1. Which is a judgement about a particular patient’s potential need or problem?

a. A goal

b. An assessment

c. Subjective data

d. A nursing diagnosis

ANS: D

Nursing diagnosis is the phase of the nursing process during which a clinical judgement is made about how a patient respondstoheath conditions and life processes or vulnerability for that response. DIF: Cognitive Level: Knowledge

2. The patient is to receive oral furosemide (Lasix) every day; however, because the patient is unable to swallow, he cannot takemedication orally, as ordered. The nurse needs to contact the physician. What type of problem is this?

a. A “right time” problem

b. A “right dose” problem

c. A “right route” problem

d. A “right medication” problem

ANS: C

This is a “right route” problem: the nurse cannot assume the route and must clarify the route with the prescriber. This is not a“righttime” problem because the ordered frequency has not changed. This is not a “right dose” problem because the dose is not relatedtoan inability to swallow. This is not a “right medication” problem because the medication ordered will not change, just the route. DIF: Cognitive Level: Application

3. The nurse has been monitoring the patient’s progress on his new drug regimen since the first dose and has been documentingsignsof possible adverse effects. What nursing process phase is the nurse practising?

a. Planning

b. Evaluation

c. Implementation

d. Nursing diagnosis

ANS: B

Monitoring the patient’s progress is part of the evaluation phase. Planning, implementation, and nursing diagnosis are not

illustrated by this example. DIF: Cognitive Level: Application

4. The nurse is caring for a patient who has been newly diagnosed with type 1 diabetes mellitus. Which statement best illustratesanoutcome criterion for this patient?

a. The patient will follow instructions. b. The patient will not experience complications. c. The patient adheres to the new insulin treatment regimen. d. The patient demonstrates safe insulin self-administration technique. ANS: D

Having the patient demonstrate safe insulin self-administration technique is a specific and measurable outcome criterion. Followinginstructions and avoiding complications are not specific criteria. Adherence to the new insulin treatment regimen is not objectiveand would be difficult to measure. DIF: Cognitive Level: Application

5. Which activity best reflects the implementation phase of the nursing process for the patient who is newly diagnosed withtype1diabetes mellitus?

a. Providing education regarding self-injection technique

b. Setting goals and outcome criteria with the patient’s input

c. Recording a history of over-the-counter medications used at home

d. Formulating nursing diagnoses regarding knowledge deficits related to the new

treatment regimen

ANS: A

Education is an intervention that occurs during the implementation phase. Setting goals and outcome criteria reflects the planningphase. Recording a drug history reflects the assessment phase. Formulating nursing diagnoses regarding a knowledge deficit

reflects analysis of data as part of the planning phase. DIF: Cognitive Level: Analysis