QUESTIONS AND ANSWERS + RATIONALES | STUDY GUIDE |
100% CORRECT
1. After completing an initial assessment of a patient, the nurse charts that the patient's respirations
are eupneic and the pulse is 58 beats per minute. These types of data would be classified as:
A) Reflective
B) Subjective
C) Objective
D) Introspective
Correct Answer: C) Objective
Rationale: Objective data are measurable and observable facts obtained through physical
examination, observation, or diagnostic tests. The patient's respiratory rate and pattern, along
with the pulse rate, are directly observed and measured by the nurse. Subjective data are what the
patient reports, while reflective and introspective are not standard categories.
2. A patient tells the nurse that they feel very nervous, nauseated, and hot. The nurse recognizes
these as:
A) Objective data
B) Subjective data
C) Clinical data
D) Reflective data
Correct Answer: B) Subjective data
Rationale: Subjective data consist of information reported by the patient, including their feelings,
perceptions, and symptoms such as nervousness and nausea. This type of data is considered the
patient's personal experience and cannot be directly measured by the nurse. It forms a vital part
of the health history.
3. The patient's record, laboratory studies, objective data, and subjective data combine to form the:
A) Financial statement
B) Database
C) Discharge summary
D) Admitting data
Correct Answer: B) Database
Rationale: The database is the comprehensive collection of all health information about a patient.
This includes subjective data from the health history, objective data from the physical exam, and
information from the patient's record and lab studies. This database is used for clinical decision-
making and forming nursing diagnoses.
,4. When listening to a patient's breath sounds, the nurse is unsure of a sound that is heard. The
nurse's next action should be to:
A) Document the sound exactly as it was heard
B) Notify the patient's provider immediately
C) Validate the data by asking a colleague to listen to the breath sounds
D) Reassess again in 20 minutes to note whether the sound is still present
Correct Answer: C) Validate the data by asking a colleague to listen to the breath sounds
Rationale: When an assessment finding is uncertain, it is crucial to validate the data. Having a
more experienced nurse or colleague listen to the breath sounds can help confirm the finding and
reduce the risk of misinterpretation. This is a key principle of ensuring accurate assessment.
5. A novice nurse, without a background of skills and experience from which to draw, is more
likely to make decisions using:
A) A set of rules
B) Intuition
C) Advice from supervisors
D) Articles in journals
Correct Answer: A) A set of rules
Rationale: Benner's novice-to-expert theory posits that novice nurses operate by applying learned
rules and context-free guidelines to patient situations. They lack the experiential background to
use intuition or pattern recognition effectively and rely on established protocols.
6. Expert nurses learn to attend to a pattern of assessment data and act without consciously labeling
it. These responses are referred to as:
A) Clinical knowledge
B) The nursing process
C) Diagnostic reasoning
D) Intuition
Correct Answer: D) Intuition
Rationale: According to Benner's model, expert nurses develop an intuitive grasp of clinical
situations. This "intuition" is not a guess, but rather the ability to recognize patterns and act
rapidly based on deep experience, without consciously analyzing each step. It is a hallmark of
expert clinical practice.
7. The nurse is reviewing information about evidence-based practice (EBP). Which statement best
reflects EBP?
A) EBP is simply the use of best practice techniques
B) EBP relies on tradition for support of best practices
C) EBP emphasizes the use of best evidence with the clinician's experience
D) The patient's own preferences are not important with EBP
, Correct Answer: C) EBP emphasizes the use of best evidence with the clinician's experience
Rationale: Evidence-based practice is the integration of the best available research evidence, the
clinician's expertise, and the patient's unique values and circumstances. It is a problem-solving
approach to care that ensures decisions are made based on the most current and valid evidence.
8. The nurse is conducting a class on priority setting for new graduate nurses. Which is an example
of a first-level priority problem?
A) Patient with postoperative pain
B) Individual with shortness of breath and respiratory distress
C) Newly diagnosed patient with diabetes who needs diabetic teaching
D) Individual with a small laceration on the sole of the foot
Correct Answer: B) Individual with shortness of breath and respiratory distress
Rationale: First-level priority problems are immediate, life-threatening issues that require urgent
attention. Airway, breathing, and circulation (ABCs) are the highest priority. Respiratory distress
compromises the airway and breathing, making it a first-level priority over pain, teaching, or a
minor laceration.
9. When considering priority setting of problems, the nurse keeps in mind that second-level priority
problems include which of these aspects?
A) Lack of knowledge
B) Severely abnormal vital signs
C) Low self-esteem
D) Abnormal laboratory values
Correct Answer: D) Abnormal laboratory values
Rationale: Second-level priority problems are those that require prompt intervention to prevent
further deterioration, such as abnormal lab values, mental status changes, or acute pain. These
are not immediately life-threatening but can become serious if not addressed quickly.
10. The nurse knows that developing appropriate nursing interventions for a patient relies on the
appropriateness of the __________ diagnosis.
A) Medical
B) Admission
C) Nursing
D) Collaborative
Correct Answer: C) Nursing
Rationale: Nursing diagnoses are clinical judgments about individual, family, or community
responses to actual or potential health problems. These diagnoses are the foundation for planning
nursing interventions. While other types of diagnoses are important, they guide different aspects
of care.