Exam 2 Practice Questions P2 with
Latest Update
A school nurse notices that a student is losing weight and decides to perform a focused
nutritional assessment to rule out an eating disorder. What is the nurse's best action?
Perform the focused assessment as this is an independent nurse-initiated intervention.
Request an order from Jill's physician since this is a physician-initiated intervention.
Request an order from Jill's physician since this is a collaborative intervention.
Request an order from the nutritionist since this is a collaborative intervention. - Answer-
Perform the focused assessment as this is an independent nurse-initiated intervention.
Performing a focused assessment is an independent nurse-initiated intervention; thus
the nurse does not need an order from the physician or the nutritionist.
Nurses use the NIC Taxonomy structure as a resource when planning nursing care for
patients. What information is found in this structure?
Case studies illustrating a complete set of activities that a nurse performs to carry out
nursing interventions
Nursing interventions, each with a label, a definition, and a set of activities that a nurse
performs to carry it out, with a short list of background readings
A complete list of nursing diagnoses, outcomes, and related nursing activities for each
nursing intervention
A complete list of reimbursable charges for each nursing intervention - Answer-Nursing
interventions, each with a label, a definition, and a set of activities that a nurse performs
to carry it out, with a short list of background readings
The NIC Taxonomy lists nursing interventions, each with a label, a definition, a set of
activities that a nurse performs to carry it out, and a short list of background readings. It
does not contain case studies, diagnoses, or charges.
A new RN is being oriented to a nursing unit that is currently understaffed and is told
that the UAPs have been trained to obtain the initial nursing assessment. What is the
best response of the new RN?
Allow the UAPs to do the admission assessment and report the findings to the RN.
Do his or her own admission assessments but don't interfere with the practice if other
professional RNs seem comfortable with the practice.
,Tell the charge nurse that he or she chooses not to delegate the admission assessment
until further clarification is received from administration.
Contact his or her labor representative to report this practice to the state board of
nursing. - Answer-Tell the charge nurse that he or she chooses not to delegate the
admission assessment until further clarification is received from administration.
The nurse should not delegate this nursing admission assessment because only nurses
can perform this intervention. The nurse should seek clarification for this policy from the
nursing administration.
A nurse is about to perform pin site care for a patient who has a halo traction device
installed. What is the FIRST nursing action that should be taken prior to performing this
care?
Administer pain medication.
Reassess the patient.
Prepare the equipment.
Explain the procedure to the patient. - Answer-Reassess the patient.
Before implementing any nursing action, the nurse should reassess the patient to
determine whether the action is still needed. Then the nurse may collect the equipment,
explain the procedure, and, if necessary, administer pain medications.
A student nurse is on a clinical rotation at a busy hospital unit. The RN in charge tells
the student to change a surgical dressing on a patient while she takes care of other
patients. The student has not changed dressings before and does not feel confident
performing the procedure. What would be the student's best response?
Tell the RN that he or she lacks the technical competencies to change the dressing
independently.
Assemble the equipment for the procedure and follow the steps in the procedure
manual.
Ask another student nurse to work collaboratively with him or her to change the
dressing.
Report the RN to his or her instructor for delegating a task that should not be assigned
to student nurses. - Answer-Tell the RN that he or she lacks the technical competencies
to change the dressing independently.
Student nurses should notify their nursing instructor or nurse mentor if they believe they
lack any competencies needed to safely implement the care plan. It is within the realm
of a student nurse to change a dressing if he or she is technically prepared to do so.
,A nurse develops a detailed care plan for a 16-year-old patient who is a new single
mother of a premature infant. The plan includes collaborative care measures and home
health care visits. When presented with the plan, the patient states, "We will be fine on
our own. I don't need any more care." What would be the nurse's best response?
"You know your personal situation better than I do, so I will respect your wishes."
"If you don't accept these services, your baby's health will suffer."
"Let's take a look at the plan again and see if we can adjust it to fit your needs."
"I'm going to assign your case to a social worker who can explain the services better." -
Answer-"Let's take a look at the plan again and see if we can adjust it to fit your needs."
When a patient does not follow the care plan despite your best efforts, it is time to
reassess strategy. The first objective is to identify why the patient is not following the
therapy. If the nurse determines, however, that the care plan is adequate, the nurse
must identify and remedy the factors contributing to the patient's noncompliance.
A student nurse is organizing clinical responsibilities for a patient who is diabetic and is
being treated for foot ulcers. The patient tells the student, "I need to have my hair
washed before I can do anything else today; I'm ashamed of the way I look." The
patient's needs include diagnostic testing, dressing changes, meal planning and
counseling, and assistance with hygiene. How would the nurse best prioritize this
patient's care?
Explain to the patient that there is not enough time to wash her hair today because of
her busy schedule.
Schedule the testing and meal planning first and complete hygiene as time permits.
Perform the dressing changes first, schedule the testing and counseling, and complete
hygiene last.
Arrange to wash the patient's hair first, perform hygiene, and schedule diagnostic
testing and counseling - Answer-Arrange to wash the patient's hair first, perform
hygiene, and schedule diagnostic testing and counseling
As long as time constraints permit, the most important priorities when scheduling
nursing care are priorities identified by the patient as being most important. In this case,
washing the patient's hair and assisting with hygiene puts the patient first and sets the
tone for an effective nurse-patient partnership.
A student health nurse is counseling a college student who wants to lose 20 lb. The
nurse develops a plan to increase the student's activity level and decrease her
consumption of the wrong types of foods and excess calories. The nurse plans to
evaluate the student's weight loss monthly. When the student arrives for her first
"weigh-in," the nurse discovers that instead of the projected weight loss of 5 lb, the
student has lost only 1 lb. Which is the BEST nursing response?
, Congratulate the student and continue the care plan.
Terminate the care plan since it is not working.
Try giving the student more time to reach the targeted outcome.
Modify the care plan after discussing possible reasons for the student's partial success.
- Answer-1.Modify the care plan after discussing possible reasons for the student's
partial success.
Since the student has only partially met her outcome, the nurse should first explore the
factors making it difficult for her to reach her outcome and then modify the care plan. It
would not be appropriate to continue the plan as it is since it is not working, and it is
premature to terminate the care plan since the student has not met her targeted
outcome. The student may need more than just additional time to reach her outcome.
A nurse is collecting evaluative data for a patient who is finished receiving
chemotherapy for an osteosarcoma. Which nursing action represents this step of the
nursing process?
The nurse collects data to identify health problems.
The nurse collects data to identify patient strengths.
The nurse collects data to justify terminating the care plan.
The nurse collects data to measure outcome achievement. - Answer-The nurse collects
data to measure outcome achievement.
The nurse collects evaluative data to measure outcome achievement. While this may
justify terminating the care plan, that is not necessarily so. Data to assess health
problems and patient variables are collected during the first step of the nursing process.
A nurse writes the following outcome for a patient who is trying to stop smoking: "The
patient values a healthy body sufficiently to stop smoking." This is an example of what
type of outcome?
Cognitive
Psychomotor
Affective
Physical changes - Answer-Affective
Affective outcomes pertain to changes in patient values, beliefs, and attitudes. Cognitive
outcomes involve increases in patient knowledge; psychomotor outcomes describe the
patient's achievement of new skills; physical changes are actual bodily changes in the
patient (e.g., weight loss, increased muscle tone).
A nurse writes the following outcome for a patient who is trying to lose weight: "The
patient can explain the relationship between weight loss, increased exercise, and
decreased calorie intake." This is an example of what type of outcome?
