,NR 226 Exam 1 Study Guide | Fundamentals – Patient
1. A nurse is caring for a client who reports, "I feel anxious about my surgery tomorrow." The nurse
observes the client is restless, wringing hands, and has an elevated heart rate. The nurse documents:
"Client states feeling anxious, appears restless with elevated vital signs." What type of data has the
nurse collected?
A) Objective data only
B) Subjective data only
C) Both subjective and objective data
D) Secondary data
Correct Answer: Both subjective and objective data
Rationale: Subjective data includes the client's stated feelings ("I feel anxious"). Objective data
includes observable, measurable findings (restlessness, hand-wringing, elevated heart rate). The nurse
has collected both types of data during this assessment. Primary data comes directly from the client,
not secondary sources.
2. A nurse is using the clinical judgment model to care for a client with newly diagnosed diabetes. The
nurse reviews the client's blood glucose log, diet history, and medication list. Which step of the
clinical judgment model is the nurse performing?
A) Recognize cues
B) Analyze cues
C) Prioritize hypotheses
D) Generate solutions
Correct Answer: Analyze cues
Rationale: Analyzing cues involves interpreting and organizing assessment data to identify patterns
and relationships. Recognizing cues is initial data collection, and prioritizing hypotheses follows
analysis to identify the most likely client concerns. Generating solutions involves planning
interventions based on the prioritized hypotheses.
,3. A nurse is developing a care plan for a client with impaired mobility. Which goal statement follows
SMART criteria?
A) "Client will walk more"
B) "Client will ambulate 50 feet with a walker by discharge"
C) "Client will improve mobility"
D) "Nurse will assist client with walking daily"
Correct Answer: "Client will ambulate 50 feet with a walker by discharge"
Rationale: SMART goals are Specific, Measurable, Attainable, Relevant, and Time-bound. "Ambulate
50 feet with a walker by discharge" specifies the action, distance, assistive device, and timeframe,
making it evaluable. The other options lack specificity, measurability, or are nurse-centered rather
than patient-centered.
4. A nurse is caring for a client with a new colostomy. The client states, "I don't think I can manage this
at home." The nurse collaborates with the WOC nurse for teaching and arranges home health follow-
up. What type of nursing intervention is this?
A) Independent intervention
B) Dependent intervention
C) Collaborative intervention
D) Evaluation intervention
Correct Answer: Collaborative intervention
Rationale: Collaborative interventions require coordination with other healthcare team members
(WOC nurse, home health). Independent interventions are nurse-initiated (positioning, teaching), and
dependent interventions require provider orders (medications, procedures). Evaluation is a separate
phase of the nursing process.
5. A nurse is evaluating a client's response to pain medication administered 1 hour ago. The client
reports pain decreased from 8/10 to 3/10. What type of evaluation is the nurse performing?
A) Formative evaluation
, B) Summative evaluation
C) Ongoing evaluation
D) Terminal evaluation
Correct Answer: Ongoing evaluation
Rationale: Ongoing evaluation occurs during care delivery to determine if interventions are effective
and if the care plan needs modification. The pain reduction indicates the intervention is working, but
continued monitoring is needed. Formative and summative evaluations are educational terms, and
terminal evaluation occurs at the end of care.
6. A nurse is prioritizing care for four clients. Which client should the nurse see first using Maslow's
hierarchy of needs?
A) Client requesting assistance with discharge planning
B) Client with a new colostomy who needs teaching
C) Client who is short of breath and has oxygen saturation of 88%
D) Client requesting pain medication for a headache
Correct Answer: Client who is short of breath and has oxygen saturation of 88%
Rationale: According to Maslow's hierarchy, physiological needs (oxygen, breathing) take priority over
safety, love/belonging, esteem, and self-actualization needs. A client with oxygen saturation of 88% is
experiencing impaired oxygenation, which is a physiological need requiring immediate intervention.
Discharge planning, teaching, and mild headache are lower priority.
7. A nurse asks a client, "Describe for me your typical diet over a 24-hour day. What foods do you
prefer? Have you noticed a change in your weight recently?" This series of questions would likely
occur during which phase of a patient-centered interview?
