NUR 514: EXAM 1 QUESTIONS AND
ANSWERS
A9client9comes9to9the9walk-
in9clinic9with9reports9of9abdominal9pain9and9diarrhea.9While9taking9the9client's9vital9sign
s,9the9nurse9is9implementing9which9phase9of9the9nursing9process?
A.9Assessment
B.9Diagnosis
C.9Planning
D.9Implementation9-9ans✔A.9Assessment
Rationale:9The9first9step9in9the9nursing9process9is9assessment,9the9process9of9collectin
g9data.9All9subsequent9phases9of9the9nursing9process9(options92,93,9and94)9rely9on9acc
urate9and9complete9data.
Six9Competencies9of9QSEN9-9ans✔Patient-Centered9Care
Teamwork9and9Collaboration
Evidence-Based9Practice
Quality9Improvement
Safety
Informatics
The9nurse9is9measuring9the9client's9urine9output9and9straining9the9urine9to9assess9for9st
ones.9Which9of9the9following9should9the9nurse9record9as9objective9data?
A.9The9client9reports9abdominal9pain
B.9The9client's9urine9output9was94509mL
C.9The9client9states,9"I9didn't9see9any9stones9in9my9urine."
D.9The9client9states,9"I9feel9like9I9have9passed9a9stone."9-
9ans✔B.9The9client's9urine9output9was94509mL.
Rationale:9Objective9data9is9measurable9data9that9can9be9seen,9heard,9or9verified9by9th
e9nurse.9The9objective9data9is9the9measurement9of9the9urine9output.9A9client's9stateme
nts9and9reports9of9symptoms9are9documented9as9subjective9data,9such9as9the9data9fou
nd9in9options91,93,9and94.
,The9Joint9Commission9-9ans✔an9independent,9not-for-
profit9organization9that9evaluates9and9accredits9healthcare9organizations
Core9measures9developed9to9improve9the9quality9of9health9care9by9implementing9a9nati
onal,9standardized9performance9measurement9system
emergency9preparedness9(internal/external)
When9evaluating9an9elderly9client's9blood9pressure9(BP)9of9146/789mmHg,9the9nurse9do
es9which9of9the9following9before9determining9whether9the9BP9is9normal9or9represents9h
ypertension?
A.9Compare9this9reading9against9defined9standards
B.9Compare9the9reading9with9one9taken9in9the9opposite9arm
C.9Determine9gaps9in9the9vital9signs9in9the9client9record
D.9Compare9the9current9measurement9with9previous9ones9-
9ans✔A.9Compare9this9reading9against9defined
Rationale:9Analysis9of9the9client's9BP9requires9knowledge9of9the9normal9BP9range9for9a
n9older9adult.9The9nurse9compares9the9client's9data9against9identified9standards9to9dete
rmine9whether9this9reading9is9normal9or9abnormal.9Measuring9the9BP9in9the9other9arm9(
option92)9and9comparing9the9reading9to9previous9ones9(option94)9will9give9additional9clie
nt9data,9but9the9comparison9alone9will9not9determine9whether9the9BP9is9normal.9Gaps9i
n9the9record9(option93)9will9not9aid9in9interpreting9the9current9measurement.
Patient9Rights9-9ans✔Right9to9accept9or9refuse9treatment
Right9to9dignity,9respect,9confidentiality9and9privacy
Right9to9an9informed9consent
Right9to9an9advance9directive
Right9to9information9and9communication
Right9to9personal9safety
Right9to9understand9cost9and9coverage
Which9of9the9following9behaviors9by9the9nurse9demonstrates9that9the9nurse9is9participat
ing9in9critical9thinking?9Select9all9that9apply.
A.9Admitting9not9knowing9how9to9do9a9procedure9and9requesting9help
B.9Using9clever9and9persuasive9remarks9to9support9an9opinion9or9position
C.9Accepting9without9question9the9values9acquired9in9nursing9school
D.9Finding9a9quick9and9logical9answer,9even9to9complex9questions
E.9Gathering9three9assistants9to9transfer9the9client9to9a9stretcher9after9noting9the9client9
weighs93009lbs.9-
9ans✔A.9Admitting9not9knowing9how9to9do9a9procedure9and9requesting9help
E.9Gathering9three9assistants9to9transfer9the9client9to9a9stretcher9after9noting9the9client9
weighs93009lbs.
