4.

What is the problem with the following outcome goal, ―Patient will state
pain is less than or equal to 3 on a 0 to 10 pain scale‖?
A. None, goal is written correctly B. It is not measurable C. No target time is
given D. Patient behavior is missing Answer: C Rationale: Outcome goals
should be SMART (specific, measurable, appropriate, realistic, and timely).
There is no time estimate for goal attainment. Thus, option A is incorrect.
(Hogan et. al., Prentice Hall Reviews and Rationales Series for Nursing:
Fundamentals of Nursing)
5. When evaluating an adult patient's blood pressure reading. The nurse
considers the patient's age. This is an example of which of the following?

A. Comparing data against standards B. Clustering data C. Determining gaps

in the data D. Differentiating cues and inferences Answer: A Rationale:
Analysis of the client data (blood pressure reading) requires knowledge of the
normal blood pressure range for an adult. The nurse compares client data
against standards to identify significant cues. (Hogan et. al., Prentice Hall
Reviews and Rationales Series for Nursing: Fundamentals of Nursing)
Situation 2. Jason has a nursing diagnosis of ineffective airway clearance
related to excessive secretions and is at risk for infection because of retained
secretions. Part of Nurse Melai’s nursing care plan is to loosen and remove
excessive secretions in the airway.
11. Nurse Melai listens to Jason’s bilateral sounds and finds that congestion
is in the upper lobes of the lungs. The appropriate position to drain the
anterior and posterior apical segment of the lungs when the nurse does
percussion would be:

A. Patient lying on his back then flat on his abdomen on Trendelenburg

position B. Patient seated upright in bed or on a chair then leaning forward in
sitting position then flat on his back and on his abdomen C. Patient lying flat
in his back and then flat on his abdomen D. Patient lying on his right then left
side on Trendelenburg position Answer: B
Rationale: Chest physiotherapy is a dependent nursing function that uses principles
of percussion, vibration and postural drainage to drain thick tenacious bronchial
secretions. Percussion is done by clapping cupped hand over the affected lobe of
the lung. Positioning varies according to the area of affectation. Patients with