1
Santa Clara County Clinical Nurse
I Examination – Practice
Question Bank Comprehensive
150-Question Multiple-Choice
Examination a well detailed one
written and graded
A+ upgraded
SECTION 1: NURSING PROCESS AND CLINICAL JUDGMENT (Questions 1–20)
1. A newly hired Clinical Nurse I is performing an initial assessment on a patient admitted with
pneumonia. Which action demonstrates the correct application of the assessment phase of
the nursing process?
, 2
A) Documenting the patient's vital signs and lung sounds
B) Formulating a nursing diagnosis of Impaired Gas Exchange
C) Administering prescribed antibiotics as ordered
D) Evaluating the effectiveness of oxygen therapy after 2 hours
Correct Answer: A
Rationale: Assessment is the first step of the nursing process and involves collecting objective
and subjective data, including vital signs and lung sounds. Formulating a diagnosis (B) occurs
after assessment, implementation (C) follows planning, and evaluation (D) is the final step of the
nursing process.
2. A Clinical Nurse I is caring for a patient who reports severe pain rated 9/10. The nurse
administers morphine as ordered. Thirty minutes later, the patient reports pain is now 3/10.
The nurse documents this finding. Which phase of the nursing process does this represent?
A) Assessment
B) Diagnosis
C) Implementation
D) Evaluation
Correct Answer: D
Rationale: Evaluation involves determining whether the patient's outcomes have been met and
documenting the patient's response to interventions. The nurse is evaluating the effectiveness
of the analgesic administered.
3. A Clinical Nurse I working under close supervision observes a patient becoming increasingly
agitated and confused. According to the Clinical Nurse I classification, what is the most
appropriate initial action?
A) Administer a PRN sedative independently
B) Document the behavior and seek supervision from the charge nurse
C) Restrain the patient for safety
D) Discontinue all medications
Correct Answer: B
Rationale: Clinical Nurse I incumbents work under close supervision of another registered nurse
and should seek supervision and guidance when functioning in unfamiliar situations. The nurse
should document observations and consult with the supervising RN before implementing
interventions.
, 3
4. Which of the following represents a correctly written nursing diagnosis?
A) "Potential for infection related to surgical incision"
B) "Impaired Skin Integrity related to immobility as evidenced by stage 2 pressure ulcer on
sacrum"
C) "Patient will ambulate three times daily"
D) "Administer wound care every shift"
Correct Answer: B
Rationale: A properly written nursing diagnosis includes the problem (Impaired Skin Integrity),
etiology (related to immobility), and defining characteristics (as evidenced by stage 2 pressure
ulcer). Option A is a risk diagnosis that should be stated as "Risk for Infection." Option C is an
outcome statement, and Option D is an intervention.
5. A Clinical Nurse I is planning care for a patient with diabetes. Which intervention should the
nurse prioritize?
A) Teaching the patient about foot care
B) Administering insulin as prescribed
C) Assessing blood glucose levels before meals
D) All of the above based on priority determination
Correct Answer: D
Rationale: Planning involves setting priorities, identifying patient-centered outcomes, and
selecting interventions. All options represent appropriate interventions; the nurse must
prioritize based on the patient's immediate needs and safety considerations.
6. The nurse receives report on four patients. Which patient should the nurse assess first?
A) A patient scheduled for physical therapy at 10:00 AM
B) A patient who received pain medication 30 minutes ago and is sleeping
C) A patient with new-onset confusion and oxygen saturation of 88%
D) A patient requesting assistance with ambulation to the bathroom
Correct Answer: C
Rationale: The patient with new-onset confusion and hypoxia (SpO2 88%) demonstrates acute
deterioration requiring immediate assessment. Priority is given to patients with unstable or
potentially life-threatening conditions.
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7. A Clinical Nurse I is documenting care provided to a patient. Which documentation entry is
most appropriate and legally sound?
A) "Patient appears comfortable and resting"
B) "Patient sleeping quietly in bed, vital signs stable, no complaints of pain"
C) "Patient is doing well today"
D) "Patient seems better than yesterday"
Correct Answer: B
Rationale: Documentation must be objective, specific, and factual. Option B provides specific,
observable data without subjective interpretation. Vague terms like "appears," "doing well," and
"seems better" are inappropriate for legal documentation.
8. A patient tells the nurse, "I don't want to take that medication. It makes me feel dizzy."
What is the nurse's best response?
A) "You need to take it because the doctor ordered it"
B) "I understand. Let me notify the provider about your concerns"
C) "That's not a serious side effect; you should still take it"
D) "I'll crush it and put it in your applesauce so you won't notice"
Correct Answer: B
Rationale: Patients have the right to refuse treatment. The nurse should acknowledge the
patient's concern, advocate for the patient, and notify the provider. Options A and C disregard
patient autonomy, and Option D constitutes deception and is unethical.
9. Which of the following is the most appropriate delegation by a Clinical Nurse I to an
unlicensed assistive personnel (UAP)?
A) Administering oral medications to stable patients
B) Performing a sterile wound dressing change
C) Assisting a patient with ambulation and recording intake and output
D) Assessing a patient's response to pain medication
Correct Answer: C
Rationale: Delegation requires matching the task to the appropriate scope of practice. UAPs can
assist with ambulation and record intake/output. Medication administration (A), sterile
procedures (B), and assessment (D) require licensed nursing judgment and cannot be delegated.