, Rationale:9Critical9thinking9in9nursing9is9self-
directed,9supporting9what9nurses9know9and9making9clear9what9they9do9not9know.9It9is9i
mportant9for9nurses9to9recognize9when9they9lack9the9knowledge9they9need9to9provide9s
afe9care9for9a9client9(option91).9Nurses9must9also9utilize9their9resources9to9acquire9the9s
upport9they9need9to9care9for9a9client9safely9(option95).9Options92,93,9and949do9not9demo
nstrate9critical9thinking.
Nurse's9role9in9the9informed9consent9process9is:9-
9ans✔Nurses9witness9informed9consents
Ensure9provider9gave9the9necessary9information
Ensure9patient9is9competent9and9understood
Have9patient9sign9the9document
Notify9the9provider9if9the9patient9appears9not9to9understand9or9still9has9questions
The9nurse9has9documented9the9following9outcome9goal9in9the9care9plan:9"The9client9will
9transfer9from9bed9to9chair9with9two-
person9assist."9The9charge9nurse9tells9the9nurse9to9add9which9of9the9following9to9compl
ete9the9goal?
A.9Client9behavior
B.9Conditions9or9modifiers
C.9Performance9criteria
D.9Target9time9-9ans✔D.9Target9time
Rationale:9The9outcome9goal9does9not9state9the9target9timeframe9for9when9the9nurse9s
hould9expect9to9see9the9client9behavior9("transfer").9The9condition9or9modifier9is9present
9("with9two9assists").9The9performance9criterion9is9"from9bed9to9chair."
Nurses9Role9in9Advance9Directives9-
9ans✔Provide9written9information9about9advance9directives
Document9the9client's9advance9directives9status
Ensure9that9the9advance9directives9reflect9the9client's9current9decisions
Inform9all9members9of9the9health9care9team9of9the9client's9advance9directives
69Rights9of9Medication9Administration9-9ans✔Right9dose
Right9time9
Right9patient9
Right9route
Right9documentation
Right9medication
The9nurse9who9documents9on9the9client's9care9plan9the9outcome9goal9"Anxiety9will9be9r
elieved9within9209to9409minutes9following9administration9of9lorazepam9(Ativan)"9is9enga
ged9in9which9step9of9the9nursing9process?
A.9Assessment
ANSWERS
A9client9comes9to9the9walk-
in9clinic9with9reports9of9abdominal9pain9and9diarrhea.9While9taking9the9client's9vital9sign
s,9the9nurse9is9implementing9which9phase9of9the9nursing9process?
A.9Assessment
B.9Diagnosis
C.9Planning
D.9Implementation9-9ans✔A.9Assessment
Rationale:9The9first9step9in9the9nursing9process9is9assessment,9the9process9of9collectin
g9data.9All9subsequent9phases9of9the9nursing9process9(options92,93,9and94)9rely9on9acc
urate9and9complete9data.
Six9Competencies9of9QSEN9-9ans✔Patient-Centered9Care
Teamwork9and9Collaboration
Evidence-Based9Practice
Quality9Improvement
Safety
Informatics
The9nurse9is9measuring9the9client's9urine9output9and9straining9the9urine9to9assess9for9st
ones.9Which9of9the9following9should9the9nurse9record9as9objective9data?
A.9The9client9reports9abdominal9pain
B.9The9client's9urine9output9was94509mL
C.9The9client9states,9"I9didn't9see9any9stones9in9my9urine."
D.9The9client9states,9"I9feel9like9I9have9passed9a9stone."9-
9ans✔B.9The9client's9urine9output9was94509mL.
Rationale:9Objective9data9is9measurable9data9that9can9be9seen,9heard,9or9verified9by9th
e9nurse.9The9objective9data9is9the9measurement9of9the9urine9output.9A9client's9stateme
nts9and9reports9of9symptoms9are9documented9as9subjective9data,9such9as9the9data9fou
nd9in9options91,93,9and94.
,The9Joint9Commission9-9ans✔an9independent,9not-for-
profit9organization9that9evaluates9and9accredits9healthcare9organizations
Core9measures9developed9to9improve9the9quality9of9health9care9by9implementing9a9nati
onal,9standardized9performance9measurement9system
emergency9preparedness9(internal/external)
When9evaluating9an9elderly9client's9blood9pressure9(BP)9of9146/789mmHg,9the9nurse9do
es9which9of9the9following9before9determining9whether9the9BP9is9normal9or9represents9h
ypertension?
