Nursing Process

Question 1

A nurse is admitting a client with pneumonia.
The client has crackles in the right lower lobe, oxygen saturation of 91%, and a respiratory rate of 26 breaths/min.
Which nursing diagnosis has the highest priority?

Accepted Answer

Impaired gas exchange related to alveolar inflammation

Answer

Activity intolerance related to fatigue

Answer

Deficient knowledge related to antibiotic therapy

Answer

Anxiety related to hospitalization

Question 2

During the assessment phase of the nursing process, the nurse obtains subjective data. Which is an example of subjective data?

Accepted Answer

The client states, 'My chest feels tight and I am short of breath'

Answer

The client's blood pressure is 158/96 mmHg

Answer

The client has pitting edema of 2+ in both ankles

Answer

The client's respiratory rate is 22 breaths per minute

Question 3

A nurse has identified the nursing diagnosis 'Risk for infection related to impaired skin integrity.' In the planning phase, which outcome is written correctly using SMART criteria?

Accepted Answer

The client will remain free of signs of wound infection as evidenced by no erythema, edema, or purulent drainage by day 3

Answer

The client will understand wound care before discharge

Answer

The nurse will change the wound dressing every day

Answer

The client will have a better wound by the end of the week

Question 4

A nurse implements a turning schedule for a client with limited mobility. During evaluation, the nurse notes a new stage 2 pressure ulcer on the client's sacrum. What is the nurse's next action?

Accepted Answer

Revise the care plan to increase repositioning frequency and add a pressure-relief mattress

Answer

Continue the current care plan because pressure ulcers can develop despite good care

Answer

Document the finding and reassess the client at the next scheduled evaluation

Answer

Discharge the client to a long-term care facility for wound management

Question 5

A nurse is collecting data on a newly admitted client. Which action is part of the assessment phase of the nursing process?

Accepted Answer

Auscultating lung sounds and reviewing recent laboratory results

Answer

Setting a goal that the client will ambulate 50 feet three times daily

Answer

Administering prescribed antibiotics for a confirmed urinary tract infection

Answer

Teaching the client how to use an incentive spirometer postoperatively

Question 6

A nurse writes the following nursing diagnosis: 'Impaired physical mobility related to left hip pain as evidenced by inability to bear weight and refusal to ambulate.' Which part of this statement represents the defining characteristics?

Accepted Answer

Inability to bear weight and refusal to ambulate

Answer

Impaired physical mobility

Answer

Related to left hip pain

Answer

The entire three-part PES statement