Practice Test: Fundamentals Of Nursing Quiz

Reviewed by Allison Martin
Allison Martin, BSN |
Healthcare
Review Board Member
Allison Martin is a dedicated School Nurse at St. Bernard's School, with over 20 years of invaluable nursing experience. Holding a Bachelor of Science in Nursing (BSN) from Drexel University's College of Nursing and Health Professions, specializing in neuroscience and cardiac care, Allison's commitment to excellence is evident in her professional focus, as she continually strives to provide high-quality care and support to the school community. Additionally, she actively contributes to nursing education by reviewing and refining quizzes, ensuring they align with current standards and promote learning excellence.
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Practice Test: Fundamentals Of Nursing Quiz - Quiz

Delve into the core principles of nursing with our Fundamentals of Nursing Quiz. This comprehensive quiz covers essential topics such as patient care, health promotion, infection control, and nursing ethics. Challenge yourself to assess your understanding of fundamental nursing concepts. Whether you're a nursing student, a practicing nurse, or simply interested in healthcare, this quiz offers an opportunity to test your knowledge and deepen your understanding of the foundational aspects of nursing practice. Get ready to sharpen your skills and enhance your proficiency in the art and science of nursing with our engaging quiz!


Fundamentals of Nursing Questions and Answers

  • 1. 

    Jake is complaining of shortness of breath. The nurse assesses his respiratory rate to be 30 breaths per minute and documents that Jake is tachypneic. The nurse understands that tachypnea means:

    • A.

      Pulse rate greater than 100 beats per minute

    • B.

      Blood pressure of 140/90

    • C.

      Respiratory rate greater than 20 breaths per minute

    • D.

      Frequent bowel sounds

    Correct Answer
    C. Respiratory rate greater than 20 breaths per minute
    Explanation
    Tachypnea is a medical term used to describe rapid and shallow breathing, characterized by a respiratory rate greater than 20 breaths per minute. In Jake's case, his respiratory rate of 30 breaths per minute indicates tachypnea. This condition can be a symptom of various underlying health issues, such as heart or lung problems, infection, or anxiety. The nurse's documentation of Jake's tachypnea will help inform the healthcare team of his condition and guide further assessment and treatment.

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  • 2. 

    The nurse listens to Mrs. Sullen’s lungs and notes a hissing sound or musical sound. The nurse documents this as:

    • A.

      Wheezes

    • B.

      Rhonchi

    • C.

      Gurgles

    • D.

      Vesicular

    Correct Answer
    A. Wheezes
    Explanation
    Wheezes are high-pitched, whistling, or hissing sounds that occur during breathing, usually on exhalation. These sounds are often associated with narrowed airways, as air is forced through a smaller opening than normal. In Mrs. Sullen's case, the nurse's documentation of wheezes will alert the healthcare team to a potential issue with her respiratory system, such as inflammation, obstruction, or other underlying conditions. The other options (rhonchi, gurgles, and vesicular sounds) are different types of lung sounds that describe various other respiratory conditions or normal breath sounds.

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  • 3. 

    The nurse in charge measures a patient’s temperature at 101 degrees F. What is the equivalent centigrade temperature?

    • A.

      36.3 degrees C

    • B.

      38.3 degrees C 

    • C.

      40.03 degrees C

    • D.

      38.01 degrees C

    Correct Answer
    B. 38.3 degrees C 
    Explanation
    To convert a temperature from Fahrenheit (°F) to Celsius (°C), you can use the following formula:

    °C = (°F - 32) / 1.8

    In this case, the patient's temperature is 101 degrees Fahrenheit (°F):

    °C = (101°F - 32) / 1.8

    °C = (69°F) / 1.8

    °C ≈ 38.33

    So, the equivalent temperature in degrees Celsius is approximately 38.33°C.

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  • 4. 

    Which approach to problem-solving tests any number of solutions until one is found that works for that particular problem?

    • A.

      Intuition

    • B.

      Routine

    • C.

      Scientific method

    • D.

