Fundamentals Of Nursing ( FON 2 )

Unit # 01 ( Nursing Process )

Q.1 : The nurse in charge identifies a patient's responses to actual or potential

health problems during which step of the nursing process?

A. Assessing
B. Diagnosing
C. Planning
D. Evaluating

Q.2 : A nurse is revising a client's care plan. During which step of the
nursing process does such a revision take place?

A. Assessment
B. Planning
C. Implementation
D. Evaluation

Q.3 Using Maslow's hierarchy of needs, a nurse assigns the highest

priority to which client need?

A. Elimination
B. Security
C. Safety
D. Belonging

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Q.4 : The most important nursing intervention to correct skin dryness is:

A. avoid bathing until the condition is remedied and notify physician

B. ask physician to refer the patient to a dermatologist
C. Consult the dietitian about increasing fat intake, and take necessary
measures to prevent infection
D. encourage the patient to increase fluid intake, use nonirritating soap,
and apply lotion to involved areas.

Q.5 In emergency Situation, Nurse should go first for the assisment of*

A. Bone fracture

B. Circulation

C. Airway

D. Pulse

Q.6 : The nurse repositions a client who has difficulty breathing. Which nursing
action, when performed following the intervention, demonstrates evaluation?

A. Instructing the client the importance of mobility

B. Arranging the pillows behind the client's back

C. Checking the client's respiratory status

D. Changing the rate of flow for the oxygen delivery system

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Q.7: The nurse is caring for a one day postoperative client with a new
colostomy. What nursing diagnosis would be the primary concern for the nurse?

A. Activity intolerance
B. Ineffective Health Maintenance
C. Impaired bowel elimination
D. Ineffective coping

Q. 8: _______ assessments can be done with an initial assessment. They identify

new or overlooked problems. They are important because they can "flag"
existing problems.

A. Initial
B. Focused
C. On-going
D. Emergency

Q. 9: Time lapsed assessments compare current status to the ______data

A. Subjective
B. Projected
C. Objective
D. Baseline

Q.10: _____ is the conscious and deliberate use of the five senses to gather data

A. Assessment
B. Interview
C. Observation

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Q. 11: The _____ step of the nursing process interprets and analyzes data
gathered

A. Assessment
B. Diagnosis
C. Implementation
D. Evaluation

Q. 12: A permanent, confidential, legal collection of medical information that

includes assessments, implementations, evaluations, management plans, and
progress notes.

A. Care Tracker
B. Resident Care plan
C. Resident Medical Record
D. ADLs

Q. 13: Which is not included in care plans?

A. level of independence in ADLs

B. treatments
C. statement of issues
D. none of the above

Q. 14: What is the purpose of the nursing process?

A. Assist family members to make healthcare decisions.

B. Provide nurses with a framework to deliver comprehensive care.
C. Help other healthcare professionals know what is going on with the client.
D. Organize information so the nurse knows what is wrong with the client.

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Q. 15: Assessment includes:

A. Subjective findings
B. Physical findings
C. Social information
D. All of the above

Q. 16: Which of the following is objective data?

A. Pain 5/10
B. Temp 100.3
C. Complaints of fatigue
D. Client states "I am sleepy."

Q.17: Which of the following are subjective?

A. WBC 8,000
B. X ray results
C. Complains of hunger
D. Report from surgeon

Q. 18: Analysis of subjective and objective data leads to which outcome?

A. The cause of the surgeon's behavior.

B. Information for the family.
C. Conclusions about skills of nurse.
D. Accurate nursing diagnosis.

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Q. 19: What is the North American Nursing Diagnosis Association (NANDA)
responsible for?

A. Determine independent nursing diagnosis and action.

B. Support NLN in making new diagnosis.
C. Establishing and determining new diagnosis for allied health.
D. Developing criteria for collaborative practice between nursing and MD.

Q. 20: The planning stage of the nursing process involves:

A. Outcomes and goals

B. Goals, outcomes, and interventions
C. Interventions based on medical diagnosis.
D. Goals based on medical diagnosis.

Q. 21: Client outcomes include which of the following?

A. Actions of the client to accomplish goals.

B. Cues clustered to enhance diagnostic goals.
C. List of unit policies and procedures.
D. Staff credentials and goals for renewal.

Q. 22: Which of the following is true about interventions?

A. They assist with data collection.

B. Connect patient goals and outcomes.
C. They are broadly applied to all patients.
D. Improve relationship between nursing staff and allied health.

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Q. 23: During the evaluation stage,

A. Determine progress toward goals completion.

B. Assess outcomes for completion.
C. Edit nursing care plan.
D. All of the above

Q. 24: If the client has not completed the plan, but the goal is still relevant

A. Create a new plan.

B. Initiate new interventions.
C. Reassess in 24 hours.
D. Adjust diagnosis to suit outcome.

Q. 25: The stem part of the nursing diagnosis statement guides the nurse in
developing which other part of the nursing care plan?

