NURS 514 Exam 1 (Nursing 100- Fundamentals of Nursing (Nursing Process) Questions with
Correct Answers| Latest Update Guaranteed Success
A client comes to the walk-in clinic with reports of abdominal pain and diarrhea. While taking
the client's vital signs, the nurse is implementing which phase of the nursing process?
A. Assessment
B. Diagnosis
C. Planning
D. Implementation A. Assessment
Rationale: The first step in the nursing process is assessment, the process of collecting data. All
subsequent phases of the nursing process (options 2, 3, and 4) rely on accurate and complete
data.
Six Competencies of QSEN Patient-Centered Care
Teamwork and Collaboration
Evidence-Based Practice
Quality Improvement
Safety
Informatics
The nurse is measuring the client's urine output and straining the urine to assess for stones.
Which of the following should the nurse record as objective data?
A. The client reports abdominal pain
B. The client's urine output was 450 mL
C. The client states, "I didn't see any stones in my urine."
D. The client states, "I feel like I have passed a stone." B. The client's urine output was 450
mL.
,Rationale: Objective data is measurable data that can be seen, heard, or verified by the nurse.
The objective data is the measurement of the urine output. A client's statements and reports of
symptoms are documented as subjective data, such as the data found in options 1, 3, and 4.
The Joint Commission an independent, not-for-profit organization that evaluates and
accredits healthcare organizations
Core measures developed to improve the quality of health care by implementing a national,
standardized performance measurement system
emergency preparedness (internal/external)
When evaluating an elderly client's blood pressure (BP) of 146/78 mmHg, the nurse does which
of the following before determining whether the BP is normal or represents hypertension?
A. Compare this reading against defined standards
B. Compare the reading with one taken in the opposite arm
C. Determine gaps in the vital signs in the client record
D. Compare the current measurement with previous ones A. Compare this reading against
defined
Rationale: Analysis of the client's BP requires knowledge of the normal BP range for an older
adult. The nurse compares the client's data against identified standards to determine whether
this reading is normal or abnormal. Measuring the BP in the other arm (option 2) and
comparing the reading to previous ones (option 4) will give additional client data, but the
comparison alone will not determine whether the BP is normal. Gaps in the record (option 3)
will not aid in interpreting the current measurement.
Patient Rights Right to accept or refuse treatment
Right to dignity, respect, confidentiality and privacy
Right to an informed consent
Right to an advance directive
, Right to information and communication
Right to personal safety
Right to understand cost and coverage
Which of the following behaviors by the nurse demonstrates that the nurse is participating in
critical thinking? Select all that apply.
A. Admitting not knowing how to do a procedure and requesting help
B. Using clever and persuasive remarks to support an opinion or position
C. Accepting without question the values acquired in nursing school
D. Finding a quick and logical answer, even to complex questions
E. Gathering three assistants to transfer the client to a stretcher after noting the client weighs
300 lbs. A. Admitting not knowing how to do a procedure and requesting help
E. Gathering three assistants to transfer the client to a stretcher after noting the client weighs
300 lbs.
Rationale: Critical thinking in nursing is self-directed, supporting what nurses know and making
clear what they do not know. It is important for nurses to recognize when they lack the
knowledge they need to provide safe care for a client (option 1). Nurses must also utilize their
resources to acquire the support they need to care for a client safely (option 5). Options 2, 3,
and 4 do not demonstrate critical thinking.
Nurse's role in the informed consent process is: Nurses witness informed consents
Ensure provider gave the necessary information
Ensure patient is competent and understood
Have patient sign the document
Notify the provider if the patient appears not to understand or still has questions
Correct Answers| Latest Update Guaranteed Success
A client comes to the walk-in clinic with reports of abdominal pain and diarrhea. While taking
the client's vital signs, the nurse is implementing which phase of the nursing process?
A. Assessment
B. Diagnosis
C. Planning
D. Implementation A. Assessment
Rationale: The first step in the nursing process is assessment, the process of collecting data. All
subsequent phases of the nursing process (options 2, 3, and 4) rely on accurate and complete
data.
Six Competencies of QSEN Patient-Centered Care
Teamwork and Collaboration
Evidence-Based Practice
Quality Improvement
Safety
Informatics
The nurse is measuring the client's urine output and straining the urine to assess for stones.
Which of the following should the nurse record as objective data?
A. The client reports abdominal pain
B. The client's urine output was 450 mL
C. The client states, "I didn't see any stones in my urine."
D. The client states, "I feel like I have passed a stone." B. The client's urine output was 450
mL.
,Rationale: Objective data is measurable data that can be seen, heard, or verified by the nurse.
The objective data is the measurement of the urine output. A client's statements and reports of
symptoms are documented as subjective data, such as the data found in options 1, 3, and 4.
The Joint Commission an independent, not-for-profit organization that evaluates and
accredits healthcare organizations
Core measures developed to improve the quality of health care by implementing a national,
standardized performance measurement system
emergency preparedness (internal/external)
When evaluating an elderly client's blood pressure (BP) of 146/78 mmHg, the nurse does which
of the following before determining whether the BP is normal or represents hypertension?
A. Compare this reading against defined standards
B. Compare the reading with one taken in the opposite arm
C. Determine gaps in the vital signs in the client record
D. Compare the current measurement with previous ones A. Compare this reading against
defined
Rationale: Analysis of the client's BP requires knowledge of the normal BP range for an older
adult. The nurse compares the client's data against identified standards to determine whether
this reading is normal or abnormal. Measuring the BP in the other arm (option 2) and
comparing the reading to previous ones (option 4) will give additional client data, but the
comparison alone will not determine whether the BP is normal. Gaps in the record (option 3)
will not aid in interpreting the current measurement.
Patient Rights Right to accept or refuse treatment
Right to dignity, respect, confidentiality and privacy
Right to an informed consent
Right to an advance directive
, Right to information and communication
Right to personal safety
Right to understand cost and coverage
Which of the following behaviors by the nurse demonstrates that the nurse is participating in
critical thinking? Select all that apply.
A. Admitting not knowing how to do a procedure and requesting help
B. Using clever and persuasive remarks to support an opinion or position
C. Accepting without question the values acquired in nursing school
D. Finding a quick and logical answer, even to complex questions
E. Gathering three assistants to transfer the client to a stretcher after noting the client weighs
300 lbs. A. Admitting not knowing how to do a procedure and requesting help
E. Gathering three assistants to transfer the client to a stretcher after noting the client weighs
300 lbs.
Rationale: Critical thinking in nursing is self-directed, supporting what nurses know and making
clear what they do not know. It is important for nurses to recognize when they lack the
knowledge they need to provide safe care for a client (option 1). Nurses must also utilize their
resources to acquire the support they need to care for a client safely (option 5). Options 2, 3,
and 4 do not demonstrate critical thinking.
Nurse's role in the informed consent process is: Nurses witness informed consents
Ensure provider gave the necessary information
Ensure patient is competent and understood
Have patient sign the document
Notify the provider if the patient appears not to understand or still has questions