      Trial and error

    Correct Answer
    D. Trial and error
    Explanation
    The trial and error approach to problem-solving involves testing various solutions until one is found that effectively addresses the problem. This method is often used when there is limited information or understanding of the problem, and it may require persistence and patience to find a successful solution. In contrast, the scientific method is a more systematic approach to problem-solving that involves forming a hypothesis, designing and conducting experiments or observations, and drawing conclusions based on the results. Routine and intuition are not specific problem-solving approaches but rather refer to established habits or instincts that may guide decision-making.

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  • 5. 

      What is the order of the nursing process?

    • A.

      Assessing, diagnosing, implementing, evaluating, and planning

    • B.

      Diagnosing, assessing, planning, implementing, and evaluating

    • C.

      Assessing, diagnosing, planning, implementing, and evaluating

    • D.

      Planning, evaluating, diagnosing, assessing, and implementing

    Correct Answer
    C. Assessing, diagnosing, planning, implementing, and evaluating
    Explanation
    The nursing process is a systematic, problem-solving approach to patient care, consisting of five steps:Assessment: Collecting and analyzing data about the patient's health status, needs, and concerns.Diagnosis: Identifying and defining the patient's actual or potential health problems, also known as nursing diagnoses.Planning: Developing an individualized care plan with specific goals, interventions, and expected outcomes.Implementation: Executing the nursing interventions outlined in the care plan to help the patient achieve their health goals.Evaluation: Assessing the patient's progress towards the expected outcomes and determining the effectiveness of the interventions.This process provides a structured framework for nurses to deliver holistic, patient-centered care and ensure that the patient's needs are met efficiently and effectively.

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  • 6. 

    During the planning phase of the nursing process, which of the following is the outcome?

    • A.

      Nursing history

    • B.

      Nursing notes

    • C.

      Nursing care plan

    • D.

      Nursing diagnosis

    Correct Answer
    C. Nursing care plan
    Explanation
    The outcome of the planning phase in the nursing process is the development of a nursing care plan. This individualized plan outlines specific goals, interventions, and expected outcomes for the patient based on their unique needs, health problems, and priorities. The nursing care plan serves as a roadmap for the implementation phase of the nursing process, guiding nurses in delivering appropriate and targeted care to help the patient achieve their health goals. The other options (nursing history, nursing notes, and nursing diagnosis) are not outcomes of the planning phase but rather components of the overall nursing process. The nursing history and assessment data contribute to the formulation of nursing diagnoses, while nursing notes document the patient's progress, interventions, and any changes in their condition throughout the care process.

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  • 7. 

    What is an example of a subjective data?

    • A.

      Heart rate of 68 beats per minute

    • B.

      Yellowish sputum

    • C.

      Client verbalized, “I feel pain when urinating.”

    • D.

      Noisy breathing

    Correct Answer
    C. Client verbalized, “I feel pain when urinating.”
    Explanation
    Subjective data refers to information that is provided by the patient or their family members, which cannot be directly observed or measured by the healthcare professional. This type of data includes the patient's perceptions, feelings, and concerns, such as pain, discomfort, or emotional distress. In this case, the patient's statement, "I feel pain when urinating," is an example of subjective data because it reflects their personal experience and cannot be directly verified by the nurse. The other options (heart rate of 68 beats per minute, yellowish sputum, and noisy breathing) are examples of objective data, which can be directly observed, measured, or verified by the healthcare professional through physical examination or diagnostic tests.

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  • 8. 

      Which expected outcome is correctly written?

    • A.

      “The patient will feel less nauseated in 24 hours.”

    • B.

      “The patient will eat the right amount of food daily.”

    • C.

      “The patient will identify all the high-salt food from a prepared list by discharge.”

    • D.

      “The patient will have enough sleep.”

    Correct Answer
    C. “The patient will identify all the high-salt food from a prepared list by discharge.”
    Explanation
    A well-written expected outcome should be specific, measurable, achievable, realistic, and time-bound (SMART). The outcome "The patient will identify all the high-salt food from a prepared list by discharge" meets these criteria because it clearly states:What the patient will do (identify high-salt foods)How it will be measured (from a prepared list)When it will be achieved (by discharge)The other options are not as well-written because they lack specificity or are not easily measurable. For instance, "The patient will feel less nauseated in 24 hours" is subjective and difficult to measure, while "The patient will eat the right amount of food daily" does not specify what the "right amount" is or how it will be determined. Similarly, "The patient will have enough sleep" is vague and does not provide a clear, measurable goal.

