1) While the PN is providing AM care, it is noted that the patient has excessively dry skin. During the bath, the patient reports being very “thirsty”. An appropriate nursing diagnosis would be? a) Potential for impaired skin integrity, related to altered gland function b) Impaired skin integrity, related to altered circulation c) Potential for impaired skin integrity, related to dehydration d) Impaired skin integrity, related to dehydration 2) The most important nursing intervention to correct dry skin is: a) Ask physician to refer patient to a dermatologist b) Avoid bathing until the condition is healed and notify the physician c) Encourage the patient to increase fluid intake, use non-irritating soap, and apply lotion to involved areas. d) Consult the dietician about increasing fat, and necessary measures to prevent infection 3) Gathering information about the client, is which step in the nursing process? a) Intervention b) Diagnosis c) Goals d) Assessment 4) The statement “Using the best clinical evidence to make client decisions” best describes which of the following? a) Evidence based practice b) Applied research c) Nursing research d) Problem solving 5) A client has a nursing diagnosis of Bathing/Hygiene Self-Care Deficit related to left-sided weakness as evidenced by inability to get in and out of the bathroom, inability to wash hands or face, and fatigue. An appropriate goal for this client would be that the client: a) By 04/26/2021, 3 days from now client will demonstrate the ability to wash face independently b) Attend occupational therapy once a week to focus on left arm movement c) Nurse will bathe client once daily d) By June the patient will bathe independantly 6) Which of the following occurs during the evaluation phase of  the nursing process? a) It is demonstrated that the client no longer needs care b) It is the client’s responsibility to demonstrate goal attainment c) The nurse determines if the client should be discharged d) The nurse judges the clients progress towards the achievement of the goals. 7) Which of the following is an example of objective data? a) The physician reports the client is experiencing chest pain b) The client’s abdomen is round and soft c) The client reports nausea d) The client's spouse asks that he be returned to bed because he is tired. 8) All of these events are occurring at the same time. Which one should the nurse deal with first? a) The patient is requesting pain medication for a headache, rating 6/10 on the pain scale. b) The physician is requesting to speak to you c) The tube feeding pump is beeping due to the bag running dry d) The patient who has COPD has oxygen at 4LPM via nasal cannula, sats 96% 9) A nurse is making a care plan for a patient receiving enteral tube feedings. The nurse identifies which nursing diagnosis as the highest priority? a) Risk for diarrhea b) Risk for fluid volume defecit c) Risk for imbalanced nutrition d) Risk for aspiration 10) The planning phase of the nursing process includes which of the following: a) Evaluating goal achievement b) Assessing the situation and determining a problem c) Performing nursing actions and documenting them d) Setting goals with the client 11) Patient Mr. Peterson in room 10C has bilateral wrist restraints on as he has been pulling at his tracheostomy tube. Which nursing intervention would be priority? a) Assess color, resp rate and depth, check sats b) Perform passive ROM Q2H c) Assess color, sensation,  movement of hands d) Assess skin integrity and apply lotion under restraint to prevent break in skin 12) Arrange the following nursing diagnoses in order of priority: With the most important listed first: 1. Constipation, 2. Ineffective airway clearance, 3. Risk for impaired skin integrity, 4. Ineffective peripheral tissue perfusion. a) 1, 2, 3, 4 b) 2, 4, 1, 3 c) 4, 1, 3, 2 d) 3, 4, 1, 2

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