CSN Nursing 101 Exam 2--The Nursing Process UPDATED ACTUAL Questions
and CORRECT Answers
What is a nurse's framework for critical thinking? The nursing process
If a patient had a goal of walking 150 steps by end of day, Evaluate the goal. Goal not met, so must re-assess: Was it a good goal? Restart
and only ended up walking 10, what would the nurse's the nursing process.
next step be?
Which are true of the nursing process? SATA. A, B, D, E
A. It is a framework for critical thinking. (C--it does not create problems; it is a problem-solving method. F--it begins with
B. It helps to guide the nursing practice. assessment, not diagnosis.)
C. It creates problems to solve.
D. It is systematic.
E. It is dynamic.
F. It begins with a NANDA diagnosis.
A patient's call light goes off. Upon entering, the nurse C
sees blood oozing out from a wrapped wound. What
should the nurse do first? The first thing the nurse should do is ASSESS the situation.
A. Call the physician on duty.
B. Call another nurse for backup.
C. Figure out what the situation is by removing the
bandage.
D. Get another bandage to soak up the bleeding.
E. Amend the care plan.
Patient Z is admitted to the hospital at 9:00 am for Initial assessment
vomiting and diarrhea. What kind of assessment would
the nurse perform?
Later than day, the nurse checks on Patient Z. What would A, B
you expect the nurse to check in his focused (priority)
assessment of Patient Z? SATA. The nurse would check vital signs (always) and the specific issue Patient Z came in
for
A. Vital signs
B. Bowel sounds
C. Pupil dilation
D. Ability to walk
Patient P is admitted to the hospital at 11:00 pm with a gun Emergency assessment, because although it is Patient P's initial visit, the situation
shot wound. What kind of assessment would the nurse is life-threatening. No time for a lengthy initial assessment.
perform?
, What are examples of time-lapsed assessments? SATA. A, B, C, D
A. Nurse checks on a patient one hour after pain meds
are given to assess if pain has lessened.
B. Nurse checks the healing progress of a wound after 30
days.
C. Nurse follows up after revisions in the care plan.
D. Nurse checks on a patient one hour after giving
acetaminophen to determine if fever has decreased.
Which assessment provides the baseline for all other Initial assessment
assessments?
Which assessment includes a health history and head-to- Initial assessment
toe assessment?
Which are primary sources for collecting data? SATA. C, E
A. Facebook profile
B. Best friend
C. Patient him-/herself
D. Parent of an 18-year-old
E. Parent of an 8-year-old
What are examples of secondary data sources? SATA. A, B, C, D, E, F
A. Family members
B. Health history
C. Respiratory therapist report
D. Lab reports
E. Diagnostic tests
F. Parent, if the patient is 20 years old
Signs and Symptoms: what is the difference? Signs--objective data. What can be measured. BP 130/80, temp 100.5.
Symptoms--subjective data. What the patient tells you. "I feel sick."
When taking a health history, what kind of information is subjective
gathered first: subjective or objective?
Which is NOT a part of gathering a health history? B
A. Medications
B. Socioeconomic status
C. Health habits
D. Identifying patient concerns
and CORRECT Answers
What is a nurse's framework for critical thinking? The nursing process
If a patient had a goal of walking 150 steps by end of day, Evaluate the goal. Goal not met, so must re-assess: Was it a good goal? Restart
and only ended up walking 10, what would the nurse's the nursing process.
next step be?
Which are true of the nursing process? SATA. A, B, D, E
A. It is a framework for critical thinking. (C--it does not create problems; it is a problem-solving method. F--it begins with
B. It helps to guide the nursing practice. assessment, not diagnosis.)
C. It creates problems to solve.
D. It is systematic.
E. It is dynamic.
F. It begins with a NANDA diagnosis.
A patient's call light goes off. Upon entering, the nurse C
sees blood oozing out from a wrapped wound. What
should the nurse do first? The first thing the nurse should do is ASSESS the situation.
A. Call the physician on duty.
B. Call another nurse for backup.
C. Figure out what the situation is by removing the
bandage.
D. Get another bandage to soak up the bleeding.
E. Amend the care plan.
Patient Z is admitted to the hospital at 9:00 am for Initial assessment
vomiting and diarrhea. What kind of assessment would
the nurse perform?
Later than day, the nurse checks on Patient Z. What would A, B
you expect the nurse to check in his focused (priority)
assessment of Patient Z? SATA. The nurse would check vital signs (always) and the specific issue Patient Z came in
for
A. Vital signs
B. Bowel sounds
C. Pupil dilation
D. Ability to walk
Patient P is admitted to the hospital at 11:00 pm with a gun Emergency assessment, because although it is Patient P's initial visit, the situation
shot wound. What kind of assessment would the nurse is life-threatening. No time for a lengthy initial assessment.
perform?
, What are examples of time-lapsed assessments? SATA. A, B, C, D
A. Nurse checks on a patient one hour after pain meds
are given to assess if pain has lessened.
B. Nurse checks the healing progress of a wound after 30
days.
C. Nurse follows up after revisions in the care plan.
D. Nurse checks on a patient one hour after giving
acetaminophen to determine if fever has decreased.
Which assessment provides the baseline for all other Initial assessment
assessments?
Which assessment includes a health history and head-to- Initial assessment
toe assessment?
Which are primary sources for collecting data? SATA. C, E
A. Facebook profile
B. Best friend
C. Patient him-/herself
D. Parent of an 18-year-old
E. Parent of an 8-year-old
What are examples of secondary data sources? SATA. A, B, C, D, E, F
A. Family members
B. Health history
C. Respiratory therapist report
D. Lab reports
E. Diagnostic tests
F. Parent, if the patient is 20 years old
Signs and Symptoms: what is the difference? Signs--objective data. What can be measured. BP 130/80, temp 100.5.
Symptoms--subjective data. What the patient tells you. "I feel sick."
When taking a health history, what kind of information is subjective
gathered first: subjective or objective?
Which is NOT a part of gathering a health history? B
A. Medications
B. Socioeconomic status
C. Health habits
D. Identifying patient concerns
