Tiêu đề DIAGNOSTIC EXAMINATION - NP1 - STUDENT COPY ✅

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? A. 30 minutes after condom catheter application, then q 4 hours B. 1 hour after condom catheter application, then q shift TOP RANK REVIEW ACADEMY, INC. Page 2 | 7

B. Every 1-3 hours C. Every 4-6 hours D. Every 8-10 hours 45. The client’s prognosis went well and the doctor ordered the patient for possible discharge within 24 hours. As the nurse prepares the client for the removal of a nasogastric tube, she instructs the client to: A. Inhale deeply. B. Exhale slowly. C. Hold in a deep breath. D. Pause between breaths. SITUATION: Ensuring safety before, during and after a respiratory diagnostic procedure is an important responsibility of the nurse. The following questions apply. 46. A client named Daryl is suspected of having a pleural effusion. The nurse assesses him for which typical manifestations of this respiratory problem? A. Dyspnea at rest and moist, productive cough B. Dyspnea on exertion and dry, non-productive cough C. Dyspnea at rest and dry, non-productive cough D. Dyspnea on exertion and moist, productive cough 47. The nurse plans to have which of the following items available for immediate use for Daryl’s untreated condition? A. Intubation tray B. Paracentesis tray C. Thoracentesis tray D. Central venous line insertion tray 48. The nurse recalls the nursing interventions before, during, and after aspiration of fluid in the pleural cavity. She was not able to recollect accurately if she anticipates that the doctor will not insert the trocar: A. Below the seventh rib laterally and above the ninth rib posteriorly B. Below the 2nd intercostal space (ICS) anteriorly and above 4th ICS posteriorly C. Below the seventh rib laterally and below the ninth rib posteriorly D. Above the 2nd intercostal space (ICS) anteriorly and below 4th ICS posteriorly 49. The nurse is assessing Daryl’s respiratory status after thoracentesis. The nurse would become most concerned with which of the following assessment findings? A. Equal bilateral chest expansion B. Respiratory rate of 22 breaths per minute C. Diminished breath sounds on the affected side D. Few scattered wheezes, unchanged from baseline 50. Daryl has become progressively dyspneic and now has been co-diagnosed with left tension pneumothorax. Which of the following observed by the nurse indicates that his pneumothorax is rapidly worsening? A. Tracheal deviation to the left B. Tracheal deviation to the center of carina C. Pain on respiration with flat neck veins D. Tracheal deviation to the right Situation: Verbal communication is extremely important especially when the Nurse is exploring problems and disorders with the clients in any age group. Nurse Dante is assigned to different clients in the ward. 51. A client is hospitalized with a diagnosis of possible Cancer of the pancreas. On admission the client asks the nurse, “Do you think I have anything serious like cancer?” What is the nurse’s best reply? A. “What makes you think you have cancer? B. “I don’t know if you do, but let’s talk about it.” C. “Why don’t you discuss this with your doctor?” D. “Don’t worry, we won’t know until all the test result are back.” 52. Nurse Dante approaches a male client and asks how he is feeling. The client states “I’m feeling a bit nervous today.” Which of the following is the Nurse’s best reply? A. Please explain what you mean by the word nervous B. What is making you feel nervous? C. Would a backrub ease your nervousness? D. You do look like you’re nervous 53. When assessing a client what statement would indicate negative self-talk? A. Everyone has to learn something new sometime B. I am looking forward to making home visits , but I am also nervous C. This is going to be difficult, but I know I can do it D. Who can ever have enough experience to prepare for that job? 54. While receiving a preoperative enema a client starts to cry and says. “I’m sorry you have to do this messy thing me,” what is the best response by the nurse? A. “I don’t mind it.” B. “You seem to be upset.” C. “This is part of my job.” D. “Nurses get used to this.” 55. “But you don’t understand” is a common statement associated with adolescent. The best response by the nurse when communicating with an adolescent is to say: A. “I don’t understand.” B. “I would like to understand, let’s talk.” C. “I don’t understand. I was a teenager once too.” D. “I’m not sure have to I believe it’s you who has to understand.” Situation: One of the important roles of the Nurses is being a Health Educator. Clients would always seek information on Health maintenance to prevent illness. 56. Nurse Diana, daughter of Hippolita and the princess of Themycera, is teaching a client about prescribe restricted diet. What is the Nurse’s best initial comment? A. “You can eat only the on this list.” B. “What types of food do you usually eat?” C. “You need to limit the intake of food on this list.” D. “Do you understand why you have these food restrictions?” 57. Nurse Diana is preparing a nursing care plan to a client with Diabetes Mellitus (D.M.) that includes before discharge to know how to self-administer insulin, adjust the insulin dosage, understand the diet, and test the serum for glucose level. The client progresses well and is discharge 5 days following admission. Legally the: A. Nurse was properly functioning as a health teacher B. Visiting nurse should do health teaching in the client’s home C. Family members also should have been taught to administer the insulin D. Physician was responsible and the nurse should have cleared the care with the physician 58. Which teaching method has been evaluated as most effective in a new diabetic client? A. Utilizing breaks after each unit of the teaching session B. Having the client repeat the steps of insulin administration C. Encouraging the client to ask many questions D. Confirming that the client is able to give his own insulin 59. Which of the following statements by a client would alert the Nurse that further teaching on the idea of a restful sleep is indicated? A. I don’t take naps throughout the day B. I go to bed and get up routinely at the same time each day C. I have a small snack and take a bath before going to bed each day D. I went to bed earlier than usual and I rested and watched television until I fall asleep 60. What can the Nurse do to support the client’s ability to sleep in the hospital setting? A. Assess the client’s towards the end of the shift , closer to the normal awakening time B. Darken the room as much as possible by keeping the lights off C. Limit the noise and distraction on the unit D. Provide a bath or shower before bedtime Situation: Benjie, a charge nurse, is attending to the client with an intravenous fluid. 61. What does Nurse Benjie identify as the most likely cause of the infiltration of a client’s IV? A. Excessive height of the IV solution TOP RANK REVIEW ACADEMY, INC. 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