Nursing Process Practice Quiz 2

Nursing Process Practice Quiz 2

Importance of nursing process:

1. Assessment: The first step in the nursing process is assessment, which involves gathering comprehensive and accurate information about the patient’s health status. Nurses collect data through various methods, such as interviews, physical examinations, reviewing medical records, and consulting with other healthcare professionals. This step helps identify the patient’s strengths, problems, and needs.
2. Diagnosis: Once the assessment data is collected, nurses analyze and interpret it to identify actual or potential health problems. Nursing diagnoses are formulated based on the assessment findings and are different from medical diagnoses. They focus on the patient’s response to the health condition or the potential risks the patient faces. Nursing diagnoses help nurses plan appropriate interventions to address the identified problems.
3. Planning: In the planning phase, nurses collaborate with the patient, their family, and the healthcare team to establish goals and develop a plan of care. Goals should be specific, measurable, attainable, relevant, and time-bound (SMART). The plan of care outlines the interventions and actions that will be implemented to address the patient’s health issues and achieve the established goals.
4. Implementation: Implementation involves putting the plan of care into action. Nurses carry out the planned interventions, which can include activities such as administering medications, providing treatments, educating the patient and their family, and coordinating care with other healthcare professionals. This step requires effective communication and critical thinking skills to deliver safe and quality care.
5. Evaluation: The final step in the nursing process is evaluation. Nurses assess the patient’s response to the interventions and determine the effectiveness of the care provided. They compare the patient’s actual outcomes with the expected outcomes established during the planning phase. If the goals are not met, nurses reassess the situation, revise the plan of care if necessary, and continue the cycle of assessment, diagnosis, planning, implementation, and evaluation as needed.

Topics

Topics or concepts included in this exam are:

• Nursing Process
• Nursing Care Planning
• Goal Setting

Guidelines

To make the most out of this exam, follow the guidelines below:

1. Read each question carefully and choose the best answer.
2. You are given one minute per question. Spend your time wisely!
3. Answers and rationales (if any) are given below. Be sure to read them.
4. If you need more clarifications, please direct them to the comments section.

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Nursing Process

Nursing Process Practice Quiz 2

1 / 10

When developing a nursing care plan for a client with a fractured right tibia, the nurse includes in the plan of care independent nursing interventions, including:

Apply a cold pack to the tibia.

Perform range of motion to right leg every 4 hours.

Elevate the leg 5 inches above the heart.

Administer aspirin 325 mg every 4 hours as needed

This does not require a physician’s order. (A & D require an order; C is not appropriate for a fractured tibia)

2 / 10

A client’s wound is not healing and appears to be worsening with the current treatment. The nurse first considers:

Calling the wound care nurse

Notifying the physician

Consulting with another nurse

Changing the wound care treatment

Calling in the wound care nurse as a consultant is appropriate because he or she is a specialist in the area of wound management. Professional and competent nurses recognize limitations and seek appropriate consultation. (a. This might be appropriate after deciding on a plan of action with the wound care nurse specialist. The nurse may need to obtain orders for special wound care products. c. Unless the nurse is knowledgeable in wound management,

3 / 10

When calling the nurse consultant about a difficult client-centered problem, the primary nurse is sure to report the following:

Client’s concern about the current treatment

The spouse’s reaction to the client’s dressing change

Physician’s reluctance to change the current treatment plan

Length of time the current treatment has been in place

This gives the consulting nurse facts that will influence a new plan. Other choices are all subjective and emotional issues about the current treatment plant and may cause bias in the decision of a new treatment plan by the nurse consultant.

4 / 10

The planning step of the nursing process includes which of the following activities?

Assessing and diagnosing

Performing nursing actions and documenting them

Setting goals and selecting interventions

Evaluating goal achievement

5 / 10

Well formulated, client-centered goals should:

Meet immediate client needs.

Include rehabilitation needs.

All of the above.

Include preventative health care.

6 / 10

Which of the following nursing interventions are written correctly? (Select all that apply.)

Elevate head of bed 30 degrees before meals

Perform neurovascular checks

Apply continuous passive motion machine during day

Change dressing once a shift

It is specific in what to do and when.

7 / 10

The nursing care plan is:

A tool to set goals and project outcomes.

A documentation of client care.

A projection of potential alterations in client behaviors

A written guideline for implementation and evaluation.

8 / 10

After determining a nursing diagnosis of acute pain, the nurse develops the following appropriate client-centered goal:

Determine effect of pain intensity on client function.

Pain intensity reported as a 3 or less during hospital stay.

Administer analgesic 30 minutes before physical therapy treatment.

Encourage client to implement guided imagery when pain begins.

This is measurable and objective.

9 / 10

The following statements appear on a nursing care plan for a client after a mastectomy: Incision site approximated; absence of drainage or prolonged erythema at incision site; and client remains afebrile. These statements are examples of:

Nursing interventions

Expected outcomes

Long-term goals

Short-term goals

10 / 10

The following statement appears on the nursing care plan for an immunosuppressed client: The client will remain free from infection throughout hospitalization. This statement is an example of a (an):

Short-term goal

Nursing diagnosis

Expected outcome

Long-term goal

Your score is

The average score is 66%

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