuss historical contributions to modern nursing. TOP: History of Nursing
- The “graying of America” is estimated to include 65 million older Americans by 2030. What current evidence supports the need for increased nursing knowledge of geriatrics and home health care? (Select all that apply.)
| a. | The elderly utilize more health care dollars per person than younger members of society. |
| b. | The elderly rely minimally on Social Security. |
| c. | The elderly have chronic illnesses. |
| d. | The elderly typically have fewer years of schooling. |
| e. | Some elderly are widowed and need assistance with care. |
ANS: A, C, D, E
The elderly currently utilize more health care dollars per person than the younger members of society. They typically rely heavily on Social Security, have chronic illnesses, have fewer years of schooling, and are widowed.
DIF: Cognitive Level: Analysis REF: Page 106
OBJ: Understand factors influencing practice. TOP: Aging Population
MATCHING
Match each nurse with her contribution.
| a. | Clara Barton |
| b. | Florence Nightingale |
| c. | Lillian Wald |
| d. | Mary Breckenridge |
- Organized the American Red Cross
- Established a visiting nurse service
- Organized a frontier nurses organization
- Established nursing as a profession
- ANS: A DIF: Cognitive Level: Knowledge REF: Page 104
OBJ: Discuss historical contributions to modern nursing. TOP: History of Nursing
- ANS: C DIF: Cognitive Level: Knowledge REF: Page 104
OBJ: Discuss historical contributions to modern nursing. TOP: History of Nursing
- ANS: D DIF: Cognitive Level: Knowledge REF: Page 104
OBJ: Discuss historical contributions to modern nursing. TOP: History of Nursing
- ANS: B DIF: Cognitive Level: Knowledge REF: Page 104
OBJ: Discuss historical contributions to modern nursing. TOP: History of Nursing
Chapter 11: Providing Patient-Centered Care Through the Nursing Process
Test Bank
MULTIPLE CHOICE
- Which statement by the nurse illustrates how a nursing patient assessment differs from a medical patient assessment?
| a. | “The patient is able to stand for 30 seconds before walking 10 feet toward the bathroom without an assistive device.” |
| b. | “The patient is fearful that he will not be discharged home after his hospitalization.” |
| c. | “The patient stated he felt pain in his lower back after slipping on his icy driveway.” |
| d. | “The patient experienced a persistent cough, and azithromycin was prescribed 6 weeks ago. Today, she presents with a recurrent cough, green sputum, and worsening shortness of breath.” |
ANS: A
The patient’s being able to stand and walk is the correct answer. The nurse focuses on functional abilities and deficits in order to focus the plan of care and help identify the outcome priorities. These areas are not generally assessed by the physician. The patient’s feeling fearful of his disposition at discharge is incorrect because the nursing patient assessment does not focus on feelings and behavior. In addition to subjective data illustrated here by the patient’s stating the location of his pain, the nurse also uses objective data for the nursing patient assessment. The statement describing the patient’s medical history is not the focus of a nursing patient assessment.
DIF: Cognitive Level: Evaluation REF: Page 164
OBJ: Differentiate between the nursing patient assessment and the medical patient assessment.
TOP: Nursing Process
MSC: NCLEX: Safe, Effective Care Environment: Management of Care
- The nurse is using Gordon’s 11 categories for data collection in performing a health assessment. Which of the following represents assessment of cognition?
| a. | How educated is the patient? |
| b. | How does the patient describe his or her health? |
| c. | Is the patient well nourished? |
| d. | Has the patient had treatment for emotional problems? |
ANS: A
Asking the patient’s educational level is an assessment of cognition. How the patient describes his or her health is an assessment of health perception and health management. Asking whether the patient is well nourished will assess metabolic pattern, and asking the patient about treatment for emotional problems will assess the patient’s pattern of coping and stress tolerance.