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  • 9. 

      Which of the following behaviors by Nurse Jane Robles demonstrates that she understands well the elements of effecting charting?

    • A.

      She signs her charting as follows: J.R

    • B.

      She writes in the chart using a no. 2 pencils.

    • C.

      She noted: appetite is good this afternoon.

    • D.

      She signs on the medication sheet after administering the medication.

    Correct Answer
    D. She signs on the medication sheet after administering the medication.
    Explanation
    Signing on the medication sheet after administering medication is an essential element of effective charting, as it demonstrates that the nurse has completed the intervention and provides a clear record of the care provided. This practice also helps ensure patient safety by reducing the risk of medication errors or omissions.The other options do not demonstrate good charting practices:Signing her charting as "J.R." is not sufficient, as charting should include the full name and title of the person documenting to ensure accountability and clarity.Writing in the chart using a no. 2 pencil is not recommended because pencil can be easily erased or smudged, compromising the integrity and legibility of the patient's medical record.Noting "appetite is good this afternoon" is subjective and does not provide enough detail. A better charting entry would include objective information, such as the percentage of the meal consumed or specific observations related to the patient's appetite.

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  • 10. 

    What is the disadvantage of computerized documentation of the nursing process?

    • A.

      Accuracy

    • B.

      Legibility

    • C.

      Concern for privacy

    • D.

      Rapid communication

    Correct Answer
    C. Concern for privacy
    Explanation
    While computerized documentation of the nursing process offers many advantages, such as improved accuracy, legibility, and rapid communication, one of the main disadvantages is the concern for privacy. Storing sensitive patient information in digital formats increases the risk of unauthorized access, data breaches, or hacking, potentially compromising patient confidentiality. To mitigate these risks, healthcare organizations must implement robust security measures, such as encryption, access controls, and regular software updates, to protect patient data and ensure compliance with privacy regulations. Despite these concerns, the benefits of computerized documentation generally outweigh the risks, leading to its widespread adoption in modern healthcare settings.

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  • 11. 

      The theorist who believes that adaptation and manipulation of stressors are related to fostering change is:

    • A.

      Dorothea Orem

    • B.

      Sister Callista Roy

    • C.

      Imogene King

    • D.

      Virginia Henderson

    Correct Answer
    B. Sister Callista Roy
    Explanation
    Sister Roy’s theory is called the adaptation theory, and she viewed each person as a unified biophysical system in constant interaction with a changing environment. Orem’s theory is called self-care deficit theory and is based on the belief that an individual has a need for self-care actions. King’s theory is the Goal attainment theory and describes nursing as a helping profession that assists individuals and groups in society to attain, maintain, and restore health. Henderson introduced the nature of the nursing model and identified the 14 basic needs.

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  • 12. 

    Formulating a nursing diagnosis is a joint function of:

    • A.

      Patient and relatives

    • B.

      Nurse and patient

    • C.

      Doctor and family

    • D.

      Nurse and doctor

    Correct Answer
    B. Nurse and patient
    Explanation
    Formulating a nursing diagnosis is a collaborative process between the nurse and the patient. The nurse gathers subjective and objective data from the patient through assessment, including the patient's health history, physical examination, and personal experiences. Based on this information, the nurse analyzes the data to identify patterns, actual or potential health problems, and the patient's strengths and limitations. The nurse then works with the patient to develop a nursing diagnosis that accurately reflects the patient's unique health needs and goals. This collaborative approach ensures that the patient's perspectives and preferences are considered in the care planning process, fostering patient-centered care and engagement in their own healthcare. While doctors and family members may provide valuable input or contribute to the overall care plan, the primary responsibility for formulating a nursing diagnosis lies with the nurse and patient.

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  • 13. 

    Mrs. Caperlac has been diagnosed with hypertension 10 years ago. Since then, she has maintained a low-sodium, low-fat diet to control her blood pressure. This practice is viewed as:

    • A.

