Fundamentals of Nursing, Nursing Process
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1. A client comes to the walk-in clinic A. Assessment
with reports of abdominal pain and Rationale: The first step in the nursing process is as-
diarrhea. While taking the client's sessment, the process of collecting data. All subsequent
vital signs, the nurse is implement- phases of the nursing process (options 2, 3, and 4) rely
ing which phase of the nursing on accurate and complete data.
process?
A. Assessment
B. Diagnosis
C. Planning
D. Implementation
2. The nurse is measuring the client's B. The client's urine output was 450 mL.
urine output and straining the Rationale: Objective data is measurable data that can
urine to assess for stones. Which be seen, heard, or verified by the nurse. The objective
of the following should the nurse data is the measurement of the urine output. A client's
record as objective data? statements and reports of symptoms are documented
as subjective data, such as the data found in options 1,
A. The client reports abdominal 3, and 4.
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."
3. When evaluating an elderly client's A. Compare this reading against defined
blood pressure (BP) of 146/78 Rationale: Analysis of the client's BP requires knowledge
mmHg, the nurse does which of of the normal BP range for an older adult. The nurse
the following before determining compares the client's data against identified standards
whether the BP is normal or repre- to determine whether this reading is normal or abnor-
, Fundamentals of Nursing, Nursing Process
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sents hypertension? mal. Measuring the BP in the other arm (option 2) and
comparing the reading to previous ones (option 4) will
A. Compare this reading against give additional client data, but the comparison alone
defined standards will not determine whether the BP is normal. Gaps in the
B. Compare the reading with one record (option 3) will not aid in interpreting the current
taken in the opposite arm measurement.
C. Determine gaps in the vital signs
in the client record
D. Compare the current measure-
ment with previous ones
4. Which of the following behaviors A. Admitting not knowing how to do a procedure and
by the nurse demonstrates that requesting help
the nurse is participating in critical E. Gathering three assistants to transfer the client to a
thinking? Select all that apply. stretcher after noting the client weighs 300 lbs.
A. Admitting not knowing how to Rationale: Critical thinking in nursing is self-directed,
do a procedure and requesting supporting what nurses know and making clear what
help they do not know. It is important for nurses to recognize
B. Using clever and persuasive re- when they lack the knowledge they need to provide safe
marks to support an opinion or po- care for a client (option 1). Nurses must also utilize their
sition resources to acquire the support they need to care for
C. Accepting without question the a client safely (option 5). Options 2, 3, and 4 do not
values acquired in nursing school demonstrate critical thinking.
D. Finding a quick and logical an-
swer, even to complex questions
E. Gathering three assistants to
transfer the client to a stretcher af-
ter noting the client weighs 300 lbs.
5. The nurse has documented the fol- D. Target time
lowing outcome goal in the care
Rationale: The outcome goal does not state the target
, Fundamentals of Nursing, Nursing Process
Study online at https://quizlet.com/_1flwif
plan: "The client will transfer from timeframe for when the nurse should expect to see the
bed to chair with two-person as- client behavior ("transfer"). The condition or modifier is
sist." The charge nurse tells the present ("with two assists"). The performance criterion
nurse to add which of the following is "from bed to chair."
to complete the goal?
A. Client behavior
B. Conditions or modifiers
C. Performance criteria
D. Target time
6. The nurse who documents on the B. Planning
client's care plan the outcome goal
"Anxiety will be relieved within 20 Rationale: The planning step of the nursing process
to 40 minutes following administra- involves formulating client goals and designing the
tion of lorazepam (Ativan)" is en- nursing interventions required to prevent, reduce, or
gaged in which step of the nursing eliminate the client's health problems. Outcome goals
process? are documented on the client's care plan. Assessment
data (option 1) is used to help identify a client's human
A. Assessment response, and once a plan is established, the interven-
B. Planning tions are implemented (option 3) and evaluated (option
C. Implementation 4).
D. Evaluation
7. When the client resists taking a liq- B. Suggesting the medication can be diluted in a bev-
uid medication that is essential to erage
treatment, the nurse demonstrates
critical thinking by doing which of Rationale: Diluting the medication in a beverage may
the following first? make the medication more palatable. Using critical
thinking skills, the nurse should try to problem-solve in a
A. Omitting this dose of medication situation such as this before asking for the assistance of
and waiting until the client is more the nurse manager. Suggesting an alternative method
cooperative of taking the medication (provided that there are no
Study online at https://quizlet.com/_1flwif
1. A client comes to the walk-in clinic A. Assessment
with reports of abdominal pain and Rationale: The first step in the nursing process is as-
diarrhea. While taking the client's sessment, the process of collecting data. All subsequent
vital signs, the nurse is implement- phases of the nursing process (options 2, 3, and 4) rely
ing which phase of the nursing on accurate and complete data.
process?
