Download Nursing Process, Assessment, and Diagnosis: Questions and Answers and more Exams Nursing in PDF only on Docsity!
FPCC EXAM1, 2 AND 3 2025/ACTUAL
500+Qs&As|NEW UPDATE|A+GRADE
EXAM 1
Nursing process ANS:->> a systematic problem-solvingprocess that guides all nursing actions Assessment ANS:->>the systematic gathering of information related to the physiological, psychiological, sociocultural, devlopmental, and spiritual status of anindividual, group, or community. What is the purpose of an assessment? ANS:->> obtaindata to allow you to help the patient Where do we get Primary sources from? ANS:->>Subjective and Objective Where do we get secondary sources from? ANS:->>Family/friends, health record, healthcare team Subjective Data (Client States) Objective Data (Nurse observes) ANS:->>" My throathurts when i swallow" Parenteral ANS:->> any route other than through thealimentary canal (passage from mouth to anus) IV therapy ANS:->>the administration of fluids, electrolytes, medications, or nutrients by the venousroute What type of technique is used every time you start (initiate) or work with (maintain) an IV site or infusion?
- answer - Parenteral
What happens to the $$ your facility receives if a clientin your care gets a
CRBSI (catheter releated bloodstream infection)? ANS:->> The hospital must pay Lab value for serum osmolality ANS:->> 275 - 295 Primary source ( Client states or Nurse Observes) Secondarysource (everything else) ANS:->>" My heartfeels like it's beating fast" "I am feeling short of breath at night"
- EKG: Sinus tachycardia rate of 200 beats/min
- In transfer report, nurse states client is on oxygen atnight for dyspnea Who is responsible for assessment of a client? Nurse LPN AIDE ANS:->> Nurse What activities can a LPN, and Aide do? Select all
A. Assessment
B. Vital signs
C. Pain reports
D. Fingerstick blood glucose levels
E. Client teaching ANS:->>B, C, D
Suppose a patient has told you that he has never hadhigh B/P, but you obtain an abnormal BP reading of 180/98 mm Hg. How would you validate? **ANS:-
** Check the BP in the patient's other arm Wait a few minutes and take the raeding again in thesame arm Retake the BP using a different sphygmomanometerCompare the reading
stays up late partying and sleeps most of teh day. Despite a previous close relationship with her parents,she barley talks to them when they contact her.
- Nonproductive or dysfunctional behavior (A man has been abusing alcohol for many years, even though it iscausing many problems with his family and job and hasbegun to damage his liver) Nursing Diagnosis Statement ANS:->>clinical judgmentabout individual, family, or communiy RESPOSNE to actual and potential health problems or life processes that the nurse is licensed and compotent to treat. Cluster ANS:->> a group of cues that are related toeach other in some way Inference ANS:->>is not a fact, are conclusions (judgements, interpretations) that are based on thedata. Fact: Patient is crying. (You obsereve that directly) Inference: Patient is anxious. (You cannot observe anxiety, but you know taht crying and trembling mabesigns of anxiety) Forming a nursing diagnosis statement ANS:->> inference, etiology, characteristics.. evidence (clinicalmanifestitaions ) How many nursing diagnosis How many risks ANS:->>(3)(2) Actual Nursing Diagnosis ANS:->>Problem is present Risk Nursing Diagnosis ANS:->>Problem might occur Wellness (Health Promotion) Nursing Diagnosis ANS:->> No problem; client wants to be "more well"
Todd may have at least one actual nursing diagnosis (Impairied Walking or perhaps Impaired Physcial Mobility), related to his alck of peripheral sensation; however; no signs and symptoms were given in the scenario to support that diagnosis. What diagnosis typeis this?
A. Actual Nursing Diagnosis
B. Risk Nursing Diagnosis
C. Wellness Nursing Diagnosis
D. Medical Diagnosis ANS:->> A. Actual NursingDiagnosis
Todd's loss of lower limb sensation is a risk, factor for adiagnosis of Risk for Falls even though Todd has no symptoms is what type of diagnosis?
