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1. After completing an initial assessment of a patient, the nurse has charted
that his respirations are eupneic and his pulse is 58 beats per minute. These
types of data would be:
a. Objective.
b. Reflective.
c. Subjective.
d. Introspective. - ANSWER A
Objective data are what the health professional observes by inspecting,
percussing, palpating, and auscultating during the physical examination.
Subjective data is what the person says about him or herself during history taking.
The terms reflective and introspective are not used to describe data
2. A patient tells the nurse that he is very nervous, is nauseated, and feels
hot. These types of data would be:
a. Objective.
b. Reflective.
,c. Subjective.
d. Introspective. - ANSWER C
Subjective data are what the person says about him or herself during history
taking. Objective data are what the health professional observes by inspecting,
percussing, palpating, and auscultating during the physical examination. The
terms reflective and introspective are not used to describe data.
3. The patients record, laboratory studies, objective data, and subjective data
combine to form the:
a. Data base.
b. Admitting data.
c. Financial statement.
d. Discharge summary. - ANSWER A
Together with the patients record and laboratory studies, the objective and
subjective data form the data base. The other items are not part of the patients
record, laboratory studies, or data.
4. When listening to a patients breath sounds, the nurse is unsure of a sound
that is heard. The nurses next action should be to:
a. Immediately notify the patients physician.
b. Document the sound exactly as it was heard.
c. Validate the data by asking a coworker to listen to the breath sounds.
,d. Assess again in 20 minutes to note whether the sound is still present. - ANSWER
C
When unsure of a sound heard while listening to a patients breath sounds, the
nurse validates the data to ensure accuracy. If the nurse has less experience in an
area, then he or she asks an expert to listen.
5. The nurse is conducting a class for new graduate nurses. During the
teaching session, the nurse should keep in mind that novice nurses, without
a background of skills and experience from which to draw, are more likely to
make their decisions using:
a. Intuition.
b. A set of rules.
c. Articles in journals.
d. Advice from supervisors. - ANSWER B
Novice nurses operate from a set of defined, structured rules. The expert
practitioner uses intuitive links.
6. Expert nurses learn to attend to a pattern of assessment data and act
without consciously labeling it. These responses are referred to as:
a. Intuition.
b. The nursing process.
c. Clinical knowledge.
d. Diagnostic reasoning. - ANSWER A
, Intuition is characterized by pattern recognition expert nurses learn to attend to a
pattern of assessment data and act without consciously labeling it. The other
options are not correct.
7. The nurse is reviewing information about evidence-based practice (EBP).
Which statement best reflects EBP?
a. EBP relies on tradition for support of best practices.
b. EBP is simply the use of best practice techniques for the treatment of patients.
c. EBP emphasizes the use of best evidence with the clinician's experience.
d. The patients own preferences are not important with EBP. - ANSWER C
EBP is a systematic approach to practice that emphasizes the use of best evidence
in combination with the clinicians experience, as well as patient preferences and
values, when making decisions about care and treatment. EBP is more than simply
using the best practice techniques to treat patients, and questioning tradition is
important when no compelling and supportive research evidence exists.
8. The nurse is conducting a class on priority setting for a group of new
graduate nurses. Which is an example of a first-level priority problem?
a. Patient with postoperative pain
b. Newly diagnosed patient with diabetes who needs diabetic teaching
c. Individual with a small laceration on the sole of the foot
d. Individual with shortness of breath and respiratory distress - ANSWER D