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100-Question Master Prep Bank (UTA Edition)
Section 1: The Nursing Process & Clinical Judgment
1. A nurse is formulating a plan of care for a client with acute respiratory distress.
According to the nursing process, which action must occur immediately after
formulating the nursing diagnosis?
A) Implementing oxygen therapy via nasal cannula.
B) Evaluating the client's response to position changes.
C) Establishing measurable, patient-centered goals and expected outcomes.
D) Reassessing the client's lung sounds and oxygen saturation.
Elaboration: The planning phase directly follows diagnosis. Before any interventions
(implementation) occur, the nurse must establish what the goals of the care plan are to
ensure targeted, effective treatment.
2. A client reports a pain level of 8/10. The nurse administers an IV opioid analgesic. Thirty
minutes later, the nurse asks the client to rate their pain again. This action represents
which step of the nursing process?
A) Assessment
B) Planning
C) Implementation
D) Evaluation
Elaboration: Evaluation involves determining whether the expected outcomes (in this case,
pain reduction) have been met following the implementation of a nursing intervention.
3. Which of the following represents objective data collected during a comprehensive
health assessment?
A) The client states they have felt nauseous for three days.
B) The client describes their pain as a "burning" sensation.
C) The client's capillary refill time is measured at 4 seconds.
D) The client's spouse reports the client has been increasingly confused.
Elaboration: Objective data is observable and measurable by the clinician. Capillary refill is a
measurable physiological sign, whereas client and family reports are subjective data.
, 4. In the context of Tanner's Clinical Judgment Model, the nurse reviewing a patient's
chart, recognizing a trend of decreasing urine output, and associating it with possible
dehydration represents which phase?
A) Noticing
B) Interpreting
C) Responding
D) Reflecting
Elaboration: "Noticing" involves recognizing cues and patterns in the patient's clinical
presentation based on the nurse's background and contextual understanding.
5. A nurse delegates the measurement of vital signs to an unlicensed assistive personnel
(UAP). The UAP reports a blood pressure of 88/50 mmHg. What is the nurse's most
appropriate initial action?
A) Administer a prescribed IV fluid bolus.
B) Personally reassess the client's blood pressure.
C) Document the finding in the electronic health record.
D) Notify the primary healthcare provider immediately.
Elaboration: When a delegated task yields an abnormal result, the registered nurse is
accountable for validating the data through personal reassessment before initiating
interventions or contacting the provider.
Section 2: Vital Signs & Health Assessment
6. A client presents with a respiratory rate of 28 breaths per minute, deep and labored
breathing, and a fruity breath odor. This breathing pattern is classified as:
A) Cheyne-Stokes respirations.
B) Kussmaul respirations.
C) Biot's respirations.
D) Bradypnea.
Elaboration: Kussmaul respirations are an abnormally deep, rapid breathing pattern typically
seen as a compensatory mechanism in metabolic acidosis (such as diabetic ketoacidosis).
7. When assessing a client's radial pulse, the nurse notes it is irregular. What is the
standard protocol for accurately determining the heart rate?
, A) Count the radial pulse for 30 seconds and multiply by 2.
B) Auscultate the apical pulse for one full minute.
C) Palpate the carotid pulse for 15 seconds and multiply by 4.
D) Utilize a pulse oximeter to obtain a digital heart rate reading.
Elaboration: An irregular peripheral pulse requires auscultation of the apical pulse at the
point of maximal impulse (PMI) for a full 60 seconds to accurately assess rate and rhythm.
8. A blood pressure cuff that is too narrow for a client's arm will result in which
measurement error?
A) A falsely low systolic reading.
B) A falsely low diastolic reading.
C) A falsely high reading.
D) An accurate reading if placed correctly over the brachial artery.
Elaboration: A cuff that is too small or narrow requires more pressure to occlude the artery,
artificially elevating the blood pressure reading.
9. The nurse assesses a client's oxygen saturation as 89% on room air. The client has a
history of chronic obstructive pulmonary disease (COPD). What is the physiological
rationale for avoiding high-flow oxygen therapy in this client?
A) High-flow oxygen will cause acute pulmonary edema.
B) High-flow oxygen increases the risk of oxygen toxicity in the alveoli.
C) COPD patients rely on a hypoxic drive to breathe; high $O_2$ may suppress
respiratory effort.
D) It will lead to severe metabolic alkalosis.
Elaboration: Clients with chronic hypercapnia (high $CO_2$) lose their hypercapnic drive and
rely on low oxygen levels (hypoxic drive) to stimulate breathing. High oxygen administration
can eliminate this drive, leading to respiratory arrest.
10. A client's core body temperature is 102.4°F (39.1°C). Which physiological response is the
body using to facilitate heat loss?
A) Shivering.
B) Peripheral vasoconstriction.
C) Peripheral vasodilation and diaphoresis.
