(2026) Actual Q&A PDF
1. A newly admitted patient reports severe abdominal pain and has a rigid abdomen on
inspection. The nurse gathers vital signs, reviews the medical history, and prepares to notify the
provider. Which step of the nursing process is the nurse primarily performing when collecting
and organizing these data?
A) Assessment, focusing on systematic collection of subjective and objective data
B) Diagnosis, assigning a formal nursing diagnosis without further validation
C) Planning, writing specific outcome statements before data are complete
D) Evaluation, determining whether previously set goals have been met
Correct Answer: A) Assessment, focusing on systematic collection of subjective and objective
data
Rationale: Assessment is the deliberate collection and organization of data that forms the
foundation for subsequent steps. Diagnosis, planning, and evaluation occur after sufficient data
have been gathered and analyzed.
2. What is the least effective decision-making process in nursing?
A) Establishing assumptions
B) Gathering objective data
C) Validating information
D) Using evidence-based practice
Correct Answer: A) Establishing assumptions
Rationale: Establishing assumptions is the least effective decision-making process because
assumptions are based on personal beliefs or guesses rather than facts. Effective decision-
,making requires gathering and analyzing objective data, validating information, and using
evidence-based practice.
3. The nurse is using the personal critical thinking indicator of honesty when he or she does
which of the following?
A) Feels certain about being able to perform the skill
B) Provides factual and true information to the patient
C) Considers all of the information before moving forward with the plan of care
D) Follows an orderly approach to completing the required interventions
Correct Answer: B) Provides factual and true information to the patient
Rationale: Honesty in critical thinking involves being truthful and providing factual information.
Giving accurate information to the patient demonstrates this trait. Confidence, thoroughness,
and discipline are separate critical thinking indicators.
4. A nurse reviews a patient's falling blood pressure, rising heart rate, and cool clammy skin and
concludes that the patient is likely experiencing early hypovolemic shock. Which cognitive skill is
the nurse demonstrating by linking these findings to a physiologic pattern?
A) Clinical judgment that synthesizes cues and recognizes a deteriorating pattern
B) Simple recall of isolated vital-sign normal ranges without interpretation
C) Delegation of all further assessment to unlicensed assistive personnel
D) Documentation of findings without any analysis or prioritization
Correct Answer: A) Clinical judgment that synthesizes cues and recognizes a deteriorating
pattern
,Rationale: Clinical judgment involves noticing relevant cues, interpreting their meaning, and
recognizing patterns that require action. Isolated recall, delegation without assessment, and
documentation alone do not constitute interpretive clinical judgment.
5. Which assessment question should the nurse use to clarify patient information that has been
obtained?
A) "What are the most important things you need to know about your diet?"
B) "Am I incorrect that you take two medications at home for your blood pressure?"
C) "Have we talked about all of the issues that you have with wound care?"
D) "Can you talk about your discomfort?"
Correct Answer: B) "Am I incorrect that you take two medications at home for your blood
pressure?"
Rationale: Clarification is used to verify the accuracy of information the nurse has received. This
question directly seeks validation of previously obtained data. The other options are used to
explore needs, check for completeness, or evaluate understanding.
6. The nurse keeps working with the patient to help him ambulate, motivating him to reach his
goal of being independent. The nurse is demonstrating which critical thinking trait?
A) Confidence
B) Humility
C) Persistence
D) Fairness
Correct Answer: C) Persistence
, Rationale: Persistence involves continuing to work toward a goal despite obstacles or resistance.
Motivating a patient to achieve independence demonstrates persistence. Confidence is belief in
oneself, humility is recognizing one's limitations, and fairness is being impartial.
7. Which of the following best describes the primary purpose of the nursing process?
A) To provide a standardized method for documenting patient care
B) To offer a framework for critical thinking and clinical decision-making
C) To ensure all patients receive identical nursing interventions
D) To replace the need for clinical judgment with established protocols
Correct Answer: B) To offer a framework for critical thinking and clinical decision-making
Rationale: The nursing process provides a systematic framework that guides nurses in providing
organized, patient-centered care. It is not meant to standardize all care or replace clinical
judgment.
8. After completing a head-to-toe assessment, the nurse identifies that a postoperative patient
has diminished breath sounds at the bases, a productive cough, and a low-grade fever. Which
nursing diagnosis statement is written in the correct PES format?
A) Ineffective airway clearance related to retained secretions as evidenced by diminished breath
sounds and productive cough
B) Patient has pneumonia and needs antibiotics and incentive spirometry every hour
C) Risk for infection related to surgical incision without supporting signs or symptoms
D) Acute pain related to surgery as evidenced by patient stating pain is controlled
Correct Answer: A) Ineffective airway clearance related to retained secretions as evidenced by
diminished breath sounds and productive cough