DIF: Cognitive Level: Application REF: Page 165
OBJ: Discuss the five realms that may affect a patient’s health status that should be addressed in order to complete a thorough nursing assessment. TOP: Nursing Process
MSC: NCLEX: Psychosocial Integrity
- The nurse is charting on the patient who is status post surgery for an abdominal abscess and notes: “Pt’s temperature has not exceeded 37°C this shift.” This is an example of a(n):
| a. | intervention. |
| b. | outcome. |
| c. | plan. |
| d. | diagnosis or analysis. |
ANS: B
An outcome measures the effectiveness of the plan of care. An intervention, a plan, and a diagnosis or analysis are incorrect.
DIF: Cognitive Level: Analysis REF: Page 168
OBJ: Compare and contrast the nursing tasks in each phase of the nursing process.
TOP: Nursing Process
MSC: NCLEX: Safe, Effective Care Environment: Management of Care
- Which outcome statement is a properly written goal?
| a. | “The patient will be free of pain.” |
| b. | “The patient will verbalize the importance of lifestyle changes.” |
| c. | “The patient will get up into the chair one time daily for 1 hour.” |
| d. | “The patient will demonstrate breathing techniques by the end of shift.” |
ANS: C
To be evaluated, an expected outcome must be specific and measurable, meaning that the outcomes can be consistently evaluated. “The patient will get up into the chair one time daily for 1 hour” is specific and measurable. The other outcome statements are vague and open to interpretation. First, being free from pain may mean absolutely no pain or a tolerable level of pain. Second, identifying which lifestyle changes are important to teach the patient may differ from nurse to nurse. Finally, there may be several breathing techniques to teach the patient.
DIF: Cognitive Level: Evaluation REF: Page 168
OBJ: Explain the steps of the nursing process. TOP: Nursing Process
MSC: NCLEX: Safe, Effective Care Environment: Management of Care
- The nurse is planning care for a patient with hypertension and obesity. Which of the following is a reasonable and measurable outcome for the nursing diagnosis of noncompliance with treatment regimen related to side effects of medications?
| a. | The patient will state two lifestyle modifications for weight management by (date certain). |
| b. | The patient will be compliant with the treatment regimen by (date certain). |
| c. | The patient will understand the disease process by (date certain). |
| d. | The patient’s blood pressure will never increase. |
ANS: A
The patient’s stating two lifestyle modifications for weight management is reasonable and measurable. The patient’s being compliant with the treatment regimen is vague. The patient’s understanding the disease process does not state how the effectiveness of teaching will be measured (e.g., by return demonstration or verbalization). The patient’s blood pressure not increasing is not reasonable.
DIF: Cognitive Level: Application REF: Page 168
OBJ: Formulate and apply reasonable and measurable outcomes to the practice setting.
TOP: Nursing Process
MSC: NCLEX: Safe, Effective Care Environment: Management of Care
- A patient admitted with a diagnosis of Alzheimer’s disease is anxious and dehydrated, has reportedly not been eating, and has had a weight loss of 5 lb in 1 week. Which nursing diagnosis is a priority?
| a. | Fluid volume deficit related to fluid loss |
| b. | Altered nutrition: Less than body requirements related to anorexia |
| c. | Fluid volume excess related to reduced urine output |
| d. | Risk for impaired skin integrity |
ANS: A
Replacing fluids is the priority. Anorexia is common in the elderly and can be related to many conditions, including dementia. Fluid volume excess is not present. Risk for impaired skin integrity is not the priority.
DIF: Cognitive Level: Analysis REF: Page 167
OBJ: Formulate an actual, potential, and wellness nursing diagnosis.
TOP: Nursing Process
MSC: NCLEX: Safe, Effective Care Environment: Management of Care
- An RN team leader has one LPN and one medical assistant assigned to the unit. Which patient would be most appropriate to assign to the LPN?
| a. | Right lower lobectomy, one day postoperatively, whose temperature went from 37.1°C to 38.3°C during the last shift |
| b. | 72-year-old right hip replacement, 2 days postoperatively, complaining of leg and chest pain |
| c. | 48-year-old female patient who had a laparoscopic appendectomy 8 hours ago: urine output 165 mL, Hgb 7 g/dL, and Hct 21% |
| d. | Post cerebral vascular accident 1 week ago who had a Dobhoff feeding tube inserted and is now on continuous feedings at 45 mL/hr |
ANS: D
Licensed practical nurses can implement actions specific to the patient care needs. Monitoring the stroke patient and maintaining the continuous feeding is an appropriate delegation. LPNs can also collect data, perform basic teaching, record data as well as interventions, and report to the RNs the progress the patient is making. The patient one-day post-op from the right lower lobectomy, the patient with the hip replacement, and the patient with the appendectomy are inappropriate to delegate to a LPN because each requires a focused assessment, advanced interventions, evaluation, and updating of the patients’ plans of care and outcome priorities.
