NUR230SyllabusPennK
ramerIncludes 200+
Questions Covering All
Categories Verified
Answers With
Rationales
1. Which action is the priority when beginning an assessment of a
newly admitted client?
A. Review the client's laboratory results
B. Obtain a complete medication history
C. Determine the client's immediate physiologic stability
D. Ask the client about discharge preferences
Answer: C. Determine the client's immediate physiologic stability
Rationale: Initial assessment begins with determining whether the
client has an immediate threat to airway, breathing, circulation, or
other essential physiologic functions.
,2. Which nursing process step involves identifying the client's actual
and potential health problems?
A. Assessment
B. Diagnosis
C. Planning
D. Evaluation
Answer: B. Diagnosis
Rationale: During the diagnostic step, the nurse analyzes assessment
findings and identifies actual or potential nursing diagnoses.
3. A nurse documents, “Client reports pain of 7/10.” This is an
example of which type of data?
A. Objective
B. Subjective
C. Secondary
D. Laboratory
Answer: B. Subjective
Rationale: Subjective data are symptoms or experiences reported by
the client and cannot be directly measured by the nurse.
4. Which finding is objective data?
A. “I feel dizzy.”
B. “My stomach hurts.”
C. Blood pressure of 168/94 mm Hg
D. “I am anxious.”
Answer: C. Blood pressure of 168/94 mm Hg
Rationale: Objective data are measurable or observable findings
obtained by the nurse.
,5. Which nursing action best demonstrates clinical judgment?
A. Following every intervention exactly as written
B. Recognizing deterioration and determining the appropriate
priority intervention
C. Completing documentation at the end of the shift
D. Asking another nurse to make all clinical decisions
Answer: B. Recognizing deterioration and determining the
appropriate priority intervention
Rationale: Clinical judgment involves recognizing relevant findings,
interpreting their significance, prioritizing problems, and selecting
appropriate actions.
6. Which client should the nurse assess first?
A. Client requesting assistance with bathing
B. Client with a new onset of difficulty breathing
C. Client requesting a snack
D. Client awaiting discharge instructions
Answer: B. Client with a new onset of difficulty breathing
Rationale: A new respiratory problem represents a potential airway
or breathing emergency and takes priority.
7. Which goal is written correctly?
A. Client will feel better.
B. Nurse will monitor the client's temperature.
C. Client will ambulate 50 meters with assistance by 1400.
D. Client will have improved health.
Answer: C. Client will ambulate 50 meters with assistance by 1400.
, Rationale: An effective goal is specific, measurable, achievable,
relevant, and time limited.
8. Which finding indicates that a nursing intervention has been
effective?
A. The nurse completed the intervention.
B. The client demonstrates the expected outcome.
C. The intervention was documented.
D. The provider approved the intervention.
Answer: B. The client demonstrates the expected outcome.
Rationale: Evaluation determines whether the client's response meets
the established expected outcome.
9. Which action should the nurse take when assessment data are
inconsistent?
A. Ignore the discrepancy
B. Immediately document both findings as normal
C. Validate the data
D. Ask the client to leave the unit
Answer: C. Validate the data
Rationale: Unexpected or conflicting findings should be reassessed or
validated before clinical decisions are made.
10. Which nursing action demonstrates evidence-based practice?
A. Using a procedure solely because it has always been done that
way
B. Combining research evidence, clinical expertise, and client
preferences
ramerIncludes 200+
Questions Covering All
Categories Verified
Answers With
Rationales
1. Which action is the priority when beginning an assessment of a
newly admitted client?
A. Review the client's laboratory results
B. Obtain a complete medication history
C. Determine the client's immediate physiologic stability
D. Ask the client about discharge preferences
Answer: C. Determine the client's immediate physiologic stability
Rationale: Initial assessment begins with determining whether the
client has an immediate threat to airway, breathing, circulation, or
other essential physiologic functions.
,2. Which nursing process step involves identifying the client's actual
and potential health problems?
A. Assessment
B. Diagnosis
C. Planning
D. Evaluation
Answer: B. Diagnosis
Rationale: During the diagnostic step, the nurse analyzes assessment
findings and identifies actual or potential nursing diagnoses.
3. A nurse documents, “Client reports pain of 7/10.” This is an
example of which type of data?
A. Objective
B. Subjective
C. Secondary
D. Laboratory
Answer: B. Subjective
Rationale: Subjective data are symptoms or experiences reported by
the client and cannot be directly measured by the nurse.
4. Which finding is objective data?
A. “I feel dizzy.”
B. “My stomach hurts.”
C. Blood pressure of 168/94 mm Hg
D. “I am anxious.”
Answer: C. Blood pressure of 168/94 mm Hg
Rationale: Objective data are measurable or observable findings
obtained by the nurse.
,5. Which nursing action best demonstrates clinical judgment?
A. Following every intervention exactly as written
B. Recognizing deterioration and determining the appropriate
priority intervention
C. Completing documentation at the end of the shift
D. Asking another nurse to make all clinical decisions
Answer: B. Recognizing deterioration and determining the
appropriate priority intervention
Rationale: Clinical judgment involves recognizing relevant findings,
interpreting their significance, prioritizing problems, and selecting
appropriate actions.
6. Which client should the nurse assess first?
A. Client requesting assistance with bathing
B. Client with a new onset of difficulty breathing
C. Client requesting a snack
D. Client awaiting discharge instructions
Answer: B. Client with a new onset of difficulty breathing
Rationale: A new respiratory problem represents a potential airway
or breathing emergency and takes priority.
7. Which goal is written correctly?
A. Client will feel better.
B. Nurse will monitor the client's temperature.
C. Client will ambulate 50 meters with assistance by 1400.
D. Client will have improved health.
Answer: C. Client will ambulate 50 meters with assistance by 1400.
, Rationale: An effective goal is specific, measurable, achievable,
relevant, and time limited.
8. Which finding indicates that a nursing intervention has been
effective?
A. The nurse completed the intervention.
B. The client demonstrates the expected outcome.
C. The intervention was documented.
D. The provider approved the intervention.
Answer: B. The client demonstrates the expected outcome.
Rationale: Evaluation determines whether the client's response meets
the established expected outcome.
9. Which action should the nurse take when assessment data are
inconsistent?
A. Ignore the discrepancy
B. Immediately document both findings as normal
C. Validate the data
D. Ask the client to leave the unit
Answer: C. Validate the data
Rationale: Unexpected or conflicting findings should be reassessed or
validated before clinical decisions are made.
10. Which nursing action demonstrates evidence-based practice?
A. Using a procedure solely because it has always been done that
way
B. Combining research evidence, clinical expertise, and client
preferences