A. goal/outcome
B. intervention
C. evaluation
D. etiology

Q. 26: What are two types of nursing diagnosis?

A. direct and indirect

B. independent and collaborative
C. actual and potential
D. independent and dependent

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Q. 27: Which of the following are valid sources for patient assessment data?

A. patient's family
B. medical record/chart
C. healthcare team
D. All of the above

Q. 28: The medical diagnosis is never included as a part of the nursing diagnosis.

A. True
B. False

Q. 29: The implementation phase of the nursing care plan should include:

A. evaluation of the nursing care plan

B. patient teaching
C. identifying a nursing diagnosis
D. selection of the nursing diagnosis

Q. 30: Goals and outcomes should be:

A. written after determining patient interventions

B. written before developing a nursing diagnosis
C. evaluated based on doctor's orders
D. evaluated and labeled as met, unmet, partially met

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Q. 31: Which of the following will help the nurse prioritize needs?

A. identifying a problem, cause of the problem, and defining characteristics

B. ensuring assessment data is thorough and complete
C. utilization of Maslow's Hierarchy
D. assessment, teaching, and evaluation

Q. 32: The nurse understands the following statement " The patient will reduce
his risk of falls by correct use of his walker each time him ambulates" is an
example of...

A. nursing diagnosis
B. outcome
C. goal
D. intervention

Q. 33: It is important to document: (select all that apply)

A. only what the patient tells you

B. what you as the nurse observe
C. what you as the nurse interpret or infer from the data collected
D. nursing history and physical assessment

Q. 34: What is the first and most critical step in the nursing process, and
accuracy of the data collected affects all other phases of the nursing process

A. Planning
B. Assessment
C. Diagnosis
D. Evaluating

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Q. 35: The nurse knows which intervention is a dependent intervention?

A. Obtaining a client's BP
B. Massaging a client's back
C. Administering medications to a client
D. Assessing a client's lung sounds

Q. 36: A ________ is performed to identify a life-threatening problem (choking,

stab wound, heart attack).

A. Initial assessment
B. Focus assessment
C. Emergency assessment
D. Critical assessment

Q. 37: Nursing Process is accepted for clinical practice established by the ___?

A. NANDA
B. WHO
C. ANA
D. None of the above

Q. 38: A nurse is performing an initial assessment for a client. Which of the

following would be considered subjective information received during the
assessment?

A. The client has a pinpoint rash on the face and trunk

B. The client's blood pressure increases when the provider enters the
room
C. The client rates pain at a level of 6 on the numeric rating scale
D. The client weighs 186 pounds

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Q. 39: A nurse is assessing a client who is being admitted to the hospital from
home for knee surgery. Which part of the assessment would be included with
an admission assessment but not with a routine focused assessment?

A. Assessment of the client's vital signs

B. Assessment of the client's pain
C. Assessment of knee range of motion
D. Assessment of the cause of the client's knee injury

Q. 40: The nurse is planning care for a client and prioritizes health promotion
and accident prevention. Which of the following age groups does this
client most likely fall into, with accidents and injuries from recreational
activities as the main health concern?

A. Middle adulthood
B. Adolescence
C. Early adulthood
D. School age

Q. 41: A nurse is caring for a client who has been sexually abused. Which of the
following interventions should the nurse implement to establish rapport and to
demonstrate safety?

A. Let the client spend time alone in a quiet area

B. Delay treatment until the client can talk about the situation
C. Assess the client's stress level before performing procedures
D. Respond to shocking information by ignoring or disregarding the
account

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Q. 42: Evaluation are further in which two forms are considered?

A. Formative
B. Summative
C. Outcomes
D. Both a and b

Q. 43: Which phase of nursing process is based on critical thinking?

A. Assessment
B. Planning
C. Diagnosis
D. Interventions

Q. 44: The signature of nurse on documentation represent which role of nurse ?

A. Care giver
B. Accountable
C. Reflective
D. Commitment

Q. 45: Nursing process developed on based of which theory and by whom ?

A. Nursing theory, Ida jean Orlando

B. Environmental theory, Florence nightingale
C. need based theory, Maslow
D. Skills based ,verginia

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Q. 46: How many format in which weh formulate our diagnosis?

A. Three
B. Two
C. Four
D. One

Q. 47: Checking of vital signs comes in which types of nursing interventions?

A. Dependent
B. Independent
C. Collaborative
D. Non of them

Q. 48: When the sign are abesnt but their chance that they have suffer from it
it's comes in which status of nursing diagnosis?

A. ACTUAL
B. RISK
C. POSSIBLE
D. SYNDROME

Q. 49: When nurse documents in nursing diagnosis that clients have disturb
body image so in medical diagnosis which term written by physician?

A. CvA
B. Amputation
C. Post tractoetomy
D. Non of them

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Q. 50: The ongoing phase of nursing process are

A. Assessment
B. Planning
C. Evaluation
D. Daignose

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