COLLEGE OF NURSING, VERIFIED AND CORRECT ANSWER,
SECURE HIGH GRADE
1. A nurse is providing care based on Maslow's Hierarchy of Needs. Which client action would
the nurse address first?
A. Expressing feelings of loneliness
B. Having a fear of surgery
C. Difficulty breathing
D. Dissatisfaction with the hospital food
Answer: C. Difficulty breathing
2. The nurse is preparing to administer a medication and identifies the client using two
identifiers. Which of the following is an acceptable pair of identifiers?
A. Room number and birth date
B. Client's name and room number
C. Client's name and medical record number
D. Bed number and photograph
Answer: C. Client's name and medical record number
3. A client tells the nurse, "I am feeling very anxious about this test." The nurse responds, "You
are feeling anxious?" This communication technique is known as:
A. Reflecting
B. Restating
C. Focusing
D. Summarizing
Answer: B. Restating
4. Which nursing action best demonstrates the concept of advocacy?
A. Informing the physician of the client's refusal of a procedure
B. Completing all assigned tasks on time
C. Documenting care accurately in the client's chart
,D. Following the facility's policies and procedures
Answer: A. Informing the physician of the client's refusal of a procedure
5. The nurse is reviewing the concepts of critical thinking. Which attribute is essential for a
critical thinker?
A. Always agreeing with the healthcare team
B. Being able to recall facts quickly
C. Considering alternative perspectives
D. Relying solely on past experiences
Answer: C. Considering alternative perspectives
6. A client with a history of falls is identified as a high risk. Which nursing intervention is most
appropriate to ensure client safety?
A. Restraining the client in the chair
B. Placing the client in a room close to the nurses' station
C. Administering a sedative medication
D. Raising all four side rails on the bed
Answer: B. Placing the client in a room close to the nurses' station
7. During the admission process, the nurse is collecting subjective data. Which of the following
is an example of subjective data?
A. Blood pressure 150/88 mmHg
B. Client's report of nausea
C. Oxygen saturation of 92%
D. Presence of a 2cm wound on the leg
Answer: B. Client's report of nausea
8. The primary purpose of the nursing process is to:
A. Provide a framework for implementing physician orders.
B. Establish a medical diagnosis for the client.
C. Deliver standardized care for all clients.
,D. Provide a systematic method for planning and delivering nursing care.
Answer: D. Provide a systematic method for planning and delivering nursing care.
9. A client is scheduled for surgery. The nurse reviews the client's chart to ensure the surgical
consent form is signed. This role of the nurse is best described as:
A. Caregiver
B. Advocate
C. Manager
D. Educator
Answer: B. Advocate
10. Which of the following is the correct order of the nursing process?
A. Assessment, Diagnosis, Planning, Implementation, Evaluation
B. Diagnosis, Assessment, Planning, Evaluation, Implementation
C. Planning, Assessment, Diagnosis, Implementation, Evaluation
D. Assessment, Planning, Diagnosis, Implementation, Evaluation
Answer: A. Assessment, Diagnosis, Planning, Implementation, Evaluation
11. A nurse is providing perineal care to a female client. The correct technique is to wipe:
A. Back to front
B. In a circular motion
C. Front to back
D. Side to side
Answer: C. Front to back
12. Which vital sign is considered the fifth vital sign?
A. Oxygen saturation
B. Pain
C. Level of consciousness
D. Capillary refill
, Answer: B. Pain
13. When moving a client up in bed, the nurse should primarily use which principle to prevent
self-injury?
A. Use a rocking motion
B. Keep feet close together
C. Use the muscles of the back
D. Use the muscles of the legs
Answer: D. Use the muscles of the legs
14. A client has an order for "NPO after midnight." The nurse should:
A. Offer clear liquids only
B. Withhold all food and fluids
C. Provide a full liquid diet
D. Allow sips of water with medications
Answer: B. Withhold all food and fluids
15. The nurse is teaching a client about a new medication. What is the best way to evaluate the
client's understanding?
A. Ask, "Do you understand the instructions?"
B. Provide a written pamphlet.
C. Ask the client to explain the instructions back in their own words.
D. Repeat the instructions a second time.
Answer: C. Ask the client to explain the instructions back in their own words.
16. Which of the following is an example of a nursing diagnosis?
A. Pneumonia
B. Diabetes Mellitus
C. Impaired Gas Exchange
D. Hypertension