DIF: Cognitive Level: Application REF: Page 171
OBJ: Explain the steps of the nursing process. TOP: Nursing Process
MSC: NCLEX: Safe, Effective Care Environment: Management of Care
- Which of these strategies should be a priority when the nurse is planning care for a patient with hypertension?
| a. | Obtain less expensive antihypertensive medications. |
| b. | Assist with dietary changes as the first action. |
| c. | Follow evidence-based guidelines for appropriate interventions. |
| d. | Teach about the impact of exercise on hypertension. |
ANS: C
Planning goals and desired outcomes occurs in the planning phase. The plan of care includes the process of identifying the interventions needed for the patient to regain a level of independence at or higher than the patient had before admission into the hospital.
DIF: Cognitive Level: Application REF: Page 169
OBJ: Explain the steps of the nursing process. TOP: Nursing Process
MSC: NCLEX: Safe, Effective Care Environment: Management of Care
- The nurse reviews assessment findings for assigned patients. Based on this information, which patient demands the nurse’s immediate attention? The patient with:
| a. | renal failure on dialysis whose WBC is 10,000 mm3 (normal) |
| b. | abdominal aneurysm whose blood pressure is 170/90 |
| c. | atrial fibrillation whose lab results show and INR of 2.5 (normal) |
| d. | endocarditis who has a loud heart murmur |
ANS: B
Assessment contains both objective and subjective data. Among other things, the nurse interprets laboratory data to determine whom to see first. The hypertensive patient with an abdominal aneurysm presents the greatest emergency. The patient on dialysis, the patient with A-Fib, and the patient with endocarditis all have normal lab values and clinical findings and present no urgent need for attention.
DIF: Cognitive Level: Application REF: Page 163
OBJ: Explain the steps of the nursing process. TOP: Nursing Process
MSC: NCLEX: Safe, Effective Care Environment: Management of Care
- While the nurse is taking the health history, the patient states, “My father and grandfather both had heart attacks and were unable to be very active afterward.” This statement is related to the functional health pattern of:
| a. | activity-exercise. |
| b. | cognitive-perceptual. |
| c. | health perception–health management. |
| d. | coping-stress tolerance. |
ANS: C
The information in the patient’s statement relates to risk factors that may cause cardiovascular problems in the future. Identification of risk factors falls into the health perception–health management pattern. This pattern describes a patient’s perceived pattern of health and how health is managed.
DIF: Cognitive Level: Knowledge REF: Page 164
OBJ: Explain the steps of the nursing process. TOP: Nursing Process
MSC: NCLEX: Safe, Effective Care Environment: Management of Care
- Which of the following is an example of a measurable outcome for the patient who has undergone a surgical procedure with a pain rating of 7 on a scale of 0 to 10?
| a. | The patient’s pain will be under control by Sunday. |
| b. | The patient will have no pain by the end of this shift. |
| c. | The patient’s pain will decrease by the end of shift on (date). |
| d. | The patient’s pain will decrease to 2 or lower by the end of shift on (date). |
ANS: D
“The patient’s pain will decrease to 2 or lower by the end of shift on (date)” states what is to be measured, how much it will decrease, and by when. “The patient’s pain will be under control by Sunday,” “The patient will have no pain by the end of this shift,” and “The patient’s pain will decrease by the end of shift on (date)” do not include these elements.
DIF: Cognitive Level: Application REF: Page 168
OBJ: Formulate and apply reasonable and measurable outcomes to the practice setting.