      Cultural belief

    • B.

      Personal belief

    • C.

      Health belief

    • D.

      Superstitious belief

    Correct Answer
    C. Health belief
    Explanation
    Mrs. Caperlac's practice of maintaining a low-sodium, low-fat diet to control her blood pressure is an example of a health belief. Health beliefs are personal convictions or perceptions about health-related behaviors, conditions, or treatments that influence how individuals approach their healthcare. In this case, Mrs. Caperlac believes that following a low-sodium, low-fat diet will help her manage her hypertension, which is supported by scientific evidence and healthcare recommendations. Cultural, personal, and superstitious beliefs may also play a role in shaping an individual's health behaviors, but in this scenario, Mrs. Caperlac's actions are directly related to her understanding of the connection between diet and blood pressure management, making it a health belief.

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  • 14. 

    Becky has been NPO since midnight in preparation for a blood test. The adreno-cortical response is activated. Which of the following is an expected response?

    • A.

      Low blood pressure

    • B.

      Warm, dry skin

    • C.

      Decreased serum sodium levels

    • D.

      Decreased urine output

    Correct Answer
    D. Decreased urine output
    Explanation
    In this context, the adreno-cortical response can lead to decreased urine output (oliguria) as a result of increased water and sodium reabsorption in the kidneys. The hormones released during the adreno-cortical response, such as cortisol and adrenaline, can promote the retention of water and electrolytes to maintain fluid balance and blood pressure during periods of stress or fasting. While this response is not the primary focus of the adreno-cortical activation, it is an important aspect of the overall physiological adaptation to stress, ensuring that the body can conserve water and essential ions when needed.

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  • 15. 

    What nursing action is appropriate when obtaining a sterile urine specimen from an indwelling catheter to prevent infection?

    • A.

      Use sterile gloves when obtaining urine.

    • B.

      Open the drainage bag and pour out the urine.

    • C.

      Disconnect the catheter from the tubing and get urine.

    • D.

      Aspirate urine from the tubing port using a sterile syringe.

    Correct Answer
    D. Aspirate urine from the tubing port using a sterile syringe.
    Explanation
    To obtain a sterile urine specimen from an indwelling catheter while minimizing the risk of infection, the nurse should aspirate urine from the tubing port using a sterile syringe. This method allows for the collection of a fresh and uncontaminated urine sample without disrupting the closed catheter system, which helps maintain sterility and reduce the risk of introducing bacteria into the urinary tract. Using sterile gloves is important for maintaining aseptic technique during the procedure, but it is not sufficient on its own to prevent infection when obtaining a urine sample. Opening the drainage bag or disconnecting the catheter from the tubing can introduce bacteria into the system, increasing the risk of contamination and urinary tract infection. By aspirating urine from the tubing port with a sterile syringe, the nurse can collect an appropriate sample for testing while adhering to best practices for infection prevention.

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  • 16. 

    A client is receiving 115 ml/hr of continuous IVF. The nurse noticed that the venipuncture site was red and swollen. Which of the following interventions would the nurse perform first?

    • A.

      Stop the infusion

    • B.

      Call the attending physician

    • C.

      Slow that infusion to 20 ml/hr

    • D.

      Place a clod towel on the site

    Correct Answer
    A. Stop the infusion
    Explanation
    If the nurse notices that the venipuncture site is red and swollen, the first action should be to stop the infusion. These signs may indicate inflammation, infection, or extravasation (leakage of IV fluid into the surrounding tissue), which require immediate attention. Stopping the infusion prevents further harm and allows the nurse to assess the situation and intervene appropriately. After stopping the infusion, the nurse can elevate the extremity and apply a warm or cold compress as needed, based on the specific issue. The nurse should also notify the physician about the complication and document the incident in the patient's medical record. Slowing the infusion or placing a cold towel on the site might be considered after the initial assessment but should not be the first intervention in this case.

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  • 17. 

      The nurse enters the room to give a prescribed medication but the patient is inside the bathroom. What should the nurse do?

    • A.

      Leave the medication at the bedside and leave the room.

    • B.

      After a few minutes, return to that patient’s room and do not leave until the patient takes the medication.

