UNIT I: FOUNDATIONS OF NURSING
PRACTICE (CRITICAL THINKING, NURSING
PROCESS, SAFETY)
1. A nurse is assessing a patient's IV site and notes it is not infusing at the prescribed rate. The nurse
checks the flow regulator, ensures the patient is not lying on the tubing, examines the connection site,
and inspects the insertion site for signs of infiltration. After readjusting the flow rate, the IV infuses
correctly. This process is an example of:
A. Diagnostic reasoning
B. Problem-solving
C. Inference
D. Competency
Answer: B. Problem-solving
Rationale: The nurse identified a problem (IV not infusing) and systematically tested variables (tubing,
site, regulator) to find the cause and implement a solution. Problem-solving is a key component of
critical thinking.
2. A nurse sits with a grieving patient who reports insomnia, fatigue, and an inability to concentrate at
work. After listening, the nurse documents the assessment finding as "Ineffective Coping." This
reflects which step of the nursing process?
A. Assessment
B. Planning
C. Diagnosis
D. Implementation
, Answer: C. Diagnosis
Rationale: The nursing diagnosis phase involves analyzing assessment data to identify actual or potential
health problems (using NANDA-I terminology, such as "Ineffective Coping").
3. A patient expires 30 minutes after a sudden code blue. The nurse manager gathers the staff
involved to discuss the sequence of events, the actions taken, and what could have been done
differently. This meeting is an example of:
A. Peer review
B. Quality assurance
C. Reflective practice
D. Risk management
Answer: C. Reflective practice
Rationale: Reflective practice involves reviewing an event to improve future clinical performance. It is a
critical thinking strategy for professional growth.
4. SATA A nurse with three years of oncology experience notices a patient is "just not acting right" and
feels "funny." The nurse asks the patient orientation questions, notices shivering, and immediately calls
the physician to report suspected sepsis. Which critical thinking concepts did the nurse demonstrate?
(Select all that apply)
A. Experience
B. Ethical dilemma
C. Analyticity
D. Self-confidence
E. Risk-taking
Answers: A, C, D
Rationale: The nurse used experience (oncology background), analyticity (assessing for cognitive
changes and shivering), and self-confidence (trusting their intuition and calling the physician with a
suspected diagnosis).
5. Before entering a patient's room to perform a wound dressing change, the nurse reviews the
patient's allergies, checks the medical record, and performs hand hygiene. Which initial step is most
critical for patient safety?
A. Performing hand hygiene
B. Assessing for pain
C. Identifying the patient using two identifiers
D. Providing privacy
Answer: C. Identifying the patient using two identifiers
Rationale: While all steps are important, the Joint Commission identifies using two patient identifiers
(name and date of birth) as the primary safety goal to ensure the right patient receives the right care.
PRACTICE (CRITICAL THINKING, NURSING
PROCESS, SAFETY)
1. A nurse is assessing a patient's IV site and notes it is not infusing at the prescribed rate. The nurse
checks the flow regulator, ensures the patient is not lying on the tubing, examines the connection site,
and inspects the insertion site for signs of infiltration. After readjusting the flow rate, the IV infuses
correctly. This process is an example of:
A. Diagnostic reasoning
B. Problem-solving
C. Inference
D. Competency
Answer: B. Problem-solving
Rationale: The nurse identified a problem (IV not infusing) and systematically tested variables (tubing,
site, regulator) to find the cause and implement a solution. Problem-solving is a key component of
critical thinking.
2. A nurse sits with a grieving patient who reports insomnia, fatigue, and an inability to concentrate at
work. After listening, the nurse documents the assessment finding as "Ineffective Coping." This
reflects which step of the nursing process?
A. Assessment
B. Planning
C. Diagnosis
D. Implementation
, Answer: C. Diagnosis
Rationale: The nursing diagnosis phase involves analyzing assessment data to identify actual or potential
health problems (using NANDA-I terminology, such as "Ineffective Coping").
3. A patient expires 30 minutes after a sudden code blue. The nurse manager gathers the staff
involved to discuss the sequence of events, the actions taken, and what could have been done
differently. This meeting is an example of:
A. Peer review
B. Quality assurance
C. Reflective practice
D. Risk management
Answer: C. Reflective practice
Rationale: Reflective practice involves reviewing an event to improve future clinical performance. It is a
critical thinking strategy for professional growth.
4. SATA A nurse with three years of oncology experience notices a patient is "just not acting right" and
feels "funny." The nurse asks the patient orientation questions, notices shivering, and immediately calls
the physician to report suspected sepsis. Which critical thinking concepts did the nurse demonstrate?
(Select all that apply)
A. Experience
B. Ethical dilemma
C. Analyticity
D. Self-confidence
E. Risk-taking
Answers: A, C, D
Rationale: The nurse used experience (oncology background), analyticity (assessing for cognitive
changes and shivering), and self-confidence (trusting their intuition and calling the physician with a
suspected diagnosis).
5. Before entering a patient's room to perform a wound dressing change, the nurse reviews the
patient's allergies, checks the medical record, and performs hand hygiene. Which initial step is most
critical for patient safety?
A. Performing hand hygiene
B. Assessing for pain
C. Identifying the patient using two identifiers
D. Providing privacy
Answer: C. Identifying the patient using two identifiers
Rationale: While all steps are important, the Joint Commission identifies using two patient identifiers
(name and date of birth) as the primary safety goal to ensure the right patient receives the right care.