TOP: Nursing Process
MSC: NCLEX: Safe, Effective Care Environment: Management of Care
- Which of the following would be a priority nursing diagnosis for a 73-year-old male patient with heart failure?
| a. | Constipation related to immobility |
| b. | Risk for infection related to IV lines |
| c. | Activity intolerance related to an imbalance of oxygen and demand |
| d. | Self-care deficit |
ANS: C
Remember your ABCs. The highest priority for this patient is to conserve energy. Constipation related to immobility, risk for infection related to IV lines, and self-care deficit are not priorities.
DIF: Cognitive Level: Analysis REF: Page 166
OBJ: Examine and prioritize nursing diagnoses in the practice setting.
TOP: Nursing Process
MSC: NCLEX: Safe, Effective Care Environment: Management of Care
- Which of the following would be an expected outcome for a patient who is 12 hours status post hip replacement?
| a. | Increase mobility and decrease pain. |
| b. | Care for the catheter independently. |
| c. | Walk without assistance. |
| d. | Bathe daily in a tub. |
ANS: A
A reasonable outcome is that the patient’s mobility will increase as pain decreases. “Care for the catheter independently” is incorrect because the patient would not be expected to have a catheter. “Walking without assistance” and “bathe daily in a tub” are not reasonable for the patient 12 hours status post hip replacement.
DIF: Cognitive Level: Analysis REF: Page 168
OBJ: Formulate and apply reasonable and measurable outcomes to the practice setting.
TOP: Nursing Process
MSC: NCLEX: Safe, Effective Care Environment: Management of Care
- An RN is making assignments on a medical-surgical unit. Which patient could the RN assign to a float RN from the maternity unit?
| a. | A 68-year-old female patient with COPD and viral pneumonia |
| b. | A 60-year-old female patient with atrial fibrillation and a heart rate of 150 |
| c. | A 50–year-old male patient post open heart surgery whose blood pressure is 90/50 |
| d. | A 36-year-old male patient who is severely neutropenic awaiting chemotherapy |
ANS: A
When prioritizing nursing care, the most critical problems receive the highest priority. In this scenario, the float nurse from another department serves as another health care team member unfamiliar with the medical-surgical patient population. The medical-surgical RN serves as an all-around organizer of care and interventions that other health care team members provide. The patient with COPD and viral pneumonia is the most stable of the group. The patient with A-Fib, the post open heart surgery patient with dangerously low blood pressure, and the neutropenic patient awaiting chemotherapy all require close attention and advanced interventions by the RN familiar with these types of patients.
DIF: Cognitive Level: Application REF: Pages 167, 171
OBJ: Explain the steps of the nursing process. TOP: Nursing Process
MSC: NCLEX: Safe, Effective Care Environment: Management of Care
- A patient with pneumonia has been using the incentive spirometer four times daily while awake during his 3-day hospitalization. How would the nurse explore the effectiveness of this intervention?
| a. | The nurse would ask whether the patient was breathing better. |
| b. | The nurse would add turn, cough, and deep breathing exercises. |
| c. | The nurse would watch the patient use the incentive spirometer. |
| d. | The nurse would auscultate the lungs for adventitious breath sounds. |
ANS: D
The nurse would evaluate the effectiveness of the incentive spirometer treatment by listening for adventitious lung sounds. Asking whether the patient is breathing better; adding turn, cough, and deep breathing exercises; and watching the patient using the incentive spirometer do not examine the effectiveness of the plan of care.
DIF: Cognitive Level: Synthesis REF: Page 171
OBJ: Explain the steps of the nursing process. TOP: Nursing Process
MSC: NCLEX: Safe, Effective Care Environment: Management of Care
- Which nursing diagnosis would be a priority for a patient in acute respiratory distress?
| a. | Pain |
| b. | Impaired gas exchange |
| c. | Activity intolerance |
| d. | Deficient knowledge |
ANS: B
Remember your ABCs. Airway is always a priority. Pain, activity intolerance, and deficient knowledge are not priorities.
DIF: Cognitive Level: Analysis REF: Page 167
OBJ: Examine and prioritize nursing diagnoses in the practice setting.
