Fundamentals of Nursing, Nursing
Process
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.
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.
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.
,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.
The nurse has documented the following outcome goal in the care plan: "The client
will transfer from bed to chair with two-person assist." The charge nurse tells the
nurse to add which of the following to complete the goal?
A. Client behavior
B. Conditions or modifiers
C. Performance criteria
D. Target time ✔✔D. Target time
Rationale: The outcome goal does not state the target timeframe for when the nurse
should expect to see the client behavior ("transfer"). The condition or modifier is
present ("with two assists"). The performance criterion is "from bed to chair."
The nurse who documents on the client's care plan the outcome goal "Anxiety will
be relieved within 20 to 40 minutes following administration of lorazepam (Ativan)"
is engaged in which step of the nursing process?
A. Assessment
B. Planning
C. Implementation
D. Evaluation ✔✔B. Planning
Rationale: The planning step of the nursing process involves formulating client goals
and designing the nursing interventions required to prevent, reduce, or eliminate the
client's health problems. Outcome goals are documented on the client's care plan.
Assessment data (option 1) is used to help identify a client's human response, and
once a plan is established, the interventions are implemented (option 3) and
evaluated (option 4).
, When the client resists taking a liquid medication that is essential to treatment, the
nurse demonstrates critical thinking by doing which of the following first?
A. Omitting this dose of medication and waiting until the client is more cooperative
B. Suggesting the medication can be diluted in a beverage
C. Asking the nurse manager about how to approach the situation
D. Notifying the physician inability to give the client this medication ✔✔B.
Suggesting the medication can be diluted in a beverage
Rationale: Diluting the medication in a beverage may make the medication more
palatable. Using critical thinking skills, the nurse should try to problem-solve in a
situation such as this before asking for the assistance of the nurse manager.
Suggesting an alternative method of taking the medication (provided that there are
no contraindications to diluting the medication) should improve the likelihood of the
client taking the medication.
Which professionally appropriate response should the nurse make when a more
stringent policy for the use of restraints is introduced on a surgical unit?
A. Use the previous, less restrictive policy conscientiously
B. Express immediate disagreement with the new policy
C. Ask for the rationale behind the new policy
D. Obey the policy but continue to voice disapproval of it to co-workers ✔✔C. Ask
for the rationale behind the new policy
Rationale: Understanding the rationale behind a decision helps the nurse analyze the
proposed change and understand its purpose. Options 1, 2, and 4 represent
unprofessional behavior. Option 1 also places a client's safety at risk.
The nurse assigned to care for a postoperative client has asked an unlicensed
assistive person (UAP) to help the client ambulate in the hall. Before delegating this
task, the nurse must do which of the following?
A. Assess the client to be sure ambulation with assistance is an appropriate care
measure
B. Ask the client if he or she is ready to ambulate
C. Ask whether the UAP has time to assist the client
D. Ask the charge nurse whether UAPs have ambulated the client during this shift
✔✔A. Assess the client to be sure ambulation with assistance is an appropriate care
measure
Rationale: Prior to delegating any client care responsibilities, the nurse must assess
the client to assure that the delegation is appropriate to his or her care. Options 2, 3,
and 4 would not constitute an assessment of the client's current status.
Process
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.
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.
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.
,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.
The nurse has documented the following outcome goal in the care plan: "The client
will transfer from bed to chair with two-person assist." The charge nurse tells the
nurse to add which of the following to complete the goal?
A. Client behavior
B. Conditions or modifiers
C. Performance criteria
D. Target time ✔✔D. Target time
Rationale: The outcome goal does not state the target timeframe for when the nurse
should expect to see the client behavior ("transfer"). The condition or modifier is
present ("with two assists"). The performance criterion is "from bed to chair."
The nurse who documents on the client's care plan the outcome goal "Anxiety will
be relieved within 20 to 40 minutes following administration of lorazepam (Ativan)"
is engaged in which step of the nursing process?
A. Assessment
B. Planning
C. Implementation
D. Evaluation ✔✔B. Planning
Rationale: The planning step of the nursing process involves formulating client goals
and designing the nursing interventions required to prevent, reduce, or eliminate the
client's health problems. Outcome goals are documented on the client's care plan.
Assessment data (option 1) is used to help identify a client's human response, and
once a plan is established, the interventions are implemented (option 3) and
evaluated (option 4).
, When the client resists taking a liquid medication that is essential to treatment, the
nurse demonstrates critical thinking by doing which of the following first?
A. Omitting this dose of medication and waiting until the client is more cooperative
B. Suggesting the medication can be diluted in a beverage
C. Asking the nurse manager about how to approach the situation
D. Notifying the physician inability to give the client this medication ✔✔B.
Suggesting the medication can be diluted in a beverage
Rationale: Diluting the medication in a beverage may make the medication more
palatable. Using critical thinking skills, the nurse should try to problem-solve in a
situation such as this before asking for the assistance of the nurse manager.
Suggesting an alternative method of taking the medication (provided that there are
no contraindications to diluting the medication) should improve the likelihood of the
client taking the medication.
Which professionally appropriate response should the nurse make when a more
stringent policy for the use of restraints is introduced on a surgical unit?
A. Use the previous, less restrictive policy conscientiously
B. Express immediate disagreement with the new policy
C. Ask for the rationale behind the new policy
D. Obey the policy but continue to voice disapproval of it to co-workers ✔✔C. Ask
for the rationale behind the new policy
Rationale: Understanding the rationale behind a decision helps the nurse analyze the
proposed change and understand its purpose. Options 1, 2, and 4 represent
unprofessional behavior. Option 1 also places a client's safety at risk.
The nurse assigned to care for a postoperative client has asked an unlicensed
assistive person (UAP) to help the client ambulate in the hall. Before delegating this
task, the nurse must do which of the following?
A. Assess the client to be sure ambulation with assistance is an appropriate care
measure
B. Ask the client if he or she is ready to ambulate
C. Ask whether the UAP has time to assist the client
D. Ask the charge nurse whether UAPs have ambulated the client during this shift
✔✔A. Assess the client to be sure ambulation with assistance is an appropriate care
measure
Rationale: Prior to delegating any client care responsibilities, the nurse must assess
the client to assure that the delegation is appropriate to his or her care. Options 2, 3,
and 4 would not constitute an assessment of the client's current status.