A. Actual Nursing Diagnosis
B. Risk Nursing Diagnosis
C. Wellness Nursing Diagnosis
D. Medical Diagnosis ANS:->>B. Risk Nursing Diagnosis
All surgical patients have at least some risk for developing infection, so do not routinely write Risk for infection or surgical site infection on every surgical care plan. Instead, write potential complication of suregry: infection (incision and systemtic)
A. Actual Nursing Diagnosis
B. Risk Nursing Diagnosis
C. Wellness Nursing Diagnosis
D. Medical Diagnosis ANS:->>B. Risk Nursing Diagnosis
Suppose that Todd tells you that he prays, participatesin religious actvities,
Long term goals- ANS:->>those you expect the patientto achieve within a few hours or days are changes in health status that you wish to achieveover a longer period of time What type of goal is this - describe pain as <3 on a 1 - 10 scale within 30 min after recieving analesic
A. Short
B. Long ANS:->>A. Short
What type of goal is this- Limits food intake to 1,500calories per day
A. Short
B. Long ANS:->>A. Short
What type of goal is this- Infant will double birthweight within 5 mo
A. Short
B. Long ANS:->>B. Long
Within 3 mo after physical therapy treatments, willdress self expect for buttons
A. Short
B. Long ANS:->>B. Long
Intervention ANS:->>any treatment, based on clinicaljudgement and knowledge, that a nurse performs to enhance patient outcomes Independent Interventions ANS:->>one that RNs are accountable for and are licensed to presribe, perform, or delegaet based on tehir knolwedge and skills.
Nurse A makes a nursing diagnosis of Anxiety related todeficient knolwedge about barium enema; she swrites a nursing order to teach the pateint what to expect from the upcoming diagostic test
A. independent
B. dependent
C. interdependent ANS:->>A. Independent
Dependent Intervention ANS:->>one that is prescribeby a physician or advanced practice nurse but carried out by the nurse Nurse B reads a prescription in a patient's chart: "Givecephalothin sodium (Keflin) 1 g IV [through the intravenous line] before suregry, and tehn every 6 hours for 24 hours. " She prepares and administers themedication
A. independent
B. dependent
C. interdependent ANS:->>B. Dependent
Interdependent ANS:->>one that is carried out incollaboration with other health team members (physcial therapists, physicians) Nurse C notes that a client newly diagnosed with diabetes has been seen by a dietitian, who taught andpro vided materials about a diabetic diet. The nurse observes the clients's menu chocies. She notes that theclient is eating candy brought by visitors. She explains to the client how concentrated sugar affects his diabetes; she also communicates her assessments and teaching to the dieitian.
A. independent
B. dependent
C. interdependent ANS:->>C. interdependent
A. Each entry withd date and time
B. Legible
C. Non-erasable ink
D. No spaces
E. Correct all errors CORRECTLY
F. Chart only for yourself, not for others ANS:->>all theabove
Which of these abbreviations you would not use? A. Drugs B. .5/0. C. QD D. QOD E.AD, AS, AU, and OD, OS, OU F.Units or IC G. SQ ANS:->>all the above Handoffs ANS:->>to provide continuity of care amongall team members who provide care to the same clients How long have to sign order?
A. whenever
B. 48 hours
C. within 24 hours
D. A week ANS:->>C. within 24 hours
For TO order what must you do
A. clearly identify the patient
B. Record the order in real time
C. Repeat order back
D. Document read back
E. Question if needed
F. Document TO/VO
G. Two nurses f required
F. Order co-signed ANS:->>all the above What are the steps in a nursing process? ANS:->>Assess, Diagnose, Plan, Implement, Evaluate Once a nurse accesses a client's condition andidentifies appropriate nursing diagnosis, a A. Plan is developed for nursing care B. Physical assessment begins C. List of priorities is determined D. Review of assessment is conducted with other team members ANS:->>A. Plan is developed for nursing care Planning is a category of nursing behaviors in which:
A. The nurse determines the health care needed for theclient
B. The Physcian determines the plan of care for theclient
C. Client-centered goals and expected outcomes areestablished
D. The client determines the care needed ANS:->>C.Client-centered goals
and expected outcomes are established Priorities are establish to help the nurse anticipate andsequence nursing interventions when a client has multiple problesm or alterations. Priorities are determined by the clinet's:
A. Physician
B. Non Emergent, non-life threatening needs
4. Creating a new intervention based on the current status of client ANS:-
- Reevaluating and creating anew nursing diagnosis and outcome A nurse is performing an assessment on a client who has been admitted for hip replacement surgery the next day. The client is tearful and appears very anxious.The nurse is considering "anxiety" as a nursing diagnosis but does not have enough information. Which would be the appropriate action? 1.Assume the anxiety is related to surgery.