TOP: Nursing Process
MSC: NCLEX: Safe, Effective Care Environment: Management of Care
- Determine which example is true of measurability within the context of the nursing diagnosis.
| a. | The patient will list signs of infection such as redness, pain, swelling, and warmth by the end of the shift. |
| b. | The patient will be pain-free and then walk to the bathroom. |
| c. | The patient reported abdominal pain for 2 days but denies nausea, vomiting, and diarrhea. |
| d. | The patient received Dilaudid 1 mg IV and 2 hours later received Lortab 500/5. |
ANS: A
Measurability provides the means to evaluate outcomes consistently. The outcome criterion of listing the specific signs of infection is consistently measurable by anyone choosing to attain that outcome criterion. Being pain-free and then walking to the bathroom is not measurable because one outcome criterion cannot depend on completion of another criterion. Each outcome criterion is considered an individual goal. The statements addressing abdominal pain and nausea, vomiting, diarrhea are collected data and taking account of the pain medications administered to the patient have nothing in common with measurability.
DIF: Cognitive Level: Evaluation REF: Page 168
OBJ: Explain the steps of the nursing process. TOP: Nursing Process
MSC: NCLEX: Safe, Effective Care Environment: Management of Care
- The nurse is admitting a 64-year-old Hispanic male patient to the rehabilitation facility following surgical intervention for a broken hip. The nurse should first assess which of the following?
| a. | Self-care ability |
| b. | Self-esteem |
| c. | Communication |
| d. | Pain |
ANS: D
Pain is the first priority for the patient admitted for rehabilitation following surgical intervention. Self-care ability and self-esteem are not the first to be assessed. The ability to communicate pain can be facilitated using graphic representations if the patient does not speak English.
DIF: Cognitive Level: Analysis REF: Page 167
OBJ: Examine and prioritize nursing diagnoses in the practice setting.
TOP: Nursing Process
MSC: NCLEX: Safe, Effective Care Environment: Management of Care
- The nurse is attempting to take the history of a newly admitted 92-year-old patient but is unable to obtain the information because of the patient’s cognitive status. The nurse should:
| a. | refuse to complete the admission without more information. |
| b. | contact the family for information on the patient’s history. |
| c. | call the doctor in the emergency room for a history. |
| d. | ask another nurse to try to obtain the information from the patient. |
ANS: B
The nurse should contact the family to obtain the needed information. Refusing to complete the admission without more information is not professional. Calling the doctor in the emergency room for a history is not likely to be helpful, and asking another nurse to try to obtain the information from the patient is not likely to change the outcome because of the patient’s cognitive status.
DIF: Cognitive Level: Analysis REF: Page 164
OBJ: Explain the steps of the nursing process. TOP: Nursing Process
MSC: NCLEX: Safe, Effective Care Environment: Management of Care
- The nurse is planning care for an 82-year-old obese female patient with Alzheimer’s dementia. The patient wanders, is unsteady on her feet, and is visually impaired. What should the nurse give priority to when developing the plan of care?
| a. | Laboratory results |
| b. | Skin condition |
| c. | Safety |
| d. | Nutrition |
ANS: C
Safety is the first priority for this patient who is cognitively and visually impaired, wanders, and is unsteady. Laboratory results should be monitored, but safety is the priority. Skin condition and nutrition are of concern but are not immediate priorities.
DIF: Cognitive Level: Analysis REF: Page 167
OBJ: Examine and prioritize nursing diagnoses in the practice setting.
TOP: Nursing Process
MSC: NCLEX: Safe, Effective Care Environment: Management of Care
- Which of the following is true about collaborative problems?
| a. | Collaborative problems fall within the definition of nursing diagnoses. |
| b. | Collaborative problems are managed using two physicians. |
| c. | Collaborative problems require the nurse to monitor for changes in status. |
| d. | Collaborative problems emphasize prevention, treatment, or health promotion. |
ANS: C
Collaborative problems require the nurse to monitor for changes in patient status and for the onset of complications for specific situations. Collaborative problems do not fall within the definition of nursing diagnoses. The statement that collaborative problems are managed using two physicians is not true, and the statement that collaborative problems emphasize prevention, treatment, or health promotion is true of the nursing diagnosis phase of the nursing process.
