Nur 514: Exam 1 Questions And
Correct Answers
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 - correct answer-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.
Six Competencies of QSEN - correct answer-Patient-Centered Care
Teamwork and Collaboration
Evidence-Based Practice
Quality Improvement
Safety
Informatics
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." - correct answer-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.
The Joint Commission - correct answer-an independent, not-for-profit organization
that evaluates and accredits healthcare organizations
Core measures developed to improve the quality of health care by implementing a
national, standardized performance measurement system
emergency preparedness (internal/external)
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 - correct answer-
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.
Patient Rights - correct answer-Right to accept or refuse treatment Right to
dignity, respect, confidentiality and privacy
Right to an informed consent
Right to an advance directive
Right to information and communication
Right to personal safety
Right to understand cost and coverage
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. - correct answer-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.
Correct Answers
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 - correct answer-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.
Six Competencies of QSEN - correct answer-Patient-Centered Care
Teamwork and Collaboration
Evidence-Based Practice
Quality Improvement
Safety
Informatics
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." - correct answer-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.
The Joint Commission - correct answer-an independent, not-for-profit organization
that evaluates and accredits healthcare organizations
Core measures developed to improve the quality of health care by implementing a
national, standardized performance measurement system
emergency preparedness (internal/external)
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 - correct answer-
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.
Patient Rights - correct answer-Right to accept or refuse treatment Right to
dignity, respect, confidentiality and privacy
Right to an informed consent
Right to an advance directive
Right to information and communication
Right to personal safety
Right to understand cost and coverage
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. - correct answer-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.
