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 responds to heath 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 take medication 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 ―right time‖ problem because the ordered frequency has not changed. This is not a ―right dose‖ problem because the dose is not related to an 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 documenting signs of 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 illustrates an outcome 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. Following instructions and avoiding complications are not specific criteria. Adherence to the new insulin treatment regimen is not objective and would be difficult to measure.