NURS 514 Final Exam Questions with Correct Answers| Latest Update Guaranteed Success
A nurse assesses a client who reports, "I feel dizzy and nauseous." Which type of data is the
nurse collecting?
A. Objective
B. Diagnostic
C. Subjective
D. Empirical C. Subjective
Rationale: Subjective data is information reported by the patient, such as feelings or symptoms.
"Dizzy" and "nauseous" are personal experiences that only the client can describe.
Which of the following cues should the nurse prioritize based on the ABC framework?
A. Blood pressure of 138/86
B. Respiratory rate of 8 breaths per minute
C. Complaints of knee pain
D. Report of fatigue B. Respiratory rate of 8 breaths per minute
Rationale: Airway and breathing issues come before circulation and other complaints. A
respiratory rate of 8 is critically low and requires immediate intervention.
During assessment, a nurse observes a surgical wound with purulent drainage. This is best
classified as:
A. Subjective data
B. Objective data
C. Inferred data
,D. Psychosocial data B. Objective data
Rationale: Objective data includes observable findings like purulent drainage, which the nurse
can directly see and assess.
A client with chronic hypertension begins exhibiting confusion and slurred speech. What should
the nurse do first?
A. Document findings
B. Notify the healthcare provider
C. Reassess blood pressure
D. Administer prescribed antihypertensives C. Administer prescribed antihypertensives
Rationale: The nurse should reassess and gather more objective data (e.g., BP, neuro status)
before notifying the provider to ensure accurate reporting.
When prioritizing care using Maslow's Hierarchy of Needs, which client need is addressed first?
A. Fear of surgery
B. Social isolation
C. Dehydration
D. Low self-esteem C. Dehydration
Rationale: Dehydration is a physiological need, which is the foundation of Maslow's hierarchy. It
takes precedence over emotional or psychological needs.
The nurse identifies a sudden drop in a patient's oxygen saturation and rapid breathing. These
findings are:
,A. Unrelated cues
B. Part of subjective data
C. Expected findings in a stable patient
D. Relevant objective cues D. Relevant objective cues
Rationale: These are measurable clinical signs (objective data) and are relevant cues that may
indicate respiratory distress.
Which of the following represents the 'Analyze Cues' step in the Clinical Judgment
Measurement Model?
A. Comparing client assessment findings to normal values
B. Asking the client to rate their pain
C. Administering pain medication
D. Collaborating with physical therapy A. Comparing client assessment findings to normal
values
Rationale: Analyzing cues involves comparing clinical data to norms to identify abnormalities
and determine the client's needs.
A nurse is caring for a post-op client complaining of abdominal pain. Which action reflects "Take
Action" in the CJMM?
A. Administering prescribed analgesic
B. Documenting pain level
C. Asking the client to rate the pain
D. Calling the surgeon A. Administering prescribed analgesic
, Rationale: "Take Action" involves implementing nursing or interdisciplinary interventions to
address client problems. Giving the analgesic is a direct intervention.
Which framework helps the nurse prioritize care for a client with multiple needs?
A. Nursing scope and standards
B. Airway-Breathing-Circulation (ABC)
C. Professional Code of Ethics
D. Time management model B. Airway-Breating-Circulation (ABC)
Rationale: The ABC framework is used to prioritize life-threatening conditions, especially when
dealing with multiple clinical concerns.
What action reflects the "Evaluate Outcomes" step in the CJMM?
A. Giving discharge instructions
B. Creating a care plan
C. Calling a rapid response team
D. Reviewing a client's response to a new medication D. Reviewing the client''s response to a
new medication
Rationale: Evaluation involves determining whether a nursing intervention achieved the desired
outcome, such as assessing how a client responded to a medication.
What is the primary difference between subjective and objective data in nursing assessment?
A. Subjective data is observable; objective data is reported by the client
B. Subjective data involves physical exams; objective data comes from feelings
A nurse assesses a client who reports, "I feel dizzy and nauseous." Which type of data is the
nurse collecting?
A. Objective
B. Diagnostic
C. Subjective
D. Empirical C. Subjective
Rationale: Subjective data is information reported by the patient, such as feelings or symptoms.
"Dizzy" and "nauseous" are personal experiences that only the client can describe.
Which of the following cues should the nurse prioritize based on the ABC framework?
A. Blood pressure of 138/86
B. Respiratory rate of 8 breaths per minute
C. Complaints of knee pain
D. Report of fatigue B. Respiratory rate of 8 breaths per minute
Rationale: Airway and breathing issues come before circulation and other complaints. A
respiratory rate of 8 is critically low and requires immediate intervention.
During assessment, a nurse observes a surgical wound with purulent drainage. This is best
classified as:
A. Subjective data
B. Objective data
C. Inferred data
,D. Psychosocial data B. Objective data
Rationale: Objective data includes observable findings like purulent drainage, which the nurse
can directly see and assess.
A client with chronic hypertension begins exhibiting confusion and slurred speech. What should
the nurse do first?
A. Document findings
B. Notify the healthcare provider
C. Reassess blood pressure
D. Administer prescribed antihypertensives C. Administer prescribed antihypertensives
Rationale: The nurse should reassess and gather more objective data (e.g., BP, neuro status)
before notifying the provider to ensure accurate reporting.
When prioritizing care using Maslow's Hierarchy of Needs, which client need is addressed first?
A. Fear of surgery
B. Social isolation
C. Dehydration
D. Low self-esteem C. Dehydration
Rationale: Dehydration is a physiological need, which is the foundation of Maslow's hierarchy. It
takes precedence over emotional or psychological needs.
The nurse identifies a sudden drop in a patient's oxygen saturation and rapid breathing. These
findings are:
,A. Unrelated cues
B. Part of subjective data
C. Expected findings in a stable patient
D. Relevant objective cues D. Relevant objective cues
Rationale: These are measurable clinical signs (objective data) and are relevant cues that may
indicate respiratory distress.
Which of the following represents the 'Analyze Cues' step in the Clinical Judgment
Measurement Model?
A. Comparing client assessment findings to normal values
B. Asking the client to rate their pain
C. Administering pain medication
D. Collaborating with physical therapy A. Comparing client assessment findings to normal
values
Rationale: Analyzing cues involves comparing clinical data to norms to identify abnormalities
and determine the client's needs.
A nurse is caring for a post-op client complaining of abdominal pain. Which action reflects "Take
Action" in the CJMM?
A. Administering prescribed analgesic
B. Documenting pain level
C. Asking the client to rate the pain
D. Calling the surgeon A. Administering prescribed analgesic
, Rationale: "Take Action" involves implementing nursing or interdisciplinary interventions to
address client problems. Giving the analgesic is a direct intervention.
Which framework helps the nurse prioritize care for a client with multiple needs?
A. Nursing scope and standards
B. Airway-Breathing-Circulation (ABC)
C. Professional Code of Ethics
D. Time management model B. Airway-Breating-Circulation (ABC)
Rationale: The ABC framework is used to prioritize life-threatening conditions, especially when
dealing with multiple clinical concerns.
What action reflects the "Evaluate Outcomes" step in the CJMM?
A. Giving discharge instructions
B. Creating a care plan
C. Calling a rapid response team
D. Reviewing a client's response to a new medication D. Reviewing the client''s response to a
new medication
Rationale: Evaluation involves determining whether a nursing intervention achieved the desired
outcome, such as assessing how a client responded to a medication.
What is the primary difference between subjective and objective data in nursing assessment?
A. Subjective data is observable; objective data is reported by the client
B. Subjective data involves physical exams; objective data comes from feelings
