Q: A nurse is using the ABCs to prioritize care. Which equation best represents the order of priorities?

$$\text{Airway} \u003e \text{Breathing} \u003e \text{Circulation}$$

Question 1

A nurse is developing a care plan for a patient who has just undergone abdominal surgery. Which of the following nursing diagnoses should be given the highest priority according to Maslow’s Hierarchy of Needs and the ABCs?

Accepted Answer

Ineffective airway clearance related to abdominal pain post hernia repair

Question 2

Which of the following statements best describes a standardized nursing care plan?

Accepted Answer

It addresses common needs for clients with similar diagnoses.

Question 3

A nurse writes the following expected outcome: 'Client will ambulate 30 m independently three times a day by Sept 30.' Which SMART criteria does this outcome meet? Select the best answer.

Accepted Answer

Specific, Measurable, Achievable, Realistic, Timeframe

Question 4

Which of the following is an example of a dependent nursing intervention?

Accepted Answer

Administering medication as prescribed by a physician

Question 5

A nurse is planning care for a patient with decreased mobility on the left side following a stroke. Which type of care plan is most appropriate?

Accepted Answer

Individualized care plan

Question 6

When evaluating the effectiveness of a nursing intervention, which of the following steps should the nurse take FIRST?

Accepted Answer

Compare collected data with expected outcomes

Question 7

A nurse documents: 'Client’s temperature decreased to 38.2°C after tepid sponge bath, but goal was temperature below 37°C.' According to the evaluation phase, what is the correct conclusion?

Accepted Answer

Goal partially met

Question 8

Which of the following is a collaborative nursing intervention?

Accepted Answer

Working with a physical therapist to develop a mobility plan

Question 9

A nurse is setting priorities for a patient with multiple health issues. Which scenario best illustrates an intermediate priority?

Accepted Answer

Preventing complications from immobility

Question 10

Which of the following nursing orders includes all components of 'How', 'What', and 'When'?

Accepted Answer

Turn patient every 2 hours, rotating from lateral to supine

Question 11

A nurse is planning discharge for a patient. Which phase of planning does this activity represent?

Accepted Answer

Discharge planning

Question 12

Which of the following is the best example of a client-centered expected outcome?

Accepted Answer

Client will report pain level less than 3 on a scale of 0 to 10 by 2200 hours on Sept 29

Question 13

Which of the following is NOT a criterion for writing a SMART goal?

Accepted Answer

Subjective

Question 14

A nurse is using the ABCs to prioritize care. Which equation best represents the order of priorities?

Accepted Answer

$$	ext{Airway} \u003e 	ext{Breathing} \u003e 	ext{Circulation}$$

Question 15

Which documentation principle is required by the Personal Health Information Privacy Act (PHIPA, 2000) in Ontario?

Accepted Answer

Documentation must be confidential, private, and secure

Question 16

A nurse is evaluating a client’s progress towards a goal. Which type of data should be used to support whether the goal was met?

Accepted Answer

Both subjective and objective data

Question 17

Which of the following is an example of an independent nursing intervention?

Accepted Answer

Initiating health teaching about self-care

Question 18

A nurse is planning care for a client with constipation related to decreased activity and use of analgesics post-surgery. Which intervention is most appropriate to address the contributing factor?

Accepted Answer

Encourage ambulation as tolerated

Question 19

Which of the following best describes the purpose of ongoing planning in the nursing process?

Accepted Answer

To update and individualize care at the beginning of each shift or visit

Question 20

A nurse is evaluating a client’s progress and finds that the client’s temperature has returned to normal and the client states comfort. According to the evaluation process, what should the nurse do next?

Accepted Answer

Discontinue the care plan for this problem

Nursing Process: Planning, Implementation, and Evaluation – Study Notes

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