Question 1
The student is learning the steps of the nursing process. What is the first thing that the student
should realize about the purpose of this process?
1. Deliver care to a client in an organized way.
2. Implement a plan that is close to the medical model.
3. Identify client needs and deliver care to meet those needs.
4. Make sure that standardized care is available to clients.
Correct Answer: 3
Question 2
While conducting a dressing change, the nurse notes a new area of skin breakdown that was
caused from the tape used to secure the dressing. In which phase of the nursing process is the
nurse working?
1. Assessment
2. Diagnosis
3. Implementation
4. Evaluation
Correct Answer: 1
Question 3
During an assessment, a client who is not very talkative appears pale, diaphoretic, and restless in
the bed, and says leave me alone. Which subjective data should the nurse document?
1. Restlessness
,2. Leave me alone
3. Not talkative
4. Pale and diaphoretic
Correct Answer: 2
Question 4
Family of a client demonstrating confusion state that this is not the clients usual behavior. How
should the nurse document this data?
,1. Inference
2. Subjective data
3. Objective data
4. Secondary subjective data
Correct Answer: 3
Question 5
The nurse provides a back rub to a client after administering a pain medication with the hope that
these two actions will help decrease the clients pain. Which phase of the nursing process is this
nurse implementing?
1. Assessment
2. Diagnosis
3. Implementation
4. Evaluation
Correct Answer: 3
Question 6
A new client has been admitted to the care area. How soon should the nurse plan to complete a
physical assessment on this patient?
1. 1 hour
2. 12 hours
3. 48 hours
4. 24 hours
Correct Answer: 4
Question 7
The nurse is admitting an infant to the care area. The parents and grandmother are present. What
should the nurse use as the best source of data for this client?
1. Medical record from the childbirth
2. Grandmother
3. Parents
4. Admitting physician
Correct Answer: 3
, Question b8
A bnewly badmitted bclient bis bangry bbecause bnursing bstaff bcontinue bto bask bthe bsame bquestions. bWhat
bshould bthe bnurse brespond bto bthis bclient?
1. In border bto bmake bsure ball bof byour binformation bis bcomplete, bI bneed bto bask bthese bquestions.
2. Youre bright. bLet bme bknow bif btheres banything byou bneed bright bnow.
3. Ill bbe bdone bshortly, bjust bgive bme ba bfew bmore bminutes.
4. You bshouldnt bbe bupset. bWere bonly bdoing bour bjobs.
Correct bAnswer: b2
b
Question b9
The bnurse bdocuments: bClient bavoids beye bcontact band bgives bonly bvague, bnonspecific banswers bto
bdirect bquestioning bby bthe bprofessional bstaff. bIs bquite banimated b(laughs baloud, bsmiles, buses bhand
bgestures) bin bconversation bwith bspouse. bWhich bmethod bof bdata bcollection bdoes bthis bdocumentation
bdemonstrate?
1. Examining
2. Interviewing
3. Listening
4. Observing
Correct bAnswer: b4
Question b10
A bnurse bhas bworked bin bthe btrauma bcritical bcare barea bfor bseveral byears. bWhich bnoise bmay bbecome
bindiscriminate bfor bthis bparticular bnurse?
1. A bclient bwith baudible bbreathing
2. Moaning bof ba bclient bin bpain
3. Whirring bof bventilators
4. Co-orkers bdiscussing btheir bclients bconditions
Correct bAnswer: b3
b
Question b11
A bclient bhas bbeen busing bthe bcall blight broutinely bthroughout bthe bevening. bUpon bentering bthe broom,
bthe bnurse bobserves bthe bfollowing bdetails. bOrganize bthem baccording bto bpriority bsequencing b(1 bis
bfirst bpriority; b5 bis bleast bpriority).
Standard bText: bClick band bdrag bthe boptions bbelow bto bmove bthem bup bor bdown.
The student is learning the steps of the nursing process. What is the first thing that the student
should realize about the purpose of this process?
1. Deliver care to a client in an organized way.
2. Implement a plan that is close to the medical model.
3. Identify client needs and deliver care to meet those needs.
4. Make sure that standardized care is available to clients.
Correct Answer: 3
Question 2
While conducting a dressing change, the nurse notes a new area of skin breakdown that was
caused from the tape used to secure the dressing. In which phase of the nursing process is the
nurse working?
1. Assessment
2. Diagnosis
3. Implementation
4. Evaluation
Correct Answer: 1
Question 3
During an assessment, a client who is not very talkative appears pale, diaphoretic, and restless in
the bed, and says leave me alone. Which subjective data should the nurse document?
1. Restlessness
,2. Leave me alone
3. Not talkative
4. Pale and diaphoretic
Correct Answer: 2
Question 4
Family of a client demonstrating confusion state that this is not the clients usual behavior. How
should the nurse document this data?
,1. Inference
2. Subjective data
3. Objective data
4. Secondary subjective data
Correct Answer: 3
Question 5
The nurse provides a back rub to a client after administering a pain medication with the hope that
these two actions will help decrease the clients pain. Which phase of the nursing process is this
nurse implementing?
1. Assessment
2. Diagnosis
3. Implementation
4. Evaluation
Correct Answer: 3
Question 6
A new client has been admitted to the care area. How soon should the nurse plan to complete a
physical assessment on this patient?
1. 1 hour
2. 12 hours
3. 48 hours
4. 24 hours
Correct Answer: 4
Question 7
The nurse is admitting an infant to the care area. The parents and grandmother are present. What
should the nurse use as the best source of data for this client?
1. Medical record from the childbirth
2. Grandmother
3. Parents
4. Admitting physician
Correct Answer: 3
, Question b8
A bnewly badmitted bclient bis bangry bbecause bnursing bstaff bcontinue bto bask bthe bsame bquestions. bWhat
bshould bthe bnurse brespond bto bthis bclient?
1. In border bto bmake bsure ball bof byour binformation bis bcomplete, bI bneed bto bask bthese bquestions.
2. Youre bright. bLet bme bknow bif btheres banything byou bneed bright bnow.
3. Ill bbe bdone bshortly, bjust bgive bme ba bfew bmore bminutes.
4. You bshouldnt bbe bupset. bWere bonly bdoing bour bjobs.
Correct bAnswer: b2
b
Question b9
The bnurse bdocuments: bClient bavoids beye bcontact band bgives bonly bvague, bnonspecific banswers bto
bdirect bquestioning bby bthe bprofessional bstaff. bIs bquite banimated b(laughs baloud, bsmiles, buses bhand
bgestures) bin bconversation bwith bspouse. bWhich bmethod bof bdata bcollection bdoes bthis bdocumentation
bdemonstrate?
1. Examining
2. Interviewing
3. Listening
4. Observing
Correct bAnswer: b4
Question b10
A bnurse bhas bworked bin bthe btrauma bcritical bcare barea bfor bseveral byears. bWhich bnoise bmay bbecome
bindiscriminate bfor bthis bparticular bnurse?
1. A bclient bwith baudible bbreathing
2. Moaning bof ba bclient bin bpain
3. Whirring bof bventilators
4. Co-orkers bdiscussing btheir bclients bconditions
Correct bAnswer: b3
b
Question b11
A bclient bhas bbeen busing bthe bcall blight broutinely bthroughout bthe bevening. bUpon bentering bthe broom,
bthe bnurse bobserves bthe bfollowing bdetails. bOrganize bthem baccording bto bpriority bsequencing b(1 bis
bfirst bpriority; b5 bis bleast bpriority).
Standard bText: bClick band bdrag bthe boptions bbelow bto bmove bthem bup bor bdown.
