1 |Page
NUR 514: EXAM 1 WITH QUESTIONS
AND CORRECT ANSWERS
A client comes to the walk-in clinic with reports of abdominal pain and
diarrhea. While taking the client's vital signs, the nurse is implementing
which phase of the nursing process?
A. Assessment
B. Diagnosis
C. Planning
D. Implementation - correct answer-A. Assessment
Rationale: The first step in the nursing process is assessment, the process
of collecting data. All subsequent phases of the nursing process (options 2,
3, and 4) rely on accurate and complete data.
Six Competencies of QSEN - correct answer-Patient-Centered Care
Teamwork and Collaboration
Evidence-Based Practice
Quality Improvement
Safety
Informatics
,2 |Page
The nurse is measuring the client's urine output and straining the urine to
assess for stones. Which of the following should the nurse record as
objective data?
A. The client reports abdominal pain
B. The client's urine output was 450 mL
C. The client states, "I didn't see any stones in my urine."
D. The client states, "I feel like I have passed a stone." - correct answer-B.
The client's urine output was 450 mL.
Rationale: Objective data is measurable data that can be seen, heard, or
verified by the nurse. The objective data is the measurement of the urine
output. A client's statements and reports of symptoms are documented as
subjective data, such as the data found in options 1, 3, and 4.
The Joint Commission - correct answer-an independent, not-for-profit
organization that evaluates and accredits healthcare organizations
Core measures developed to improve the quality of health care by
implementing a national, standardized performance measurement system
emergency preparedness (internal/external)
When evaluating an elderly client's blood pressure (BP) of 146/78 mmHg,
the nurse does which of the following before determining whether the BP is
normal or represents hypertension?
A. Compare this reading against defined standards
,3 |Page
B. Compare the reading with one taken in the opposite arm
C. Determine gaps in the vital signs in the client record
D. Compare the current measurement with previous ones - correct answer-
A. Compare this reading against defined
Rationale: Analysis of the client's BP requires knowledge of the normal BP
range for an older adult. The nurse compares the client's data against
identified standards to determine whether this reading is normal or
abnormal. Measuring the BP in the other arm (option 2) and comparing the
reading to previous ones (option 4) will give additional client data, but the
comparison alone will not determine whether the BP is normal. Gaps in the
record (option 3) will not aid in interpreting the current measurement.
Patient Rights - correct answer-Right to accept or refuse treatment
Right to dignity, respect, confidentiality and privacy
Right to an informed consent
Right to an advance directive
Right to information and communication
Right to personal safety
Right to understand cost and coverage
Which of the following behaviors by the nurse demonstrates that the nurse
is participating in critical thinking? Select all that apply.
A. Admitting not knowing how to do a procedure and requesting help
B. Using clever and persuasive remarks to support an opinion or position
C. Accepting without question the values acquired in nursing school
, 4 |Page
D. Finding a quick and logical answer, even to complex questions
E. Gathering three assistants to transfer the client to a stretcher after noting
the client weighs 300 lbs. - correct answer-A. Admitting not knowing how to
do a procedure and requesting help
E. Gathering three assistants to transfer the client to a stretcher after noting
the client weighs 300 lbs.
Rationale: Critical thinking in nursing is self-directed, supporting what
nurses know and making clear what they do not know. It is important for
nurses to recognize when they lack the knowledge they need to provide
safe care for a client (option 1). Nurses must also utilize their resources to
acquire the support they need to care for a client safely (option 5). Options
2, 3, and 4 do not demonstrate critical thinking.
Nurse's role in the informed consent process is: - correct answer-Nurses
witness informed consents
Ensure provider gave the necessary information
Ensure patient is competent and understood
Have patient sign the document
Notify the provider if the patient appears not to understand or still has
questions
The nurse has documented the following outcome goal in the care plan:
"The client will transfer from bed to chair with two-person assist." The
charge nurse tells the nurse to add which of the following to complete the
goal?