A.9Compare9this9reading9against9defined9standards
B.9Compare9the9reading9with9one9taken9in9the9opposite9arm
C.9Determine9gaps9in9the9vital9signs9in9the9client9record
D.9Compare9the9current9measurement9with9previous9ones9-
9ans✔A.9Compare9this9reading9against9defined
Rationale:9Analysis9of9the9client's9BP9requires9knowledge9of9the9normal9BP9range9for9a
n9older9adult.9The9nurse9compares9the9client's9data9against9identified9standards9to9dete
rmine9whether9this9reading9is9normal9or9abnormal.9Measuring9the9BP9in9the9other9arm9(
option92)9and9comparing9the9reading9to9previous9ones9(option94)9will9give9additional9clie
nt9data,9but9the9comparison9alone9will9not9determine9whether9the9BP9is9normal.9Gaps9i
n9the9record9(option93)9will9not9aid9in9interpreting9the9current9measurement.
Patient9Rights9-9ans✔Right9to9accept9or9refuse9treatment
Right9to9dignity,9respect,9confidentiality9and9privacy
Right9to9an9informed9consent
Right9to9an9advance9directive
Right9to9information9and9communication
Right9to9personal9safety
Right9to9understand9cost9and9coverage
Which9of9the9following9behaviors9by9the9nurse9demonstrates9that9the9nurse9is9participat
ing9in9critical9thinking?9Select9all9that9apply.
A.9Admitting9not9knowing9how9to9do9a9procedure9and9requesting9help
B.9Using9clever9and9persuasive9remarks9to9support9an9opinion9or9position
C.9Accepting9without9question9the9values9acquired9in9nursing9school
D.9Finding9a9quick9and9logical9answer,9even9to9complex9questions
E.9Gathering9three9assistants9to9transfer9the9client9to9a9stretcher9after9noting9the9client9
weighs93009lbs.9-
9ans✔A.9Admitting9not9knowing9how9to9do9a9procedure9and9requesting9help
E.9Gathering9three9assistants9to9transfer9the9client9to9a9stretcher9after9noting9the9client9
weighs93009lbs.
, Rationale:9Critical9thinking9in9nursing9is9self-
directed,9supporting9what9nurses9know9and9making9clear9what9they9do9not9know.9It9is9i
mportant9for9nurses9to9recognize9when9they9lack9the9knowledge9they9need9to9provide9s
afe9care9for9a9client9(option91).9Nurses9must9also9utilize9their9resources9to9acquire9the9s
upport9they9need9to9care9for9a9client9safely9(option95).9Options92,93,9and949do9not9demo
nstrate9critical9thinking.
Nurse's9role9in9the9informed9consent9process9is:9-
9ans✔Nurses9witness9informed9consents
Ensure9provider9gave9the9necessary9information
Ensure9patient9is9competent9and9understood
Have9patient9sign9the9document
Notify9the9provider9if9the9patient9appears9not9to9understand9or9still9has9questions
The9nurse9has9documented9the9following9outcome9goal9in9the9care9plan:9"The9client9will
9transfer9from9bed9to9chair9with9two-
person9assist."9The9charge9nurse9tells9the9nurse9to9add9which9of9the9following9to9compl
ete9the9goal?
A.9Client9behavior
B.9Conditions9or9modifiers
C.9Performance9criteria
D.9Target9time9-9ans✔D.9Target9time
Rationale:9The9outcome9goal9does9not9state9the9target9timeframe9for9when9the9nurse9s
hould9expect9to9see9the9client9behavior9("transfer").9The9condition9or9modifier9is9present
9("with9two9assists").9The9performance9criterion9is9"from9bed9to9chair."
Nurses9Role9in9Advance9Directives9-
9ans✔Provide9written9information9about9advance9directives
Document9the9client's9advance9directives9status
Ensure9that9the9advance9directives9reflect9the9client's9current9decisions
Inform9all9members9of9the9health9care9team9of9the9client's9advance9directives
69Rights9of9Medication9Administration9-9ans✔Right9dose
Right9time9
Right9patient9
Right9route
Right9documentation
Right9medication
The9nurse9who9documents9on9the9client's9care9plan9the9outcome9goal9"Anxiety9will9be9r
elieved9within9209to9409minutes9following9administration9of9lorazepam9(Ativan)"9is9enga
ged9in9which9step9of9the9nursing9process?
A.9Assessment
