EDITION (2025) BY PATRICIA A. POTTER
–TEST BANK QUESTIONS & ANSWERS |
STUDY GUIDE WITH RATIONALES
(GRADED A+) GUARANTEED PASS
1. Which nursing action best demonstrates the principle of patient-centered
care?
A. Making decisions for the patient to save time
B. Including the patient in decisions about their care
C. Following the same care plan for every patient
D. Allowing family members to make all healthcare decisions
Answer: B. Including the patient in decisions about their care
Rationale: Patient-centered care respects the patient's preferences, values,
needs, and right to participate in healthcare decisions.
2. Which component of the nursing process involves collecting subjective
and objective information about a patient?
A. Planning
B. Implementation
C. Assessment
D. Evaluation
Answer: C. Assessment
Rationale: Assessment is the systematic collection and analysis of information
about the patient's health status.
3. Which finding is considered objective data?
,A. “I feel nauseated.”
B. “My pain is severe.”
C. “I am feeling anxious.”
D. Blood pressure of 148/88 mm Hg
Answer: D. Blood pressure of 148/88 mm Hg
Rationale: Objective data are measurable or observable findings obtained
through examination, observation, or diagnostic testing.
4. A patient reports pain at a level of 8 out of 10. What type of information
is this?
A. Objective data
B. Subjective data
C. Secondary data
D. Diagnostic data
Answer: B. Subjective data
Rationale: A patient's report of symptoms, sensations, or feelings represents
subjective data because it cannot be directly measured by another person.
5. Which nursing diagnosis statement is written correctly?
A. Pneumonia related to ineffective airway clearance
B. Acute pain related to surgical incision as evidenced by patient reporting pain
of 8/10
C. Hypertension related to anxiety
D. Diabetes mellitus related to poor nutrition
Answer: B. Acute pain related to surgical incision as evidenced by patient
reporting pain of 8/10
Rationale: A nursing diagnosis identifies a patient response or problem and,
when appropriate, includes related factors and defining characteristics.
6. Which goal is written in the most measurable form?
,A. Patient will feel better soon.
B. Patient will have improved mobility.
C. Patient will ambulate 50 meters with assistance by the end of the shift.
D. Patient will understand exercise.
Answer: C. Patient will ambulate 50 meters with assistance by the end of the
shift.
Rationale: A measurable goal specifies the expected behavior, amount, and time
frame, allowing the nurse to evaluate whether the goal was achieved.
7. Which action represents the implementation phase of the nursing
process?
A. Identifying a nursing diagnosis
B. Developing expected outcomes
C. Administering prescribed medication
D. Determining whether the goal was achieved
Answer: C. Administering prescribed medication
Rationale: Implementation involves carrying out planned nursing interventions
to achieve established patient outcomes.
8. During evaluation, the nurse determines that a patient's goal has not
been met. What should the nurse do next?
A. Ignore the outcome
B. Immediately discharge the patient
C. Reassess the patient and revise the plan as appropriate
D. Document that the goal was achieved
Answer: C. Reassess the patient and revise the plan as appropriate
Rationale: When an expected outcome is not achieved, the nurse reassesses the
patient and determines whether interventions or goals need modification.
9. Which action is most effective for preventing the transmission of
infection?
, A. Wearing a mask for every patient interaction
B. Performing appropriate hand hygiene
C. Keeping all patients in isolation
D. Administering antibiotics routinely
Answer: B. Performing appropriate hand hygiene
Rationale: Hand hygiene is one of the most important measures for reducing the
transmission of microorganisms in healthcare settings.
10. When should a nurse perform hand hygiene?
A. Only after caring for a patient
B. Only when hands appear visibly dirty
C. Before and after patient contact and as otherwise indicated
D. Once at the beginning of the shift
Answer: C. Before and after patient contact and as otherwise indicated
Rationale: Hand hygiene is required at appropriate points during patient care
to prevent transmission of microorganisms.
11. Which intervention is most appropriate when assisting a patient who is
at risk for falls?
A. Keep the bed in the highest position
B. Keep frequently used items within the patient's reach
C. Encourage the patient to walk without assistance
D. Keep the room dark at night
Answer: B. Keep frequently used items within the patient's reach
Rationale: Keeping essential items within reach reduces unnecessary attempts
by the patient to get out of bed and therefore helps reduce fall risk.
12. Which assessment finding should the nurse recognize as requiring
immediate attention?