Fundamentals of Nursing, Nursing Process
Test Questions with Verified Answers Graded A
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 - Ans -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.
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." - Ans -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.
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,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
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 - Ans -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.
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
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. - Ans -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.
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, 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.
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
B. Conditions or modifiers
C. Performance criteria
D. Target time - Ans -D. Target time
Rationale: The outcome goal does not state the target timeframe for when the nurse should
expect to see the client behavior ("transfer"). The condition or modifier is present ("with two
assists"). The performance criterion is "from bed to chair."
The nurse who documents on the client's care plan the outcome goal "Anxiety will be
relieved within 20 to 40 minutes following administration of lorazepam (Ativan)" is engaged
in which step of the nursing process?
A. Assessment
B. Planning
C. Implementation
D. Evaluation - Ans -B. Planning
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Test Questions with Verified Answers Graded A
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 - Ans -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.
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." - Ans -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.
1
Page
,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
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 - Ans -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.
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
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. - Ans -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.
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Page
, 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.
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
B. Conditions or modifiers
C. Performance criteria
D. Target time - Ans -D. Target time
Rationale: The outcome goal does not state the target timeframe for when the nurse should
expect to see the client behavior ("transfer"). The condition or modifier is present ("with two
assists"). The performance criterion is "from bed to chair."
The nurse who documents on the client's care plan the outcome goal "Anxiety will be
relieved within 20 to 40 minutes following administration of lorazepam (Ativan)" is engaged
in which step of the nursing process?
A. Assessment
B. Planning
C. Implementation
D. Evaluation - Ans -B. Planning
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