Fundamentals of Nursing, Nursing Process (Latest Update) Questions and Verified Answers 100% Correct Grade A.pdf

Fundamentals of Nursing, Nursing Process n n n n




1. A client comes to the walk-
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in clinic with reports of abdominal pain and diarrhea. While taking the client's vi
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tal signs, the nurse is implementing which phase of the nursing process?
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A. Assessment

B. Diagnosis

C. Planning

D. Implementation: A. Assessment n n




Rationale: The first step in the nursing process is assessment, the process of collecting
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data. All subsequent phases of the nursing process (options 2, 3, and 4) rely on accurate
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n and complete data.
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2. The nurse is measuring the client's urine output and straining the urine to ass
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ess for stones.Which of the following should the nurse record as objective data?
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A. The client reports abdominal pain
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B. The client's urine output was 450 mL
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C. The client states, "I didn't see any stones in my urine."
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D. The client states, "I feel like I have passed a stone.": B. The client's urine outp
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,ut was 450 mL.
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Rationale: Objective data is measurable data that can be seen, heard, or verified by the
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nurse. The objective data is the measurement of the urine output. A client's statements
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and reports of symptoms are documented as subjective data, such as the data found in
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options 1, 3, and 4. n n n n




3. When evaluating an elderly client's blood pressure (BP) of 146/78 mmHg, th
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e nurse does which of the following before determining whether the BP is norm
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al or represents hypertension?
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A. Compare this reading against defined standards n n n n n




B. Compare the reading with one taken in the opposite arm n n n n n n n n n




C. Determine gaps in the vital signs in the client record n n n n n n n n n




D. Compare the current measurement with previous ones: A. Compare this rea
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ding against definedn n




Rationale: Analysis of the client's BP requires knowledge of the normal BP range for an
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older adult. The nurse compares the client's data against identified standards to determ
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ine whether this reading is normal or abnormal. Measuring the BP in the other arm (op
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tion 2) and comparing the reading to previous ones (option 4) will give additional clien
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t data, but the comparison alone will not determine whether the
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,BP is normal. Gaps in the record (option 3) will not aid in interpreting the current meas
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urement.

4. Which of the following behaviors by the nurse demonstrates that the nurse is p
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articipating in critical thinking? Select all that apply.
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A. Admitting not knowing how to do a procedure and requesting help
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B. Using clever and persuasive remarks to support an opinion or position
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C. Accepting without question the values acquired in nursing school
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D. Finding a quick and logical answer, even to complex questions
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E. Gathering three assistants to transfer the client to a stretcher after noting the
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client weighs 300 lbs.: A. Admitting not knowing how to do a procedure and request
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ing helpn




E. Gathering three assistants to transfer the client to a stretcher after noting the client wei
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ghs 300 lbs.n n




Rationale: Critical thinking in nursing is self-
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directed, supporting what nurses know and making clear what they do not know. It is im
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portant for nurses to recognize when they lack the knowledge they need to provide safe c
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are for a client (option 1). Nurses must also utilize their resources to acquire the support
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they need to care for a client safely (option 5). Options 2, 3, and 4 do not demonstrate cr
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, itical thinking. n




5. The nurse has documented the following outcome goal in the care plan: "The c
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lient will transfer from bed to chair with two-
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person assist." The charge nurse tells the nurse to add which of the following to c
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omplete the goal? n n




A. Client behavior n




B. Conditions or modifiers n n




C. Performance criteria n




D. Target time: D. Target time n n n n




Rationale: The outcome goal does not state the target timeframe for when the nurse sho
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uld expect to see the client behavior ("transfer"). The condition or modifier is present (
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"with two assists"). The performance criterion is "from bed to chair."
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6. The nurse who documents on the client's care plan the outcome goal "Anxiet
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y will be relieved within 20 to 40 minutes following administration of lorazepa
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m (Ativan)" is engaged in which step of the nursing process?
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A. Assessment

B. Planning

C. Implementation
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