A) Setting the stage
B) Gathering information about the client's chief concerns
C) Collecting the assessment
D) Termination
1. A nurse is caring for a client who reports, "I feel anxious about my surgery tomorrow." The nurse
observes the client is restless, wringing hands, and has an elevated heart rate. The nurse documents:
"Client states feeling anxious, appears restless with elevated vital signs." What type of data has the
nurse collected?
A) Objective data only
B) Subjective data only
C) Both subjective and objective data
D) Secondary data
Correct Answer: Both subjective and objective data
Rationale: Subjective data includes the client's stated feelings ("I feel anxious"). Objective data
includes observable, measurable findings (restlessness, hand-wringing, elevated heart rate). The nurse
has collected both types of data during this assessment. Primary data comes directly from the client,
not secondary sources.
2. A nurse is using the clinical judgment model to care for a client with newly diagnosed diabetes. The
nurse reviews the client's blood glucose log, diet history, and medication list. Which step of the
clinical judgment model is the nurse performing?
A) Recognize cues
B) Analyze cues
C) Prioritize hypotheses
D) Generate solutions
Correct Answer: Analyze cues
Rationale: Analyzing cues involves interpreting and organizing assessment data to identify patterns
and relationships. Recognizing cues is initial data collection, and prioritizing hypotheses follows
analysis to identify the most likely client concerns. Generating solutions involves planning
interventions based on the prioritized hypotheses.
,3. A nurse is developing a care plan for a client with impaired mobility. Which goal statement follows
SMART criteria?
A) "Client will walk more"
B) "Client will ambulate 50 feet with a walker by discharge"
C) "Client will improve mobility"
D) "Nurse will assist client with walking daily"
Correct Answer: "Client will ambulate 50 feet with a walker by discharge"
Rationale: SMART goals are Specific, Measurable, Attainable, Relevant, and Time-bound. "Ambulate
50 feet with a walker by discharge" specifies the action, distance, assistive device, and timeframe,
making it evaluable. The other options lack specificity, measurability, or are nurse-centered rather
than patient-centered.
4. A nurse is caring for a client with a new colostomy. The client states, "I don't think I can manage this
at home." The nurse collaborates with the WOC nurse for teaching and arranges home health follow-
up. What type of nursing intervention is this?
A) Independent intervention
B) Dependent intervention
C) Collaborative intervention
D) Evaluation intervention
Correct Answer: Collaborative intervention
Rationale: Collaborative interventions require coordination with other healthcare team members
(WOC nurse, home health). Independent interventions are nurse-initiated (positioning, teaching), and
dependent interventions require provider orders (medications, procedures). Evaluation is a separate
phase of the nursing process.
5. A nurse is evaluating a client's response to pain medication administered 1 hour ago. The client
reports pain decreased from 8/10 to 3/10. What type of evaluation is the nurse performing?
A) Formative evaluation
, B) Summative evaluation
C) Ongoing evaluation
D) Terminal evaluation
Correct Answer: Ongoing evaluation
Rationale: Ongoing evaluation occurs during care delivery to determine if interventions are effective
and if the care plan needs modification. The pain reduction indicates the intervention is working, but
continued monitoring is needed. Formative and summative evaluations are educational terms, and
terminal evaluation occurs at the end of care.
6. A nurse is prioritizing care for four clients. Which client should the nurse see first using Maslow's
hierarchy of needs?
A) Client requesting assistance with discharge planning
B) Client with a new colostomy who needs teaching
C) Client who is short of breath and has oxygen saturation of 88%
D) Client requesting pain medication for a headache
Correct Answer: Client who is short of breath and has oxygen saturation of 88%
Rationale: According to Maslow's hierarchy, physiological needs (oxygen, breathing) take priority over
safety, love/belonging, esteem, and self-actualization needs. A client with oxygen saturation of 88% is
experiencing impaired oxygenation, which is a physiological need requiring immediate intervention.
Discharge planning, teaching, and mild headache are lower priority.
7. A nurse asks a client, "Describe for me your typical diet over a 24-hour day. What foods do you
prefer? Have you noticed a change in your weight recently?" This series of questions would likely
occur during which phase of a patient-centered interview?
A) Setting the stage
B) Gathering information about the client's chief concerns
C) Collecting the assessment
D) Termination
