The Nursing Process Questions and Answers 100% Correct
1. A nurse is developing a nursing diagnosis for a client. Which information should she include?
A) Actions to achieve goals
B) Expected outcomes
C) Factors influencing the client's problem
D) Nursing history correct answer C) Factors influencing the client's problem Reason: A nursing diagnosis
is a written statement describing a client's actual or potential health problem. It includes a specified
diagnostic label, factors that influence the client's problem, and any signs or symptoms that help define
the diagnostic label. Actions to achieve goals are nursing interventions. Expected outcomes are
measurable behavioral goals that the nurse develops during the evaluation step of the nursing process.
The nurse obtains a nursing history during the assessment step of the nursing process.
A 57-year-old Hispanic woman with breast cancer who does not speak English is admitted for a
lumpectomy. Her daughter, who speaks English, accompanies her. In order to obtain admission
information from the client, what should the nurse do?
A) Ask the client's daughter to serve as an interpreter.
B) Ask one of the Hispanic nursing assistants to serve as an interpreter.
C) Use the limited Spanish she remembers from high school along with nonverbal communication.
D) Obtain a trained medical interpreter. correct answer D) Obtain a trained medical interpreter. Reason:
A trained medical interpreter is required to ensure safety, accuracy of history data, and client
confidentiality. The medical interpreter knows the client's rights and is familiar with the client's culture.
Using the family member as interpreter violates the patient's confidentiality. Using the nursing assistant
or limited Spanish and nonverbal communication do not ensure accuracy of interpretation and back-
translation into English.
A client complains of severe abdominal pain. To elicit as much information as possible about the pain,
the nurse should ask:
A) "Do you have the pain all the time?"
B) "Can you describe the pain?"
C) "Where does it hurt the most?"
D) "Is the pain stabbing like a knife?" correct answer B) "Can you describe the pain?" Reason: Asking an
open-ended question such as "Can you describe the pain?" encourages the client to describe any and all
, aspects of the pain in his own words. The other options are likely to elicit less information because
they're more specific and would limit the client's response.
A client has the following arterial blood gas values: pH, 7.30; PaO2, 89 mm Hg; PaCO2, 50 mm Hg; and
HCO3-, 26 mEq/L. Based on these values, the nurse should suspect which condition?
A) Respiratory acidosis
B) Respiratory alkalosis
C) Metabolic acidosis
D) Metabolic alkalosis correct answer A) Respiratory acidosis Reason: This client has a below-normal
(acidic) blood pH value and an above-normal partial pressure of arterial carbon dioxide (PaCO2) value,
indicating respiratory acidosis. In respiratory alkalosis, the pH value is above normal and the PaCO2 value
is below normal. In metabolic acidosis, the pH and bicarbonate (HCO3-) values are below normal. In
metabolic alkalosis, the pH and HCO3- values are above normal.
A client is scheduled for surgery under general anesthesia. The night before surgery, the client tells the
nurse, "I can't wait to have breakfast tomorrow." Based on this statement, which nursing diagnosis
should be the nurse's priority?
A) Deficient knowledge related to food restrictions associated with anesthesia
B) Fear related to surgery
C) Risk for impaired skin integrity related to upcoming surgery
D) Ineffective coping related to the stress of surgery correct answer A) Deficient knowledge related to
food restrictions associated with anesthesia Reason: The client's statement reveals a Deficient
knowledge related to food restrictions associated with general anesthesia. Fear related to surgery, Risk
for impaired skin integrity related to upcoming surgery, and Ineffective coping related to the stress of
surgery may be applicable nursing diagnoses but they aren't related to the client's statement.
A group of nurses has established a focus group and pilot study to examine the potential application of
personal data assistants (PDAs) in bedside care. This study is a tangible application of:
A) Nursing informatics.
B) Electronic medical records.
C) Telemedicine.