    • C.

      Instruct the patient to take the medication and leave it at the bedside.

    • D.

      Wait for the patient to return to bed and just leave the medication at the bedside.

    Correct Answer
    B. After a few minutes, return to that patient’s room and do not leave until the patient takes the medication.
    Explanation
    When administering medications, it is essential for the nurse to ensure that the patient actually takes the medication as prescribed. This is necessary for both patient safety and accurate documentation. In this situation, the nurse should return to the patient's room after a few minutes and wait until the patient takes the medication. Leaving the medication at the bedside without supervision, instructing the patient to take the medication without ensuring they do so, or not waiting for the patient to return to bed before leaving the medication at the bedside are not appropriate actions. These approaches do not guarantee that the patient has taken the medication as prescribed and may lead to errors or complications. The nurse should follow the "Five Rights" of medication administration: the right patient, the right drug, the right dose, the right route, and the right time. Ensuring that the patient takes the medication while the nurse is present is an essential part of this process.

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  • 18. 

      Which of the following is inappropriate nursing action when administering NGT feeding?

    • A.

      Place the feeding 20 inches above the pint if insertion of NGT.

    • B.

      Introduce the feeding slowly.

    • C.

      Instill 60ml of water into the NGT after feeding.

    • D.

      Assist the patient in Fowler’s position.

    Correct Answer
    A. Place the feeding 20 inches above the pint if insertion of NGT.
    Explanation
    Placing the feeding 20 inches above the point of insertion of the nasogastric tube (NGT) is an inappropriate nursing action when administering NGT feeding. Elevating the feeding container too high can lead to a rapid flow of the feeding solution, increasing the risk of aspiration or discomfort for the patient. The appropriate height to hang the feeding container is around 12-18 inches above the point of insertion, allowing for a gradual and controlled flow of the feeding solution. The other options (introducing the feeding slowly, instilling 60ml of water into the NGT after feeding, and assisting the patient in Fowler's position) are all appropriate nursing actions when administering NGT feeding. It's essential to ensure that the patient is in an appropriate position, such as Fowler's position, to minimize the risk of aspiration during feeding. Introducing the feeding slowly prevents sudden distension of the stomach and associated discomfort, while instilling water into the NGT after feeding helps clear the tubing and maintain its patency.

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  • 19. 

      A female patient is being discharged after thyroidectomy. After providing the medication teaching. The nurse asks the patient to repeat the instructions. The nurse is performing which professional role?

    • A.

      Manager

    • B.

      Caregiver

    • C.

      Patient advocate

    • D.

      Educator

    Correct Answer
    D. Educator
    Explanation
    By asking the patient to repeat the medication instructions, the nurse is performing the professional role of an educator. Patient education is a crucial aspect of nursing care, as it empowers patients with the knowledge and skills necessary to manage their health and adhere to treatment plans. In this scenario, the nurse is ensuring that the patient understands the medication regimen following thyroidectomy, which is essential for preventing complications and promoting optimal recovery. By asking the patient to repeat the instructions, the nurse can assess the patient's understanding and address any misconceptions or gaps in knowledge. While the roles of manager, caregiver, and patient advocate are also important in nursing practice, the primary role being demonstrated in this situation is that of an educator.

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  • 20. 

      Which data would be of greatest concern to the nurse when completing the nursing assessment of a 68-year-old woman hospitalized due to Pneumonia?

    • A.

      Oriented to date, time and place.

    • B.

      Clear breath sounds.

    • C.

      Capillary refill greater than 3 seconds and buccal cyanosis.

    • D.

      Hemoglobin of 13 g/dl.

