Integrated Exam 2 Practice Questions and Answers
(With rationale) Latest 2022/2023
Which of the following items of subjective data would be documented in the medical
record by the nurse?
A. Client's face is pale
B. Cervical lymph nodes are palpable
C. Nursing assistant reports client refused lunch
D. Client feel nauseated
D. Client feel nauseated
Rationale:
Subjective data includes the client's sensations, feelings, and perception of health
status. Subjective data can only be verified by the affected person. Options 1, 2, and 3
represent objective data that can be detected by the nurse or measured against an
accepted norm.
A nurse explains to a student that the nursing process is a dynamic process. Which of
the following actions by the nurse best demonstrates this concept during the work shift?
A. Nurse and client agree upon health care goals for the client
B. Nurse reviews the client's history on the medical record
C. Nurse explains to the client the purpose of each administered medication
D. Nurse rapidly reset priorities for client care based on a change in the client's
condition
D. Nurse rapidly reset priorities for client care based on a change in the client's
condition
Rationale:
The nursing process is characterized by unique properties that enable it to respond to
the changing health status of the client. Options 1, 2, and 3 are appropriate nursing care
measures, but do not demonstrate the dynamic nature of the nursing process.
The rehabilitation nurse wishes to make the following entry into a client's plan of care:
"Client will reestablish a pattern of daily bowel movements without straining within two
months." The nurse would write this statement under which section of the plan of care?
A. Nursing diagnosis/problem list
B. Nursing orders
C. Short-term goals
D. Long-term goals
D. Long-term goals
Rationale:
Long-term goals describe changes in client behavior expected over a time frame greater
,than one week. They are usually designed to restore normal functioning in a problem
area and are helpful to other healthcare workers who care for the client, often in a
variety of settings.
The nursing diagnosis is Risk for impaired skin integrity related to immobility and
pressure secondary to pain and presence of a cast. Which of the following desired
outcomes should the nurse include in the care plan?
A. Client will be able to turn self by day 3
B. Skin will remain intact and without redness during hospital stay
C. Client will state pain relieved within 30 minutes after medication
D. Pressure will be prevented by repositioning client every 2 hours
B. Skin will remain intact and without redness during hospital stay
Rationale:
The human response/label is what needs to change (Risk for impaired skin integrity).
The label suggests the outcomes. In this case, "skin will remain intact" is the desired
outcome for a client at risk for impaired skin integrity. Option 1 addresses immobility.
Option 3 addresses pain. Option 4 is an intervention.
While assisting a client from bed to chair, the nurse observes that the client looks pale
and is beginning to perspire heavily. The nurse would then do which of the following
activities as a reassessment?
A. Help client into the chair but more quickly
B. Document client's vital signs taken just prior to moving the client
C. Help client back to bed immediately
D. Observe client's skin color and take another set of vital signs
D. Observe client's skin color and take another set of vital signs
Rationale:
Assessment is ongoing throughout the nurse-client relationship. During re-assessment,
the nurse collects additional data to help evaluate the status of problems or identify new
problems. Options 1, 2, and 3 are interventions.
After instructing the client on crutch walking technique, the nurse should evaluate the
client's understanding by using which of the following methods?
A. Return demonstration
B. Explanation
C. Achievement of 90 on written test
D. Have client explain produce to the family
A. Return demonstration
The nurse would do which of the following during the implementation phase of the
nursing process when working with a hospitalized adult?
A. Formulate a nursing diagnosis of impaired gas exchange
B. Record in the medical record the distance a client ambulated in the hall
, C. Write individualized nursing orders in the care plan
D. Compare client responses to the desired outcomes for pain relief
B. Record in the medical record the distance a client ambulated in the hall
Rationale:
The implementation phase of the nursing process involves carrying out or delegating
the nursing interventions and recording nursing activities and client responses in the
medical records. Option 1 represents diagnosing. Option 3 represents planning. Option
4 represents evaluation.
A client on the nursing unit is terminally ill but remains alert and oriented. Three days
after admission, the nurse observes signs of depression. The client states, "I'm tired of
being sick. I wish I could end it all." What is the most accurate and informative way to
record this data in a nursing progress note?
A. Client appears to be depressed, possibly suicidal
B. Client reports being tired of being ill and wants to die
C. Client does not want to live any longer and is tired of being ill
D. Client states, "I'm tired of being sick. I wish I could end it all."
D. Client states, "I'm tired of being sick. I wish I could end it all."
Rationale:
Subjective data includes thoughts, beliefs, feelings, perceptions, and sensations that
are apparent only to the person affected and cannot be measured, seen, or felt by the
nurse. This information should be documented using the client's exact words in quotes.
The other options indicate that the nurse has drawn the conclusion that the client no
longer wishes to live. From the data provided, the cues do not support this assumption.
A more complete assessment should be conducted to determine if the client is suicidal.
After change of shift, you are assigned to care for the following patients. Which patient
should you assess first?
A. A 60-year old patient on a ventilator for whom a sterile sputum specimen must be
sent to the lab
B. A 55-year old with COPD and a pulse oximetry reading from the previous shift of
90% saturation
C. A 70-year old with pneumonia who needs to be started on intravenous (IV) antibiotics
D. A 50-year old with asthma who complains of shortness of breath after using a
bronchodilator
D. A 50-year old with asthma who complains of shortness of breath after using a
bronchodilator
Rationale:
The patient with asthma did not achieve relief from shortness of breath after using the
bronchodilator and is at risk for respiratory complications. This patient's needs are
urgent. The other patients need to be assessed as soon as possible, but none of their
situations are urgent. in COPD patients pulse oximetry oxygen saturations of more than
90% are acceptable.
