MIDTERM EXAM REVIEW
,Sec on 1: Nursing Process and Clinical Judgment (Ques ons 1–40)
1. A nurse is reviewing the steps of the nursing process with a group of nurses. Which of the
following data should the charge nurse iden fy as objec ve data? (Select all that apply.)
A. Respiratory rate is 22/min with even, unlabored respira ons.
B. The client's partner states, "He said he hurts a er walking about 10 minutes."
C. Pain ra ng is 3 on a scale of 0 to 10.
D. Skin is pink, warm, and dry.
E. The assis ve personnel reports the client walked with a limp.
Correct Answers: A, D, E
Ra onale: Objec ve data are observable and measurable findings obtained through physical
examina on, observa on, or laboratory/diagnos c tes ng. Respiratory rate and skin
assessment are direct observa ons (A, D). The AP's report of observed gait is also objec ve (E).
Subjec ve data include the client's or partner's verbal reports of symptoms, such as pain ra ngs
and statements about pain (B, C) .
2. A nurse is reviewing the morning laboratory results for four assigned clients. Which result
requires the most immediate interven on?
A. Sodium: 136 mEq/L
B. Hemoglobin: 9.8 g/dL
C. Potassium: 6.2 mEq/L
D. Blood glucose: 138 mg/dL
Correct Answer: C
Ra onale: A potassium level of 6.2 mEq/L indicates hyperkalemia, which can lead to life-
threatening cardiac arrhythmias and requires immediate interven on (e.g., ECG monitoring,
administering prescribed calcium gluconate, insulin/dextrose). Sodium (A) is within normal
range (135–145 mEq/L). Hemoglobin (B) indicates anemia but is not an acute emergency. Blood
glucose (D) is mildly elevated but not immediately life-threatening .
3. A nurse is preparing to insert an indwelling urinary catheter. A er explaining the
procedure, the client asks, "Do you really have to do this?" What is the nurse's best response?
A. "Yes, it's doctor's orders."
B. "It will help us monitor your urine output accurately."
C. "What concerns do you have about the procedure?"
D. "I can come back later if you're not ready."
,Correct Answer: C
Ra onale: This response uses therapeu c communica on by seeking clarifica on and
addressing the client's underlying concerns, which promotes autonomy and reduces anxiety. It
opens a dialogue rather than dismissing the ques on (A), providing informa on without
addressing the concern (B), or delaying care without explora on (D) .
4. A nurse is caring for a client who is having difficulty breathing. The client is lying in bed with
a nasal cannula delivering oxygen. Which of the following interven ons should the nurse take
first?
A. Assess the client's respiratory status.
B. Increase the oxygen flow rate.
C. Reposi on the client to a high-Fowler's posi on.
D. No fy the provider.
Correct Answer: A
Ra onale: The nurse should first assess the client's respiratory status, including respiratory rate,
depth, oxygen satura on, and lung sounds, to determine the severity of the situa on and guide
further interven ons. Assessment is always the first step of the nursing process .
5. A client with newly diagnosed diabetes mellitus is being discharged. Which client statement
indicates that addi onal teaching is needed?
A. "I will rotate my injec on sites to prevent lipodystrophy."
B. "I can skip checking my blood sugar if I feel fine."
C. "I will carry a source of fast-ac ng glucose at all mes."
D. "I will inspect my feet daily for cuts or sores."
Correct Answer: B
Ra onale: Blood glucose monitoring is essen al for safe insulin dosing and detec ng
hypo/hyperglycemia, regardless of how the pa ent feels. Skipping checks (B) is unsafe and
indicates a need for further educa on. The other statements reflect correct self-management .
6. A nurse is explaining the various levels of healthcare services to a group of newly licensed
nurses. Which of the following examples of care se ngs should the nurse classify as ter ary
care? (Select all that apply.)
A. ICU
B. Oncology treatment center
C. Burn center
, D. Cardiac rehabilita on
E. Home health care
Correct Answers: A, B, C
Ra onale: Ter ary healthcare involves the provision of specialized and highly technical care,
such as care delivered in ICUs, oncology treatment centers, and burn centers. Cardiac
rehabilita on (D) is an example of restora ve care. Home health care (E) is an example of
community-based care .
7. A nurse is discussing the purpose of regulatory agencies during a staff mee ng. Which of
the following tasks should the nurse iden fy as the responsibility of the state licensing
boards?
A. Monitor evidence-based prac ce for clients who have a specific diagnosis.
B. Ensure that health care providers comply with regula ons.
C. Set quality standards for accredita on of healthcare facili es.
D. Determine if medica ons are safe for administra on.
Correct Answer: B
Ra onale: State licensing boards are responsible for ensuring that healthcare providers comply
with regula ons and prac ce within their scope. Monitoring evidence-based prac ce (A) is a
professional organiza on func on. Se ng quality standards for accredita on (C) is the
responsibility of accredi ng bodies such as The Joint Commission. Determining medica on
safety (D) is the responsibility of the FDA .
8. A nurse is caring for a group of clients on a medical-surgical unit. For which of the following
client care needs should the nurse ini ate a referral for a social worker? (Select all that apply.)
A. A client who has terminal cancer requests hospice care in her home.
B. A client asks about community resources available for older adults.
C. A client states she wants her child bap zed before surgery.
D. A client requests an electric wheelchair for use a er discharge.
E. A client states that he does not understand how to use a nebulizer.
Correct Answers: A, B, D
Ra onale: Social workers assist with discharge planning, community resources, and financial
concerns. Hospice care coordina on (A), community resources for older adults (B), and
obtaining durable medical equipment such as an electric wheelchair (D) are appropriate social
work referrals. Spiritual needs such as bap sm (C) should be referred to a chaplain. Teaching
about a nebulizer (E) is a nursing responsibility .