Santa Clara County Clinical Nurse
I Examination – Practice
Question Bank Comprehensive
150-Question Multiple-Choice
Examination a well detailed one
written and graded
A+ upgraded
SECTION 1: NURSING PROCESS AND CLINICAL JUDGMENT (Questions 1–20)
1. A newly hired Clinical Nurse I is performing an initial assessment on a patient admitted with
pneumonia. Which action demonstrates the correct application of the assessment phase of
the nursing process?
, 2
A) Documenting the patient's vital signs and lung sounds
B) Formulating a nursing diagnosis of Impaired Gas Exchange
C) Administering prescribed antibiotics as ordered
D) Evaluating the effectiveness of oxygen therapy after 2 hours
Correct Answer: A
Rationale: Assessment is the first step of the nursing process and involves collecting objective
and subjective data, including vital signs and lung sounds. Formulating a diagnosis (B) occurs
after assessment, implementation (C) follows planning, and evaluation (D) is the final step of the
nursing process.
2. A Clinical Nurse I is caring for a patient who reports severe pain rated 9/10. The nurse
administers morphine as ordered. Thirty minutes later, the patient reports pain is now 3/10.
The nurse documents this finding. Which phase of the nursing process does this represent?
A) Assessment
B) Diagnosis
C) Implementation
D) Evaluation
Correct Answer: D
Rationale: Evaluation involves determining whether the patient's outcomes have been met and
documenting the patient's response to interventions. The nurse is evaluating the effectiveness
of the analgesic administered.
3. A Clinical Nurse I working under close supervision observes a patient becoming increasingly
agitated and confused. According to the Clinical Nurse I classification, what is the most
appropriate initial action?
A) Administer a PRN sedative independently
B) Document the behavior and seek supervision from the charge nurse
C) Restrain the patient for safety
D) Discontinue all medications
Correct Answer: B
Rationale: Clinical Nurse I incumbents work under close supervision of another registered nurse
and should seek supervision and guidance when functioning in unfamiliar situations. The nurse
should document observations and consult with the supervising RN before implementing
interventions.
, 3
4. Which of the following represents a correctly written nursing diagnosis?
A) "Potential for infection related to surgical incision"
B) "Impaired Skin Integrity related to immobility as evidenced by stage 2 pressure ulcer on
sacrum"
C) "Patient will ambulate three times daily"
D) "Administer wound care every shift"
Correct Answer: B
Rationale: A properly written nursing diagnosis includes the problem (Impaired Skin Integrity),
etiology (related to immobility), and defining characteristics (as evidenced by stage 2 pressure
ulcer). Option A is a risk diagnosis that should be stated as "Risk for Infection." Option C is an
outcome statement, and Option D is an intervention.
5. A Clinical Nurse I is planning care for a patient with diabetes. Which intervention should the
nurse prioritize?
A) Teaching the patient about foot care
B) Administering insulin as prescribed
C) Assessing blood glucose levels before meals
D) All of the above based on priority determination
Correct Answer: D
Rationale: Planning involves setting priorities, identifying patient-centered outcomes, and
selecting interventions. All options represent appropriate interventions; the nurse must
prioritize based on the patient's immediate needs and safety considerations.
6. The nurse receives report on four patients. Which patient should the nurse assess first?
A) A patient scheduled for physical therapy at 10:00 AM
B) A patient who received pain medication 30 minutes ago and is sleeping
C) A patient with new-onset confusion and oxygen saturation of 88%
D) A patient requesting assistance with ambulation to the bathroom
Correct Answer: C
Rationale: The patient with new-onset confusion and hypoxia (SpO2 88%) demonstrates acute
deterioration requiring immediate assessment. Priority is given to patients with unstable or
potentially life-threatening conditions.
, 4
7. A Clinical Nurse I is documenting care provided to a patient. Which documentation entry is
most appropriate and legally sound?
A) "Patient appears comfortable and resting"
B) "Patient sleeping quietly in bed, vital signs stable, no complaints of pain"
C) "Patient is doing well today"
D) "Patient seems better than yesterday"
Correct Answer: B
Rationale: Documentation must be objective, specific, and factual. Option B provides specific,
observable data without subjective interpretation. Vague terms like "appears," "doing well," and
"seems better" are inappropriate for legal documentation.
8. A patient tells the nurse, "I don't want to take that medication. It makes me feel dizzy."
What is the nurse's best response?
A) "You need to take it because the doctor ordered it"
B) "I understand. Let me notify the provider about your concerns"
C) "That's not a serious side effect; you should still take it"
D) "I'll crush it and put it in your applesauce so you won't notice"
Correct Answer: B
Rationale: Patients have the right to refuse treatment. The nurse should acknowledge the
patient's concern, advocate for the patient, and notify the provider. Options A and C disregard
patient autonomy, and Option D constitutes deception and is unethical.
9. Which of the following is the most appropriate delegation by a Clinical Nurse I to an
unlicensed assistive personnel (UAP)?
A) Administering oral medications to stable patients
B) Performing a sterile wound dressing change
C) Assisting a patient with ambulation and recording intake and output
D) Assessing a patient's response to pain medication
Correct Answer: C
Rationale: Delegation requires matching the task to the appropriate scope of practice. UAPs can
assist with ambulation and record intake/output. Medication administration (A), sterile
procedures (B), and assessment (D) require licensed nursing judgment and cannot be delegated.
