NURSING 101 Jarvis Chapter 1-4(chapt1
to chpt4) 7th Ed Test Bank
SECTION I: EVIDENCE-BASED ASSESSMENT (Chapter 1)
1. After completing an initial assessment of a patient, the nurse has charted that his
respirations are eupneic and his pulse is 58 beats per minute. These types of data would be:
a. Objective.
b. Reflective.
c. Subjective.
d. Introspective.
Correct Answer: A
Rationale: Objective data are what the health professional observes by inspecting,
percussing, palpating, and auscultating during the physical examination. Eupneic respirations
and a pulse rate of 58 bpm are measurable, observable findings. Subjective data is what the
person says about himself or herself during history taking. The terms reflective and
introspective are not used to describe data types in health assessment.
2. A patient tells the nurse that he is very nervous, is nauseated, and "feels hot." These types
of data would be:
a. Objective.
b. Reflective.
c. Subjective.
d. Introspective.
Correct Answer: C
Rationale: Subjective data are what the person says about himself or herself during history
taking. The patient's statements about feeling nervous, nauseated, and hot are symptoms that
cannot be directly verified by the nurse through physical examination. Objective data would be
what the nurse observes through assessment techniques.
,3. The patient's record, laboratory studies, objective data, and subjective data combine to
form the:
a. Data base.
b. Admitting data.
c. Financial statement.
d. Discharge summary.
Correct Answer: A
Rationale: Together with the patient's record and laboratory studies, the objective and
subjective data form the data base. The other items are not part of the patient's record,
laboratory studies, or data collection process.
4. When listening to a patient's breath sounds, the nurse is unsure of a sound that is heard.
The nurse's next action should be to:
a. Immediately notify the patient's physician.
b. Document the sound exactly as it was heard.
c. Validate the data by asking a coworker to listen to the breath sounds.
d. Assess again in 20 minutes to note whether the sound is still present.
Correct Answer: C
Rationale: When unsure of a sound heard while listening to a patient's breath sounds, the
nurse validates the data to ensure accuracy. If the nurse has less experience in an area, then he
or she asks an expert to listen. Validating findings with another professional enhances the
reliability of assessment data and prevents errors in clinical judgment.
5. The nurse is conducting a class for new graduate nurses. During the teaching session, the
nurse should keep in mind that novice nurses, without a background of skills and experience
from which to draw, are more likely to make their decisions using:
a. Intuition.
b. A set of rules.
c. Articles in journals.
d. Advice from supervisors.
Correct Answer: B
, Rationale: Novice nurses operate from a set of defined, structured rules. The expert
practitioner uses intuitive links and draws on a wealth of clinical experience. Novice nurses rely
on established protocols and guidelines until they develop the experience necessary for more
intuitive clinical reasoning.
6. Expert nurses learn to attend to a pattern of assessment data and act without consciously
labeling it. These responses are referred to as:
a. Intuition.
b. The nursing process.
c. Clinical knowledge.
d. Diagnostic reasoning.
Correct Answer: A
Rationale: Intuition is characterized by pattern recognition—expert nurses learn to attend
to a pattern of assessment data and act without consciously labeling it. The other options are
not correct descriptions of this phenomenon.
7. The nurse is reviewing information about evidence-based practice (EBP). Which statement
best reflects EBP?
a. EBP relies on tradition for support of best practices.
b. EBP is simply the use of best practice techniques for the treatment of patients.
c. EBP emphasizes the use of best evidence with the clinician's experience.
d. The patient's own preferences are not important with EBP.
Correct Answer: C
Rationale: EBP is a systematic approach to practice that emphasizes the use of best
evidence in combination with the clinician's experience, as well as patient preferences and
values, when making decisions about care and treatment. EBP is more than simply using the
best practice techniques to treat patients, and questioning tradition is important when no
compelling and supportive research evidence exists.
8. The nurse is conducting a class on priority setting for a group of new graduate nurses.
Which is an example of a first-level priority problem?
, a. Patient with postoperative pain
b. Newly diagnosed patient with diabetes who needs diabetic teaching
c. Individual with a small laceration on the sole of the foot
d. Individual with shortness of breath and respiratory distress
Correct Answer: D
Rationale: First-level priority problems are those that are emergent, life threatening, and
immediate (e.g., establishing an airway, supporting breathing, maintaining circulation,
monitoring abnormal vital signs). Postoperative pain is a second-level priority; diabetic teaching
and a small laceration are third-level priorities.
9. When considering priority setting of problems, the nurse keeps in mind that second-level
priority problems include which of these aspects?
a. Low self-esteem
b. Lack of knowledge
c. Abnormal laboratory values
d. Severely abnormal vital signs
Correct Answer: C
Rationale: Second-level priority problems are those that require prompt intervention to
forestall further deterioration (e.g., mental status change, acute pain, abnormal laboratory
values, risks to safety or security). Severely abnormal vital signs would be first-level, while low
self-esteem and lack of knowledge are third-level priorities.
