,Chapter1: Foundations of Nursing Practice
Stem
A hospitalized patient’s condition suddenly worsens. According
to the ANA Standards of Practice, which action most directly
reflects the nurse’s responsibility under the Assessment
standard?
A. Immediately administer a PRN medication from the unit
supply.
B. Collect and document focused subjective and objective data
about the change.
C. Call a family member and ask about the patient’s baseline
health.
D. Begin discharge planning to remove risk after stabilization.
Correct Answer
B
Rationales
Correct: Collecting and documenting focused subjective and
objective data is the core of the Assessment standard—it
provides the information necessary for clinical judgment and
subsequent steps in the nursing process.
A: Administering medication may be appropriate later, but
without assessment data it risks unsafe care and does not fulfill
the Assessment standard.
C: Family input can be useful but is supplemental; it does not
replace immediate clinical data collection.
,D: Discharge planning is unrelated to the immediate assessment
required when a patient’s condition worsens.
Teaching Point
Assessment = timely, focused data collection to guide safe
nursing decisions.
2.
Chapter 1, Section 1: Scope of Nursing Practice
Stem
Which of the following best describes “Outcomes
Identification” in the ANA Standards of Practice?
A. Writing nursing diagnoses only after physician diagnosis is
confirmed.
B. Predicting and documenting expected patient-centered
outcomes for the plan of care.
C. Implementing interventions without measurable goals.
D. Delegating goal-setting to ancillary staff to save time.
Correct Answer
B
Rationales
Correct: Outcomes Identification requires the registered nurse
to identify measurable, patient-centered expected outcomes
that guide planning and evaluation.
A: Nursing diagnoses are independent clinical judgments and do
, not require prior physician confirmation.
C: Implementing interventions without measurable goals
contradicts the Outcomes Identification standard.
D: Delegation of outcome-setting to nonlicensed personnel
undermines professional accountability and the individualized
nature of outcome identification.
Teaching Point
Outcomes must be measurable, patient-centered, and guide
evaluation.
3.
Chapter 1, Section 1: Scope of Nursing Practice
Stem
A novice nurse is preparing a care plan for a post-operative
patient. Which activity demonstrates adherence to the Planning
standard?
A. Developing interventions based on best available evidence
and patient preferences.
B. Waiting for the physician to create the plan of care before
acting.
C. Using the same generic care plan for all post-op patients.
D. Deferring plan documentation until the end of shift.
Correct Answer
A
Stem
A hospitalized patient’s condition suddenly worsens. According
to the ANA Standards of Practice, which action most directly
reflects the nurse’s responsibility under the Assessment
standard?
A. Immediately administer a PRN medication from the unit
supply.
B. Collect and document focused subjective and objective data
about the change.
C. Call a family member and ask about the patient’s baseline
health.
D. Begin discharge planning to remove risk after stabilization.
Correct Answer
B
Rationales
Correct: Collecting and documenting focused subjective and
objective data is the core of the Assessment standard—it
provides the information necessary for clinical judgment and
subsequent steps in the nursing process.
A: Administering medication may be appropriate later, but
without assessment data it risks unsafe care and does not fulfill
the Assessment standard.
C: Family input can be useful but is supplemental; it does not
replace immediate clinical data collection.
,D: Discharge planning is unrelated to the immediate assessment
required when a patient’s condition worsens.
Teaching Point
Assessment = timely, focused data collection to guide safe
nursing decisions.
2.
Chapter 1, Section 1: Scope of Nursing Practice
Stem
Which of the following best describes “Outcomes
Identification” in the ANA Standards of Practice?
A. Writing nursing diagnoses only after physician diagnosis is
confirmed.
B. Predicting and documenting expected patient-centered
outcomes for the plan of care.
C. Implementing interventions without measurable goals.
D. Delegating goal-setting to ancillary staff to save time.
Correct Answer
B
Rationales
Correct: Outcomes Identification requires the registered nurse
to identify measurable, patient-centered expected outcomes
that guide planning and evaluation.
A: Nursing diagnoses are independent clinical judgments and do
, not require prior physician confirmation.
C: Implementing interventions without measurable goals
contradicts the Outcomes Identification standard.
D: Delegation of outcome-setting to nonlicensed personnel
undermines professional accountability and the individualized
nature of outcome identification.
Teaching Point
Outcomes must be measurable, patient-centered, and guide
evaluation.
3.
Chapter 1, Section 1: Scope of Nursing Practice
Stem
A novice nurse is preparing a care plan for a post-operative
patient. Which activity demonstrates adherence to the Planning
standard?
A. Developing interventions based on best available evidence
and patient preferences.
B. Waiting for the physician to create the plan of care before
acting.
C. Using the same generic care plan for all post-op patients.
D. Deferring plan documentation until the end of shift.
Correct Answer
A