100-Question Master Prep Bank (UTA Edition)
Section 1: The Nursing Process & Clinical Judgment
1. A nurse is formulating a plan of care for a client with acute respiratory distress.
According to the nursing process, which action must occur immediately after
formulating the nursing diagnosis?
A) Implementing oxygen therapy via nasal cannula.
B) Evaluating the client's response to position changes.
C) Establishing measurable, patient-centered goals and expected outcomes.
D) Reassessing the client's lung sounds and oxygen saturation.
Elaboration: The planning phase directly follows diagnosis. Before any interventions
(implementation) occur, the nurse must establish what the goals of the care plan are to
ensure targeted, effective treatment.
2. A client reports a pain level of 8/10. The nurse administers an IV opioid analgesic. Thirty
minutes later, the nurse asks the client to rate their pain again. This action represents
which step of the nursing process?
A) Assessment
B) Planning
C) Implementation
D) Evaluation
Elaboration: Evaluation involves determining whether the expected outcomes (in this case,
pain reduction) have been met following the implementation of a nursing intervention.
3. Which of the following represents objective data collected during a comprehensive
health assessment?
A) The client states they have felt nauseous for three days.
B) The client describes their pain as a "burning" sensation.
C) The client's capillary refill time is measured at 4 seconds.
D) The client's spouse reports the client has been increasingly confused.
Elaboration: Objective data is observable and measurable by the clinician. Capillary refill is a
measurable physiological sign, whereas client and family reports are subjective data.
, 4. In the context of Tanner's Clinical Judgment Model, the nurse reviewing a patient's
chart, recognizing a trend of decreasing urine output, and associating it with possible
dehydration represents which phase?
A) Noticing
B) Interpreting
C) Responding
D) Reflecting
Elaboration: "Noticing" involves recognizing cues and patterns in the patient's clinical
presentation based on the nurse's background and contextual understanding.
5. A nurse delegates the measurement of vital signs to an unlicensed assistive personnel
(UAP). The UAP reports a blood pressure of 88/50 mmHg. What is the nurse's most
appropriate initial action?
A) Administer a prescribed IV fluid bolus.
B) Personally reassess the client's blood pressure.
C) Document the finding in the electronic health record.
D) Notify the primary healthcare provider immediately.
Elaboration: When a delegated task yields an abnormal result, the registered nurse is
accountable for validating the data through personal reassessment before initiating
interventions or contacting the provider.
Section 2: Vital Signs & Health Assessment
6. A client presents with a respiratory rate of 28 breaths per minute, deep and labored
breathing, and a fruity breath odor. This breathing pattern is classified as:
A) Cheyne-Stokes respirations.
B) Kussmaul respirations.
C) Biot's respirations.
D) Bradypnea.
Elaboration: Kussmaul respirations are an abnormally deep, rapid breathing pattern typically
seen as a compensatory mechanism in metabolic acidosis (such as diabetic ketoacidosis).
7. When assessing a client's radial pulse, the nurse notes it is irregular. What is the
standard protocol for accurately determining the heart rate?
, A) Count the radial pulse for 30 seconds and multiply by 2.
B) Auscultate the apical pulse for one full minute.
C) Palpate the carotid pulse for 15 seconds and multiply by 4.
D) Utilize a pulse oximeter to obtain a digital heart rate reading.
Elaboration: An irregular peripheral pulse requires auscultation of the apical pulse at the
point of maximal impulse (PMI) for a full 60 seconds to accurately assess rate and rhythm.
8. A blood pressure cuff that is too narrow for a client's arm will result in which
measurement error?
A) A falsely low systolic reading.
B) A falsely low diastolic reading.
C) A falsely high reading.
D) An accurate reading if placed correctly over the brachial artery.
Elaboration: A cuff that is too small or narrow requires more pressure to occlude the artery,
artificially elevating the blood pressure reading.
9. The nurse assesses a client's oxygen saturation as 89% on room air. The client has a
history of chronic obstructive pulmonary disease (COPD). What is the physiological
rationale for avoiding high-flow oxygen therapy in this client?
A) High-flow oxygen will cause acute pulmonary edema.
B) High-flow oxygen increases the risk of oxygen toxicity in the alveoli.
C) COPD patients rely on a hypoxic drive to breathe; high $O_2$ may suppress
respiratory effort.
D) It will lead to severe metabolic alkalosis.
Elaboration: Clients with chronic hypercapnia (high $CO_2$) lose their hypercapnic drive and
rely on low oxygen levels (hypoxic drive) to stimulate breathing. High oxygen administration
can eliminate this drive, leading to respiratory arrest.
10. A client's core body temperature is 102.4°F (39.1°C). Which physiological response is the
body using to facilitate heat loss?
A) Shivering.
B) Peripheral vasoconstriction.
C) Peripheral vasodilation and diaphoresis.