,Sec on 1: Nursing Process and Clinical Judgment (Ques ons 1–40)
1. A nurse is reviewing the steps of the nursing process with a group of nurses. Which of the
following data should the charge nurse iden fy as objec ve data? (Select all that apply.)
A. Respiratory rate is 22/min with even, unlabored respira ons.
B. The client's partner states, "He said he hurts a er walking about 10 minutes."
C. Pain ra ng is 3 on a scale of 0 to 10.
D. Skin is pink, warm, and dry.
E. The assis ve personnel reports the client walked with a limp.
Correct Answers: A, D, E
Ra onale: Objec ve data are observable and measurable findings obtained through physical
examina on, observa on, or laboratory/diagnos c tes ng. Respiratory rate and skin
assessment are direct observa ons (A, D). The AP's report of observed gait is also objec ve (E).
Subjec ve data include the client's or partner's verbal reports of symptoms, such as pain ra ngs
and statements about pain (B, C) .
2. A nurse is reviewing the morning laboratory results for four assigned clients. Which result
requires the most immediate interven on?
A. Sodium: 136 mEq/L
B. Hemoglobin: 9.8 g/dL
C. Potassium: 6.2 mEq/L
D. Blood glucose: 138 mg/dL
Correct Answer: C
Ra onale: A potassium level of 6.2 mEq/L indicates hyperkalemia, which can lead to life-
threatening cardiac arrhythmias and requires immediate interven on (e.g., ECG monitoring,
administering prescribed calcium gluconate, insulin/dextrose). Sodium (A) is within normal
range (135–145 mEq/L). Hemoglobin (B) indicates anemia but is not an acute emergency. Blood
glucose (D) is mildly elevated but not immediately life-threatening .
3. A nurse is preparing to insert an indwelling urinary catheter. A er explaining the
procedure, the client asks, "Do you really have to do this?" What is the nurse's best response?
A. "Yes, it's doctor's orders."
B. "It will help us monitor your urine output accurately."
C. "What concerns do you have about the procedure?"
D. "I can come back later if you're not ready."
,Correct Answer: C
Ra onale: This response uses therapeu c communica on by seeking clarifica on and
addressing the client's underlying concerns, which promotes autonomy and reduces anxiety. It
opens a dialogue rather than dismissing the ques on (A), providing informa on without
addressing the concern (B), or delaying care without explora on (D) .
4. A nurse is caring for a client who is having difficulty breathing. The client is lying in bed with
a nasal cannula delivering oxygen. Which of the following interven ons should the nurse take
first?
A. Assess the client's respiratory status.
B. Increase the oxygen flow rate.
C. Reposi on the client to a high-Fowler's posi on.
D. No fy the provider.
Correct Answer: A
Ra onale: The nurse should first assess the client's respiratory status, including respiratory rate,
depth, oxygen satura on, and lung sounds, to determine the severity of the situa on and guide
further interven ons. Assessment is always the first step of the nursing process .
5. A client with newly diagnosed diabetes mellitus is being discharged. Which client statement
indicates that addi onal teaching is needed?
A. "I will rotate my injec on sites to prevent lipodystrophy."
B. "I can skip checking my blood sugar if I feel fine."
C. "I will carry a source of fast-ac ng glucose at all mes."
D. "I will inspect my feet daily for cuts or sores."
Correct Answer: B
Ra onale: Blood glucose monitoring is essen al for safe insulin dosing and detec ng
hypo/hyperglycemia, regardless of how the pa ent feels. Skipping checks (B) is unsafe and
indicates a need for further educa on. The other statements reflect correct self-management .
6. A nurse is explaining the various levels of healthcare services to a group of newly licensed
nurses. Which of the following examples of care se ngs should the nurse classify as ter ary
care? (Select all that apply.)
A. ICU
B. Oncology treatment center
C. Burn center
, D. Cardiac rehabilita on
E. Home health care
Correct Answers: A, B, C
Ra onale: Ter ary healthcare involves the provision of specialized and highly technical care,
such as care delivered in ICUs, oncology treatment centers, and burn centers. Cardiac
rehabilita on (D) is an example of restora ve care. Home health care (E) is an example of
community-based care .
7. A nurse is discussing the purpose of regulatory agencies during a staff mee ng. Which of
the following tasks should the nurse iden fy as the responsibility of the state licensing
boards?
A. Monitor evidence-based prac ce for clients who have a specific diagnosis.
B. Ensure that health care providers comply with regula ons.
C. Set quality standards for accredita on of healthcare facili es.
D. Determine if medica ons are safe for administra on.
Correct Answer: B
Ra onale: State licensing boards are responsible for ensuring that healthcare providers comply
with regula ons and prac ce within their scope. Monitoring evidence-based prac ce (A) is a
professional organiza on func on. Se ng quality standards for accredita on (C) is the
responsibility of accredi ng bodies such as The Joint Commission. Determining medica on
safety (D) is the responsibility of the FDA .
8. A nurse is caring for a group of clients on a medical-surgical unit. For which of the following
client care needs should the nurse ini ate a referral for a social worker? (Select all that apply.)
A. A client who has terminal cancer requests hospice care in her home.
B. A client asks about community resources available for older adults.
C. A client states she wants her child bap zed before surgery.
D. A client requests an electric wheelchair for use a er discharge.
E. A client states that he does not understand how to use a nebulizer.
Correct Answers: A, B, D
Ra onale: Social workers assist with discharge planning, community resources, and financial
concerns. Hospice care coordina on (A), community resources for older adults (B), and
obtaining durable medical equipment such as an electric wheelchair (D) are appropriate social
work referrals. Spiritual needs such as bap sm (C) should be referred to a chaplain. Teaching
about a nebulizer (E) is a nursing responsibility .