A. Client behavior
NUR 514: EXAM 1 WITH QUESTIONS
AND CORRECT ANSWERS
A client comes to the walk-in clinic with reports of abdominal pain and
diarrhea. While taking the client's vital signs, the nurse is implementing
which phase of the nursing process?
A. Assessment
B. Diagnosis
C. Planning
D. Implementation - correct answer-A. Assessment
Rationale: The first step in the nursing process is assessment, the process
of collecting data. All subsequent phases of the nursing process (options 2,
3, and 4) rely on accurate and complete data.
Six Competencies of QSEN - correct answer-Patient-Centered Care
Teamwork and Collaboration
Evidence-Based Practice
Quality Improvement
Safety
Informatics
,2 |Page
The nurse is measuring the client's urine output and straining the urine to
assess for stones. Which of the following should the nurse record as
objective data?
A. The client reports abdominal pain
B. The client's urine output was 450 mL
C. The client states, "I didn't see any stones in my urine."
D. The client states, "I feel like I have passed a stone." - correct answer-B.
The client's urine output was 450 mL.
Rationale: Objective data is measurable data that can be seen, heard, or
verified by the nurse. The objective data is the measurement of the urine
output. A client's statements and reports of symptoms are documented as
subjective data, such as the data found in options 1, 3, and 4.
The Joint Commission - correct answer-an independent, not-for-profit
organization that evaluates and accredits healthcare organizations
Core measures developed to improve the quality of health care by
implementing a national, standardized performance measurement system
emergency preparedness (internal/external)
When evaluating an elderly client's blood pressure (BP) of 146/78 mmHg,
the nurse does which of the following before determining whether the BP is
normal or represents hypertension?
A. Compare this reading against defined standards
,3 |Page
B. Compare the reading with one taken in the opposite arm
C. Determine gaps in the vital signs in the client record
D. Compare the current measurement with previous ones - correct answer-
A. Compare this reading against defined
Rationale: Analysis of the client's BP requires knowledge of the normal BP
range for an older adult. The nurse compares the client's data against
identified standards to determine whether this reading is normal or
abnormal. Measuring the BP in the other arm (option 2) and comparing the
reading to previous ones (option 4) will give additional client data, but the
comparison alone will not determine whether the BP is normal. Gaps in the
record (option 3) will not aid in interpreting the current measurement.
Patient Rights - correct answer-Right to accept or refuse treatment
Right to dignity, respect, confidentiality and privacy
Right to an informed consent
Right to an advance directive
Right to information and communication
Right to personal safety
Right to understand cost and coverage
Which of the following behaviors by the nurse demonstrates that the nurse
is participating in critical thinking? Select all that apply.
A. Admitting not knowing how to do a procedure and requesting help
B. Using clever and persuasive remarks to support an opinion or position
C. Accepting without question the values acquired in nursing school
, 4 |Page
D. Finding a quick and logical answer, even to complex questions
E. Gathering three assistants to transfer the client to a stretcher after noting
the client weighs 300 lbs. - correct answer-A. Admitting not knowing how to
do a procedure and requesting help
E. Gathering three assistants to transfer the client to a stretcher after noting
the client weighs 300 lbs.
Rationale: Critical thinking in nursing is self-directed, supporting what
nurses know and making clear what they do not know. It is important for
nurses to recognize when they lack the knowledge they need to provide
safe care for a client (option 1). Nurses must also utilize their resources to
acquire the support they need to care for a client safely (option 5). Options
2, 3, and 4 do not demonstrate critical thinking.
Nurse's role in the informed consent process is: - correct answer-Nurses
witness informed consents
Ensure provider gave the necessary information
Ensure patient is competent and understood
Have patient sign the document
Notify the provider if the patient appears not to understand or still has
questions
The nurse has documented the following outcome goal in the care plan:
"The client will transfer from bed to chair with two-person assist." The
charge nurse tells the nurse to add which of the following to complete the
goal?
A. Client behavior