    Correct Answer
    C. Capillary refill greater than 3 seconds and buccal cyanosis.
    Explanation
    Capillary refill greater than 3 seconds and buccal cyanosis (bluish discoloration of the inner lining of the cheek) are indicators of poor tissue perfusion and oxygenation. These findings would be of greatest concern to the nurse when assessing a patient hospitalized with pneumonia, as they may suggest worsening respiratory function or inadequate oxygenation.The other options, while still important components of the overall patient assessment, do not necessarily indicate an immediate concern in this context:Being oriented to date, time, and place suggests that the patient's cognitive function is intact and does not indicate any immediate problems.Clear breath sounds are a positive finding, as they suggest that the patient's lungs are free from abnormal sounds (e.g., crackles or wheezes) that might indicate complications or worsening pneumonia.A hemoglobin level of 13 g/dl is within the normal range for an adult woman and does not suggest any immediate concerns related to the patient's oxygen-carrying capacity.Therefore, the nurse should prioritize the finding of delayed capillary refill and buccal cyanosis, as these findings may indicate a need for further assessment, intervention, or adjustments to the patient's treatment plan.

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  • 21. 

    During a change-of-shift report, it would be important for the nurse relinquishing responsibility for the care of the patient to communicate. Which of the following facts to the nurse assuming responsibility for the care of the patient?

    • A.

      The patient verbalized, “My headache is gone.”

    • B.

      The patient’s barium enema performed 3 days ago was negative.

    • C.

      The patient’s NGT was removed 2 hours ago

    • D.

      The patient’s family came for a visit this morning.

    Correct Answer
    C. The patient’s NGT was removed 2 hours ago
    Explanation
    During a change-of-shift report, it is essential to communicate pertinent information about the patient's current status, recent interventions, and any changes in their condition. In this case, the fact that the patient's nasogastric tube (NGT) was removed 2 hours ago is the most important information to relay to the nurse assuming responsibility for the patient's care. The removal of the NGT indicates a change in the patient's treatment plan and may have implications for their nutrition, medication administration, or monitoring for complications. The nurse assuming responsibility needs to be aware of this information to provide appropriate care and assess the patient's response to the removal of the NGT. While the other options (the patient verbalizing that their headache is gone, the patient's barium enema results from 3 days ago, and the patient's family visiting in the morning) may be relevant to the patient's overall care and progress, they do not have the same immediate impact on the patient's current care plan as the removal of the NGT.

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  • 22. 

    Which statement is the most appropriate goal for a nursing diagnosis of diarrhea?

    • A.

      “The patient will experience a decreased frequency of bowel elimination.”

    • B.

      “The patient will take anti-diarrheal medication.”

    • C.

      “The patient will give a stool specimen for laboratory examinations.”

    • D.

      “The patient will save urine for inspection by the nurse.

    Correct Answer
    A. “The patient will experience a decreased frequency of bowel elimination.”
    Explanation
    When formulating a nursing diagnosis and establishing goals, it is essential to focus on patient outcomes and the desired response to interventions. In the case of diarrhea, the primary goal is to alleviate the symptoms and restore normal bowel function. Therefore, the most appropriate goal for a nursing diagnosis of diarrhea is for the patient to experience a decreased frequency of bowel elimination.The other options, while they may be part of the overall care plan, do not directly address the resolution of the patient's diarrhea:Taking anti-diarrheal medication is an intervention rather than a goal, and its effectiveness should be evaluated based on the patient's response.Providing a stool specimen for laboratory examinations may help identify the cause of diarrhea but does not constitute a goal for resolving the issue.Saving urine for inspection by the nurse is unrelated to the nursing diagnosis of diarrhea, as it does not address the patient's bowel function or the resolution of their symptoms.In summary, the most appropriate goal for a nursing diagnosis of diarrhea is to decrease the frequency of bowel elimination, as this outcome reflects the desired resolution of the patient's symptoms.

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  • 23. 

      Which of the following is the most important purpose of planning care with this patient?

    • A.

      Development of a standardized NCP.

    • B.

      Expansion of the current taxonomy of nursing diagnosis.

    • C.

      Making of individualized patient care.

    • D.

      Incorporation of both nursing and medical diagnoses in patient care.