10. Which critical thinking skill helps the nurse see relationships among the data?
a. Validation
b. Clustering related cues
c. Identifying gaps in data
d. Distinguishing relevant from irrelevant
Correct Answer: B
Rationale: Clustering related cues helps the nurse see relationships among the data. This
skill allows the nurse to group assessment findings that support a particular nursing diagnosis or
clinical judgment.
to chpt4) 7th Ed Test Bank
SECTION I: EVIDENCE-BASED ASSESSMENT (Chapter 1)
1. After completing an initial assessment of a patient, the nurse has charted that his
respirations are eupneic and his pulse is 58 beats per minute. These types of data would be:
a. Objective.
b. Reflective.
c. Subjective.
d. Introspective.
Correct Answer: A
Rationale: Objective data are what the health professional observes by inspecting,
percussing, palpating, and auscultating during the physical examination. Eupneic respirations
and a pulse rate of 58 bpm are measurable, observable findings. Subjective data is what the
person says about himself or herself during history taking. The terms reflective and
introspective are not used to describe data types in health assessment.
2. A patient tells the nurse that he is very nervous, is nauseated, and "feels hot." These types
of data would be:
a. Objective.
b. Reflective.
c. Subjective.
d. Introspective.
Correct Answer: C
Rationale: Subjective data are what the person says about himself or herself during history
taking. The patient's statements about feeling nervous, nauseated, and hot are symptoms that
cannot be directly verified by the nurse through physical examination. Objective data would be
what the nurse observes through assessment techniques.
,3. The patient's record, laboratory studies, objective data, and subjective data combine to
form the:
a. Data base.
b. Admitting data.
c. Financial statement.
d. Discharge summary.
Correct Answer: A
Rationale: Together with the patient's record and laboratory studies, the objective and
subjective data form the data base. The other items are not part of the patient's record,
laboratory studies, or data collection process.
4. When listening to a patient's breath sounds, the nurse is unsure of a sound that is heard.
The nurse's next action should be to:
a. Immediately notify the patient's physician.
b. Document the sound exactly as it was heard.
c. Validate the data by asking a coworker to listen to the breath sounds.
d. Assess again in 20 minutes to note whether the sound is still present.
Correct Answer: C
Rationale: When unsure of a sound heard while listening to a patient's breath sounds, the
nurse validates the data to ensure accuracy. If the nurse has less experience in an area, then he
or she asks an expert to listen. Validating findings with another professional enhances the
reliability of assessment data and prevents errors in clinical judgment.
5. The nurse is conducting a class for new graduate nurses. During the teaching session, the
nurse should keep in mind that novice nurses, without a background of skills and experience
from which to draw, are more likely to make their decisions using:
a. Intuition.
b. A set of rules.
c. Articles in journals.
d. Advice from supervisors.
Correct Answer: B
, Rationale: Novice nurses operate from a set of defined, structured rules. The expert
practitioner uses intuitive links and draws on a wealth of clinical experience. Novice nurses rely
on established protocols and guidelines until they develop the experience necessary for more
intuitive clinical reasoning.
6. Expert nurses learn to attend to a pattern of assessment data and act without consciously
labeling it. These responses are referred to as:
a. Intuition.
b. The nursing process.
c. Clinical knowledge.
d. Diagnostic reasoning.
Correct Answer: A
Rationale: Intuition is characterized by pattern recognition—expert nurses learn to attend
to a pattern of assessment data and act without consciously labeling it. The other options are
not correct descriptions of this phenomenon.
7. The nurse is reviewing information about evidence-based practice (EBP). Which statement
best reflects EBP?
a. EBP relies on tradition for support of best practices.
b. EBP is simply the use of best practice techniques for the treatment of patients.
c. EBP emphasizes the use of best evidence with the clinician's experience.
d. The patient's own preferences are not important with EBP.
Correct Answer: C
Rationale: EBP is a systematic approach to practice that emphasizes the use of best
evidence in combination with the clinician's experience, as well as patient preferences and
values, when making decisions about care and treatment. EBP is more than simply using the
best practice techniques to treat patients, and questioning tradition is important when no
compelling and supportive research evidence exists.
8. The nurse is conducting a class on priority setting for a group of new graduate nurses.
Which is an example of a first-level priority problem?
, a. Patient with postoperative pain
b. Newly diagnosed patient with diabetes who needs diabetic teaching
c. Individual with a small laceration on the sole of the foot
d. Individual with shortness of breath and respiratory distress
Correct Answer: D
Rationale: First-level priority problems are those that are emergent, life threatening, and
immediate (e.g., establishing an airway, supporting breathing, maintaining circulation,
monitoring abnormal vital signs). Postoperative pain is a second-level priority; diabetic teaching
and a small laceration are third-level priorities.
9. When considering priority setting of problems, the nurse keeps in mind that second-level
priority problems include which of these aspects?
a. Low self-esteem
b. Lack of knowledge
c. Abnormal laboratory values
d. Severely abnormal vital signs
Correct Answer: C
Rationale: Second-level priority problems are those that require prompt intervention to
forestall further deterioration (e.g., mental status change, acute pain, abnormal laboratory
values, risks to safety or security). Severely abnormal vital signs would be first-level, while low
self-esteem and lack of knowledge are third-level priorities.
10. Which critical thinking skill helps the nurse see relationships among the data?
a. Validation
b. Clustering related cues
c. Identifying gaps in data
d. Distinguishing relevant from irrelevant
Correct Answer: B
Rationale: Clustering related cues helps the nurse see relationships among the data. This
skill allows the nurse to group assessment findings that support a particular nursing diagnosis or
clinical judgment.