A. Assessment
B. Diagnosis
C. Planning
D. Implementation
2. The nurse is measuring the client's B. The client's urine output was 450 mL.
urine output and straining the Rationale: Objective data is measurable data that can
urine to assess for stones. Which be seen, heard, or verified by the nurse. The objective
of the following should the nurse data is the measurement of the urine output. A client's
record as objective data? statements and reports of symptoms are documented
as subjective data, such as the data found in options 1,
A. The client reports abdominal 3, and 4.
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."
3. When evaluating an elderly client's A. Compare this reading against defined
blood pressure (BP) of 146/78 Rationale: Analysis of the client's BP requires knowledge
mmHg, the nurse does which of of the normal BP range for an older adult. The nurse
the following before determining compares the client's data against identified standards
whether the BP is normal or repre- to determine whether this reading is normal or abnor-
, Fundamentals of Nursing, Nursing Process
Study online at https://quizlet.com/_1flwif
sents hypertension? mal. Measuring the BP in the other arm (option 2) and
comparing the reading to previous ones (option 4) will
A. Compare this reading against give additional client data, but the comparison alone
defined standards will not determine whether the BP is normal. Gaps in the
B. Compare the reading with one record (option 3) will not aid in interpreting the current
taken in the opposite arm measurement.
C. Determine gaps in the vital signs
in the client record
D. Compare the current measure-
ment with previous ones
4. Which of the following behaviors A. Admitting not knowing how to do a procedure and
by the nurse demonstrates that requesting help
the nurse is participating in critical E. Gathering three assistants to transfer the client to a
thinking? Select all that apply. stretcher after noting the client weighs 300 lbs.
A. Admitting not knowing how to Rationale: Critical thinking in nursing is self-directed,
do a procedure and requesting supporting what nurses know and making clear what
help they do not know. It is important for nurses to recognize
B. Using clever and persuasive re- when they lack the knowledge they need to provide safe
marks to support an opinion or po- care for a client (option 1). Nurses must also utilize their
sition resources to acquire the support they need to care for
C. Accepting without question the a client safely (option 5). Options 2, 3, and 4 do not
values acquired in nursing school demonstrate critical thinking.
D. Finding a quick and logical an-
swer, even to complex questions
E. Gathering three assistants to
transfer the client to a stretcher af-
ter noting the client weighs 300 lbs.
5. The nurse has documented the fol- D. Target time
lowing outcome goal in the care
Rationale: The outcome goal does not state the target
, Fundamentals of Nursing, Nursing Process
Study online at https://quizlet.com/_1flwif
plan: "The client will transfer from timeframe for when the nurse should expect to see the
bed to chair with two-person as- client behavior ("transfer"). The condition or modifier is
sist." The charge nurse tells the present ("with two assists"). The performance criterion
nurse to add which of the following is "from bed to chair."
to complete the goal?
A. Client behavior
B. Conditions or modifiers
C. Performance criteria
D. Target time
6. The nurse who documents on the B. Planning
client's care plan the outcome goal
"Anxiety will be relieved within 20 Rationale: The planning step of the nursing process
to 40 minutes following administra- involves formulating client goals and designing the
tion of lorazepam (Ativan)" is en- nursing interventions required to prevent, reduce, or
gaged in which step of the nursing eliminate the client's health problems. Outcome goals
process? are documented on the client's care plan. Assessment
data (option 1) is used to help identify a client's human
A. Assessment response, and once a plan is established, the interven-
B. Planning tions are implemented (option 3) and evaluated (option
C. Implementation 4).
D. Evaluation
7. When the client resists taking a liq- B. Suggesting the medication can be diluted in a bev-
uid medication that is essential to erage
treatment, the nurse demonstrates
critical thinking by doing which of Rationale: Diluting the medication in a beverage may
the following first? make the medication more palatable. Using critical
thinking skills, the nurse should try to problem-solve in a
A. Omitting this dose of medication situation such as this before asking for the assistance of
and waiting until the client is more the nurse manager. Suggesting an alternative method
cooperative of taking the medication (provided that there are no
