,SECTION 1: NURSING PROCESS, ASSESSMENT & DOCUMENTATION
(Questions 1-50)
Q1. A nurse is caring for a client who has a new diagnosis of diabetes mellitus. What is the
first action the nurse should take?
A) Administer insulin as prescribed
B) Check the client's blood glucose level
C) Teach the client how to use a glucometer
D) Evaluate the effectiveness of dietary changes
Correct Answer: B
Rationale: Assessment is the first phase of the nursing process and involves collecting objective
and subjective data. Checking blood glucose is a data collection activity. Administration and
teaching are implementation activities, and evaluation is the final step of the nursing process .
Q2. A nurse is planning care for a client who is post-operative following a hip replacement.
Which of the following outcomes is correctly written?
A) "The client will walk 50 feet by discharge"
B) "The client will ambulate independently"
C) "The client will be pain-free"
D) "The nurse will assist the client with walking"
Correct Answer: A
Rationale: A correctly written outcome is specific, measurable, achievable, realistic, and time-
bound (SMART). "The client will walk 50 feet by discharge" includes a specific distance and
timeframe. Option B lacks a timeframe and measurability. Option C is unrealistic (pain-free).
Option D is a nursing intervention, not a patient outcome .
Q3. What is the primary purpose of the assessment phase of the nursing process?
A) It allows the nurse to administer medications
B) It provides data collection for identifying patient problems
C) It is the final step of the nursing process
D) It replaces the need for physician evaluation
Correct Answer: B
,Rationale: The assessment phase involves systematic data collection (objective and subjective)
that forms the foundation for identifying nursing diagnoses, planning care, implementing
interventions, and evaluating outcomes .
Q4. What is the primary source of information during a nursing assessment?
A) The patient's family
B) The patient's medical records
C) The patient
D) The healthcare provider
Correct Answer: C
Rationale: The patient is the primary source of information during a nursing assessment. The
primary source provides the most accurate subjective data about symptoms, concerns, and
health history. If the patient is confused, disoriented, or unable to communicate, the family
becomes the secondary source .
Q5. What is the first thing the nurse should do when assessing a patient?
A) Auscultate breath sounds
B) Palpate for tenderness
C) Observe the patient's appearance and behavior
D) Percuss for organ density
Correct Answer: C
Rationale: Assessment begins with observation of the patient's overall appearance, behavior,
and general condition before proceeding to more focused physical examination techniques
(auscultation, palpation, percussion) .
Q6. What part of the stethoscope is used to detect low-frequency sounds such as abnormal
heart sounds?
A) The diaphragm
B) The bell
C) The earpieces
D) The chest piece
Correct Answer: B
, Rationale: The bell of the stethoscope is used to detect low-frequency sounds such as abnormal
heart sounds (S3, S4, murmurs) and adventitious breath sounds. The diaphragm is used for
high-pitched sounds including normal heart, lung, and bowel sounds .
Q7. Where is the apical pulse located?
A) 2nd intercostal space, midclavicular line
B) 5th intercostal space, midclavicular line
C) 4th intercostal space, sternal border
D) 6th intercostal space, anterior axillary line
Correct Answer: B
Rationale: The apical pulse is located at the 5th intercostal space at the midclavicular line (left
side of the chest). This is the point of maximal impulse (PMI) where the heartbeat is most easily
auscultated .
Q8. When auscultating heart sounds, what should the nurse do if S3 is heard?
A) Document as a normal finding
B) Listen to all four valves (tricuspid, aortic, pulmonary, mitral)
C) Notify the provider immediately
D) Disregard the finding
Correct Answer: B
Rationale: S3 is an abnormal heart sound that should prompt the nurse to listen at all four
cardiac valve areas to fully assess the client's cardiac status .
Q9. Which of the following is an appropriate nursing response when a client requests help
with tasks that are outside the nurse's job description?
A) "Let's look at some other resources to solve this problem."
B) "I'll do it for you this time but not again."
C) "That isn't my job, and there's nothing else I can do."