D) Computerized documentation. correct answer A) Nursing informatics. Reason: Nursing informatics is
a specialty that integrates nursing science, computer science, and information science to manage and
communicate data, information, and knowledge in nursing practice. A specific application of nursing
1. A nurse is developing a nursing diagnosis for a client. Which information should she include?
A) Actions to achieve goals
B) Expected outcomes
C) Factors influencing the client's problem
D) Nursing history correct answer C) Factors influencing the client's problem Reason: A nursing diagnosis
is a written statement describing a client's actual or potential health problem. It includes a specified
diagnostic label, factors that influence the client's problem, and any signs or symptoms that help define
the diagnostic label. Actions to achieve goals are nursing interventions. Expected outcomes are
measurable behavioral goals that the nurse develops during the evaluation step of the nursing process.
The nurse obtains a nursing history during the assessment step of the nursing process.
A 57-year-old Hispanic woman with breast cancer who does not speak English is admitted for a
lumpectomy. Her daughter, who speaks English, accompanies her. In order to obtain admission
information from the client, what should the nurse do?
A) Ask the client's daughter to serve as an interpreter.
B) Ask one of the Hispanic nursing assistants to serve as an interpreter.
C) Use the limited Spanish she remembers from high school along with nonverbal communication.
D) Obtain a trained medical interpreter. correct answer D) Obtain a trained medical interpreter. Reason:
A trained medical interpreter is required to ensure safety, accuracy of history data, and client
confidentiality. The medical interpreter knows the client's rights and is familiar with the client's culture.
Using the family member as interpreter violates the patient's confidentiality. Using the nursing assistant
or limited Spanish and nonverbal communication do not ensure accuracy of interpretation and back-
translation into English.
A client complains of severe abdominal pain. To elicit as much information as possible about the pain,
the nurse should ask:
A) "Do you have the pain all the time?"
B) "Can you describe the pain?"
C) "Where does it hurt the most?"
D) "Is the pain stabbing like a knife?" correct answer B) "Can you describe the pain?" Reason: Asking an
open-ended question such as "Can you describe the pain?" encourages the client to describe any and all
, aspects of the pain in his own words. The other options are likely to elicit less information because
they're more specific and would limit the client's response.
A client has the following arterial blood gas values: pH, 7.30; PaO2, 89 mm Hg; PaCO2, 50 mm Hg; and
HCO3-, 26 mEq/L. Based on these values, the nurse should suspect which condition?
A) Respiratory acidosis
B) Respiratory alkalosis
C) Metabolic acidosis
D) Metabolic alkalosis correct answer A) Respiratory acidosis Reason: This client has a below-normal
(acidic) blood pH value and an above-normal partial pressure of arterial carbon dioxide (PaCO2) value,
indicating respiratory acidosis. In respiratory alkalosis, the pH value is above normal and the PaCO2 value
is below normal. In metabolic acidosis, the pH and bicarbonate (HCO3-) values are below normal. In
metabolic alkalosis, the pH and HCO3- values are above normal.
A client is scheduled for surgery under general anesthesia. The night before surgery, the client tells the
nurse, "I can't wait to have breakfast tomorrow." Based on this statement, which nursing diagnosis
should be the nurse's priority?
A) Deficient knowledge related to food restrictions associated with anesthesia
B) Fear related to surgery
C) Risk for impaired skin integrity related to upcoming surgery
D) Ineffective coping related to the stress of surgery correct answer A) Deficient knowledge related to
food restrictions associated with anesthesia Reason: The client's statement reveals a Deficient
knowledge related to food restrictions associated with general anesthesia. Fear related to surgery, Risk
for impaired skin integrity related to upcoming surgery, and Ineffective coping related to the stress of
surgery may be applicable nursing diagnoses but they aren't related to the client's statement.
A group of nurses has established a focus group and pilot study to examine the potential application of
personal data assistants (PDAs) in bedside care. This study is a tangible application of:
A) Nursing informatics.
B) Electronic medical records.
C) Telemedicine.
D) Computerized documentation. correct answer A) Nursing informatics. Reason: Nursing informatics is
a specialty that integrates nursing science, computer science, and information science to manage and
communicate data, information, and knowledge in nursing practice. A specific application of nursing