2. Inform the physician that the client is anxious.
3. Ask the client to try to remain calm during theassessment.
4. Ask the client if there is anything in particular he or she is anxious about.
ANS:->>4. Ask the client if thereis anything in particular he or she is anxious about. Which describes the correct way to state a nursingdiagnosis?
1. Medical diagnosis and problem list linked by aconnecting phrase
2. Medical diagnosis and medical history linked byetiology
3. A problem and an etiology linked by a connectingphrase
4. A problem and a medical diagnosis linked by a connecting phrase
ANS:->>3. A problem and anetiology linked by a connecting phrase Which are examples of a direct-care nursingintervention? Select all that apply.
1. Giving a medication
2.Notifying the physician of a change in assessment
3. Obtaining vital signs
4. Giving a bedside bath
5. Consulting case management for home oxygen ANS:->>1, 3,
According to Maslow's Hierarchy of Needs, what is theappropriate order of priority of the client needs?
- Falls prevention 2.Support group
3. Adequate hydration
4. A vase of flowers
5. Medication teaching ANS:->>3,1,2,5,
When creating a care plan, which describes outcomesthat can be influenced by nursing interventions?
1. Discharge readiness goals
2. Nurse-sensitive outcomes
3. Diagnostic statements
4. Critical pathways ANS:->>2. Nurse-sensitiveoutcomes
Which nursing interventions are considered direct-careinterventions? Select All That Apply.
4. Making a referral
5. Managing the environment ANS:->>1, 2, 3
The abbreviations "AEB" and "AMB" are considered connecting phrases for which portion of the nursingplan?
1. Basic three-part statement
2. Two-part NANDA-I label
3. Collaborative problem
4. Complex etiology ANS:->>1. Basic three-partstatement
During an assessment, the nurse notes that the clienthas an elevated temperature. Which type of data is this?
1. Subjective
2. Objective
3. Secondary
4. Reported ANS:->>2. Objective
Which describes benefits of the comprehensive writtennursing care plan? Select all that apply.
1. Provides continuity of care
2. Establishes the discharge diagnosis
3. Ensures that care is complete
4. Meets accreditation requirements
5. Promotes efficient use of nursing efforts ANS:->>1,3, 4, 5
Why is the diagnosis step critical to the nursingprocess?
1. It connects the assessment with planning,interventions,
and follow-up evaluation.
2. Without a complete nursing diagnosis, insurance willnot compensate the
hospital.
3. It provides the physician with necessary informationto make a medical
diagnosis.
A nurse has delegated the task of turning a client every2 hours to a nursing assistant in order to prevent skin breakdown. Who has accountability for the actions being performed and the outcome?
1. The nurse who delegated the task
2. The nursing assistant to whom the task is delegated
3. The charge nurse, who is accountable for all activityon the unit
4. The physician, as the leader of the health-care team ANS:->>1. The nurse
who delegated the task Which describes components of implementation in thenursing process? Select all that apply.
1. Doing
2. Deciding
3. Delegating
4. Documenting
5. Caring ANS:->>1, 3, 4
Which is a valid goal statement for measuring andmanaging pain?
1. The client will not complain of pain.
2. The nurse will administer pain medication asordered.
3. The client will have minimal pain.
4. The client will report pain greater than level 4 to thenurse. ANS:->> 4
Which statement correctly identifies an outcome goalfrom the nursing diagnosis of "potential for skin breakdown related to immobility"?
1. The client will have increased mobility.
2. The client will understand strategies for preventingskin breakdown.
3. The client will be moved periodically throughout theshift.
4. The client's skin will remain intact and healthy. ANS:->>4. The
client's skin will remain intact and healthy.