    Correct Answer
    C. Making of individualized patient care.
    Explanation
    The most important purpose of planning care with a patient is to develop an individualized patient care plan. Individualized care planning ensures that the patient's unique needs, preferences, and values are considered, leading to better patient outcomes and satisfaction. By involving the patient in the planning process, nurses can tailor interventions and goals to the specific needs of the individual, fostering a collaborative and patient-centered approach to care.While the other options may be relevant to nursing practice, they do not represent the primary purpose of planning care with a patient:A standardized nursing care plan (NCP) can provide a useful framework for addressing common patient needs, but it should be adapted and individualized to meet the unique requirements of each patient.Expanding the current taxonomy of nursing diagnoses is an ongoing process in the nursing profession to better classify and address patient problems. Still, it is not the primary purpose of planning care with an individual patient.Incorporating both nursing and medical diagnoses in patient care is essential for a comprehensive approach to treatment, but the primary focus of nursing care planning is on the patient's responses to health problems and the nursing interventions required to address them.In summary, the most important purpose of planning care with a patient is to develop an individualized care plan that addresses the patient's unique needs and promotes optimal health outcomes.

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  • 24. 

     Using Maslow’s hierarchy of basic human needs, which of the following nursing diagnoses has the highest priority?

    • A.

      Ineffective breathing pattern related to pain, as evidenced by shortness of breath.

    • B.

      Anxiety related to impending surgery, as evidenced by insomnia.

    • C.

      Risk of injury related to autoimmune dysfunction.

    • D.

      Impaired verbal communication related to tracheostomy, as evidenced by the inability to speak.

    Correct Answer
    A. Ineffective breathing pattern related to pain, as evidenced by shortness of breath.
    Explanation
    According to Maslow's hierarchy of basic human needs, physiological needs, such as the need for oxygen and proper functioning of the body, are the most fundamental and take priority over other needs. In this case, the nursing diagnosis of ineffective breathing pattern related to pain and shortness of breath addresses a critical physiological need, as it may indicate a life-threatening situation requiring immediate intervention.The other nursing diagnoses, while important, do not address physiological needs as urgently:Anxiety related to impending surgery and insomnia is a psycho-social need, which is important to address but not as immediately critical as a severe breathing problem.Risk of injury related to autoimmune dysfunction is a potential problem that needs monitoring and prevention, but it does not represent an immediate threat to the patient's physiological stability.Impaired verbal communication related to a tracheostomy is a safety and communication need, which is essential for the patient's well-being and interaction with others. However, it does not have the same level of urgency as the ineffective breathing pattern.In summary, using Maslow's hierarchy of basic human needs, the nursing diagnosis of ineffective breathing pattern related to pain and shortness of breath has the highest priority, as it addresses an immediate physiological need crucial for the patient's survival.

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  • 25. 

    When performing an abdominal examination, the patient should be in a supine position with the head of the bed at what position?

    • A.

      30 degrees

    • B.

      90 degrees

    • C.

      45 degrees

    • D.

      0 degree

    Correct Answer
    D. 0 degree
    Explanation
    During an abdominal examination, the patient should be positioned supine (lying flat on their back) with the head of the bed at 0 degrees. This position allows for optimal visualization and palpation of the abdominal structures, as it helps to relax the abdominal muscles and promotes proper assessment of the abdominal organs. While some examinations or procedures may require different positions, such as elevating the head of the bed to 30 or 45 degrees, the standard position for an abdominal examination is supine with the head of the bed at 0 degrees.

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  • 26. 

    During the planning phase of the nursing process, which of the following is the outcome?

    • A.

      Nursing history

    • B.

      Nursing notes

    • C.

      Nursing care plan

    • D.

      Nursing diagnosis

    Correct Answer
    C. Nursing care plan
    Explanation
    The outcome or the product of the planning phase of the nursing process is a Nursing care plan.

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Allison Martin |BSN |
Healthcare
Allison Martin is a dedicated School Nurse at St. Bernard's School, with over 20 years of invaluable nursing experience. Holding a Bachelor of Science in Nursing (BSN) from Drexel University's College of Nursing and Health Professions, specializing in neuroscience and cardiac care, Allison's commitment to excellence is evident in her professional focus, as she continually strives to provide high-quality care and support to the school community. Additionally, she actively contributes to nursing education by reviewing and refining quizzes, ensuring they align with current standards and promote learning excellence.

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    ProProfs Editorial Team

    Expert Reviewed by
    Allison Martin
  • Aug 12, 2010
    Quiz Created by
    RNpedia.com
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