D) "Ask your neighbors; I can't help."
Correct Answer: A
(Questions 1-50)
Q1. A nurse is caring for a client who has a new diagnosis of diabetes mellitus. What is the
first action the nurse should take?
A) Administer insulin as prescribed
B) Check the client's blood glucose level
C) Teach the client how to use a glucometer
D) Evaluate the effectiveness of dietary changes
Correct Answer: B
Rationale: Assessment is the first phase of the nursing process and involves collecting objective
and subjective data. Checking blood glucose is a data collection activity. Administration and
teaching are implementation activities, and evaluation is the final step of the nursing process .
Q2. A nurse is planning care for a client who is post-operative following a hip replacement.
Which of the following outcomes is correctly written?
A) "The client will walk 50 feet by discharge"
B) "The client will ambulate independently"
C) "The client will be pain-free"
D) "The nurse will assist the client with walking"
Correct Answer: A
Rationale: A correctly written outcome is specific, measurable, achievable, realistic, and time-
bound (SMART). "The client will walk 50 feet by discharge" includes a specific distance and
timeframe. Option B lacks a timeframe and measurability. Option C is unrealistic (pain-free).
Option D is a nursing intervention, not a patient outcome .
Q3. What is the primary purpose of the assessment phase of the nursing process?
A) It allows the nurse to administer medications
B) It provides data collection for identifying patient problems
C) It is the final step of the nursing process
D) It replaces the need for physician evaluation
Correct Answer: B
,Rationale: The assessment phase involves systematic data collection (objective and subjective)
that forms the foundation for identifying nursing diagnoses, planning care, implementing
interventions, and evaluating outcomes .
Q4. What is the primary source of information during a nursing assessment?
A) The patient's family
B) The patient's medical records
C) The patient
D) The healthcare provider
Correct Answer: C
Rationale: The patient is the primary source of information during a nursing assessment. The
primary source provides the most accurate subjective data about symptoms, concerns, and
health history. If the patient is confused, disoriented, or unable to communicate, the family
becomes the secondary source .
Q5. What is the first thing the nurse should do when assessing a patient?
A) Auscultate breath sounds
B) Palpate for tenderness
C) Observe the patient's appearance and behavior
D) Percuss for organ density
Correct Answer: C
Rationale: Assessment begins with observation of the patient's overall appearance, behavior,
and general condition before proceeding to more focused physical examination techniques
(auscultation, palpation, percussion) .
Q6. What part of the stethoscope is used to detect low-frequency sounds such as abnormal
heart sounds?
A) The diaphragm
B) The bell
C) The earpieces
D) The chest piece
Correct Answer: B
, Rationale: The bell of the stethoscope is used to detect low-frequency sounds such as abnormal
heart sounds (S3, S4, murmurs) and adventitious breath sounds. The diaphragm is used for
high-pitched sounds including normal heart, lung, and bowel sounds .
Q7. Where is the apical pulse located?
A) 2nd intercostal space, midclavicular line
B) 5th intercostal space, midclavicular line
C) 4th intercostal space, sternal border
D) 6th intercostal space, anterior axillary line
Correct Answer: B
Rationale: The apical pulse is located at the 5th intercostal space at the midclavicular line (left
side of the chest). This is the point of maximal impulse (PMI) where the heartbeat is most easily
auscultated .
Q8. When auscultating heart sounds, what should the nurse do if S3 is heard?
A) Document as a normal finding
B) Listen to all four valves (tricuspid, aortic, pulmonary, mitral)
C) Notify the provider immediately
D) Disregard the finding
Correct Answer: B
Rationale: S3 is an abnormal heart sound that should prompt the nurse to listen at all four
cardiac valve areas to fully assess the client's cardiac status .
Q9. Which of the following is an appropriate nursing response when a client requests help
with tasks that are outside the nurse's job description?
A) "Let's look at some other resources to solve this problem."
B) "I'll do it for you this time but not again."
C) "That isn't my job, and there's nothing else I can do."
D) "Ask your neighbors; I can't help."
Correct Answer: A
