Title DIAGNOSTIC EXAMINATION - NP1 - ANSWER KEY ✅

B. Side-lying C. Prone D. Supine Situation: You are caring for a post-craniotomy patient, 45 yrs old. The patient is lethargic but responds to stimuli, with GCS 14 E3V5M6, PR 98bpm, RR 15 cycles/min, and a BP 120/75. You use the nursing process as you care for the patient. 16. Which of these is not a purpose of the nursing process? A. It offers a plan of care to a patient that is organized according to the goals set by the nurse. B. It helps nurses identify a client’s health status, and actual or potential health care problems. C. It delivers specific nursing interventions for the client to be able to meet his identified needs. D. It diagnoses and treats human responses to actual or potential health problems. 17. In planning for your care, you decide to use the Nursing Interventions Classification (NIC) taxonomy. Which of these indicate that you need further teaching on using NIC? A. Documenting the customized activities as planned, rather than the broad NIC labels. B. Only selecting NIC intervention labels that are appropriate to the client and can fit the available resources. C. Including all the activities under the appropriate NIC label selected D. Using the nursing problems, goals, and outcomes identified as guide to selecting NIC labels 18. Which of the following principles does the nurse use in selecting interventions for the care plan? A. Always select independent interventions when possible. B. Actions should address the etiology of the nursing diagnosis. C. There is one best intervention for each goal or outcome. D. Interventions should be “doing,” not just “monitoring.” 19. Implementation is related to other steps of the nursing process. Which of the following statements is true regarding the relationship of the implementing phase to other phases? A. After implementing, the nurse moves towards the diagnosing phase. B. The data that the nurse gathered during assessment are reassessed in the implementing phase. C. The nurse’s need for actual involvement of members from other health disciplines in implementing occurs during the planning phase. D. Evaluation can begin after all interventions have been carried out. 20. Evaluation is done primarily to identify whether: A. The nursing interventions planned were carried out B. Desired outcomes have been achieved C. There was a change in the client’s condition D. The implemented activities were effective SITUATION: The nurse contributes to the assessment of a client’s health status by collecting specimens of body fluids. All hospitalized clients have at least one laboratory specimen collected during their stay in the hospital or health care facility. 21. Nursing responsibilities associated with specimen collection include: (Select all that applies) 1. To remind the medical technologist to explain the purpose of the specimen collection. 2. Provide client comfort, privacy and safety. 3. Ensure that the client or staff follows the correct procedure. 4. Transport the specimen promptly. 5. Report abnormal finding to the health care provider. A. 1,2,3 B. 3,4,5 C. 1,2,3,4 D. 2,3,4,5 22. Analysis of stool specimen can provide information about a client’s health condition. Which of the following statements is CORRECT? A. To analyze for dietary products and digestive secretions like Steatorrhea, the nurse needs to collect at least 1 inch of formed stool. B. To detect parasites in the stool it is important to let it stay in the nurse’s station for a while to let the stool cool down. C. To determine presence of blood or hidden blood in the stool, the nurse needs to perform stool culture. D. To detect bacteria and viruses. Only small amount of feces is required. Note if the client receives antibiotics. 23. Nurses need to give clients which of the following instructions in collecting stool specimen? (Select all that applies) 1. Notify the nurse as soon as possible after defecation, particularly for specimens that need to be sent to the laboratory immediately. 2. When obtaining stool samples, handling the bedpan and disposing the contents, the nurse follows a medical aseptic technique. 3. If possible do not contaminate with urine and blood. 4. Use one or two tongue blades to transfer the specimen into the container. A. 1,2,3 B. 2,3 C. 2,3,4 D. 1,2,3,4 24. Certain foods and medications may cause inaccurate results for Guaiac Test. A false negative result may occur because of ingestion of: (Select all that applies) A. Red meat such as beef, lamb, liver and processed meat. B. Raw fruits like melon C. Aspirin and Steroids D. Vitamin C 250 mg / day 25. To collect urine from a Foley (retention) catheter, the nurse should follow the following nursing actions, EXCEPT: A. To aspirate urine and to facilitate sealing of the rubber, insert the needle at a 10 degree angle. B. Withdraw the required amount of urine. 3 ml for urine culture and 30 ml for routine urinalysis. C. Clean and wipe the area with Alcohol or a Disinfectant swab prior to insertion of needle. D. For a needleless port, insert the Luer Lock Syringe at 90 degree angle. SITUATION: A nurse is caring for an ambulatory 60 y/o male patient who has overflow urinary incontinence secondary to benign prostatic hypertrophy (BPH). The physician orders external catheter application for the patient. 26. The nurse is aware that the following are the purposes of condom catheter application BUT: A. To collect urine and control urinary incontinence B. To permit physical activity of the patient C. To promote relaxation of the urinary bladder D. To prevent skin irritation 27. During condom catheter application, the nurse must follow these standards apart from: A. Roll the condom outward onto itself B. Roll the condom over the penis, leaving 2.5-inch distance from the tip of the penis to the connecting tube C. Make sure that the tip of the penis is not touching the condom and that the condom is not twisted. D. Instruct the client to keep the drainage below the level of the condom and avoid loops or kinks in the tubing. 28. The nurse is aware that she should attach the urinary drainage bag of the condom catheter to the: A. Side rails B. Bed frame C. Patient’s gown D. Patient’s leg 29. The nurse is knowledgeable that how often should she assess the penis of the patient? TOP RANK REVIEW ACADEMY, INC. Page 2 | 7