DIF: Cognitive Level: Knowledge REF: Page 170
OBJ: Explain collaborative problems with respect to formulating the nursing diagnosis in the practice setting. TOP: Nursing Process
MSC: NCLEX: Safe, Effective Care Environment: Management of Care
- Errors may occur with the use of data in formulating an appropriate nursing diagnosis. Based on what you know, which of the following represents the main source of errors in the nursing diagnosis process?
| a. | Making assumptions without supporting data |
| b. | Placing data in incorrect categories |
| c. | Not validating data with the patient |
| d. | Relying on team members for data |
ANS: A
Every nursing diagnosis must be substantiated by identifying criteria, also known as defining characteristics. For a nursing diagnosis to be accepted, often numerous signs and symptoms together make up the actual diagnosis. These identifying criteria must be present in the patient to assign that diagnosis. Placing data in incorrect categories, not validating data with the patient, and relying on team members are not discussed.
DIF: Cognitive Level: Evaluation REF: Page 166
OBJ: Explain the steps of the nursing process. TOP: Nursing Process
MSC: NCLEX: Safe, Effective Care Environment: Management of Care
- An example of an intervention independently initiated by the nurse is:
| a. | starting a teaching plan for the patient who will go home tomorrow. |
| b. | instituting diet restrictions with subsequent progression of diet as tolerated. |
| c. | sending an abnormal appearing urine sample to the lab for routine urinalysis. |
| d. | writing an order for aspirin for a headache. |
ANS: A
Starting a teaching plan is an independent nursing function. Accountability for both independent and interdependent functions remains a part of the role of the RN. Instituting diet restrictions, sending a sample for urinalysis, and writing an order are not functions of a nurse and require physician’s orders to carry out.
DIF: Cognitive Level: Application REF: Page 171
OBJ: Explain the steps of the nursing process. TOP: Nursing Process
MSC: NCLEX: Safe, Effective Care Environment: Management of Care
- A nursing intervention directs the patient to be turned every 2 hours to prevent skin breakdown from immobility. Assessment findings on new reddened areas on the lateral aspects of the right knee and ankle are obtained. What is the most appropriate way for these findings to be used when the care plan is evaluated?
| a. | The information will be added to the relevant area of the electronic medical record. |
| b. | The nursing diagnosis will be changed from an actual problem to a potential problem. |
| c. | The new intervention of calling the physician will be added to the care plan. |
| d. | The intervention will change to have the patient turned every hour. |
ANS: D
Evaluation is the process of examining the effectiveness of the plan of care and adjusting it to ultimately meet the needs of the patient. Because redness is observed over bony prominences with turning the patient every 2 hours, the intervention must be adjusted, so the patient must be turned more frequently to prevent further skin breakdown. Documenting of information in the electronic medical record does not address the immediate skin integrity problem. Changing the actual problem to a potential problem is incorrect. Calling the physician is not an independent nursing intervention and does not address the issue of skin integrity.
DIF: Cognitive Level: Application REF: Page 171
OBJ: Explain the steps of the nursing process. TOP: Nursing Process
MSC: NCLEX: Safe, Effective Care Environment: Management of Care
MULTIPLE RESPONSE
- In the assessment phase of the nursing process, there are several ways to collect data. Which statements reflect the need for more training? (Select all that apply.)
| a. | “The patient is talking in full sentences with visitors and appears to be breathing without distress.” |
| b. | “Bowel sounds are hypoactive in all four quadrants; no pain with palpation.” |
| c. | “Mrs. Collins, are you experiencing any pain right now?” |
| d. | “According to the chart, the patient slept well last night as a result of the pain medicine administered at 2100.” |
| e. | “The abdominal wound is slightly red at the approximated edges, no edema noted.” |
ANS: C, D
Methods of data collection include observation, physical assessment, and interviewing. Asking yes-no questions may limit the information received. Reading the chart for any previous notes is important to know for continuity of care, but it is not a method of data collection in the assessment phase of the nursing process. Noticing the patient speaking in full sentences tells the nurse the patient is in no distress. Auscultating and palpating the abdomen are part of the physical assessment done at the beginning of every shift and as needed. Noting wound healing including redness and edema is a direct observation.