(With rationale) Latest 2022/2023
Which of the following items of subjective data would be documented in the medical
record by the nurse?
A. Client's face is pale
B. Cervical lymph nodes are palpable
C. Nursing assistant reports client refused lunch
D. Client feel nauseated
D. Client feel nauseated
Rationale:
Subjective data includes the client's sensations, feelings, and perception of health
status. Subjective data can only be verified by the affected person. Options 1, 2, and 3
represent objective data that can be detected by the nurse or measured against an
accepted norm.
A nurse explains to a student that the nursing process is a dynamic process. Which of
the following actions by the nurse best demonstrates this concept during the work shift?
A. Nurse and client agree upon health care goals for the client
B. Nurse reviews the client's history on the medical record
C. Nurse explains to the client the purpose of each administered medication
D. Nurse rapidly reset priorities for client care based on a change in the client's
condition
D. Nurse rapidly reset priorities for client care based on a change in the client's
condition
Rationale:
The nursing process is characterized by unique properties that enable it to respond to
the changing health status of the client. Options 1, 2, and 3 are appropriate nursing care
measures, but do not demonstrate the dynamic nature of the nursing process.
The rehabilitation nurse wishes to make the following entry into a client's plan of care:
"Client will reestablish a pattern of daily bowel movements without straining within two
months." The nurse would write this statement under which section of the plan of care?
A. Nursing diagnosis/problem list
B. Nursing orders
C. Short-term goals
D. Long-term goals
D. Long-term goals
Rationale:
Long-term goals describe changes in client behavior expected over a time frame greater
,than one week. They are usually designed to restore normal functioning in a problem
area and are helpful to other healthcare workers who care for the client, often in a
variety of settings.
The nursing diagnosis is Risk for impaired skin integrity related to immobility and
pressure secondary to pain and presence of a cast. Which of the following desired
outcomes should the nurse include in the care plan?
A. Client will be able to turn self by day 3
B. Skin will remain intact and without redness during hospital stay
C. Client will state pain relieved within 30 minutes after medication
D. Pressure will be prevented by repositioning client every 2 hours
B. Skin will remain intact and without redness during hospital stay
Rationale:
The human response/label is what needs to change (Risk for impaired skin integrity).
The label suggests the outcomes. In this case, "skin will remain intact" is the desired
outcome for a client at risk for impaired skin integrity. Option 1 addresses immobility.
Option 3 addresses pain. Option 4 is an intervention.
While assisting a client from bed to chair, the nurse observes that the client looks pale
and is beginning to perspire heavily. The nurse would then do which of the following
activities as a reassessment?
A. Help client into the chair but more quickly
B. Document client's vital signs taken just prior to moving the client
C. Help client back to bed immediately
D. Observe client's skin color and take another set of vital signs
D. Observe client's skin color and take another set of vital signs
Rationale:
Assessment is ongoing throughout the nurse-client relationship. During re-assessment,
the nurse collects additional data to help evaluate the status of problems or identify new
problems. Options 1, 2, and 3 are interventions.
After instructing the client on crutch walking technique, the nurse should evaluate the
client's understanding by using which of the following methods?
A. Return demonstration
B. Explanation
C. Achievement of 90 on written test
D. Have client explain produce to the family
A. Return demonstration
The nurse would do which of the following during the implementation phase of the
nursing process when working with a hospitalized adult?
A. Formulate a nursing diagnosis of impaired gas exchange
B. Record in the medical record the distance a client ambulated in the hall
, C. Write individualized nursing orders in the care plan
D. Compare client responses to the desired outcomes for pain relief
B. Record in the medical record the distance a client ambulated in the hall
Rationale:
The implementation phase of the nursing process involves carrying out or delegating
the nursing interventions and recording nursing activities and client responses in the
medical records. Option 1 represents diagnosing. Option 3 represents planning. Option
4 represents evaluation.
A client on the nursing unit is terminally ill but remains alert and oriented. Three days
after admission, the nurse observes signs of depression. The client states, "I'm tired of
being sick. I wish I could end it all." What is the most accurate and informative way to
record this data in a nursing progress note?
A. Client appears to be depressed, possibly suicidal
B. Client reports being tired of being ill and wants to die
C. Client does not want to live any longer and is tired of being ill
D. Client states, "I'm tired of being sick. I wish I could end it all."
D. Client states, "I'm tired of being sick. I wish I could end it all."
Rationale:
Subjective data includes thoughts, beliefs, feelings, perceptions, and sensations that
are apparent only to the person affected and cannot be measured, seen, or felt by the
nurse. This information should be documented using the client's exact words in quotes.
The other options indicate that the nurse has drawn the conclusion that the client no
longer wishes to live. From the data provided, the cues do not support this assumption.
A more complete assessment should be conducted to determine if the client is suicidal.
After change of shift, you are assigned to care for the following patients. Which patient
should you assess first?
A. A 60-year old patient on a ventilator for whom a sterile sputum specimen must be
sent to the lab
B. A 55-year old with COPD and a pulse oximetry reading from the previous shift of
90% saturation
C. A 70-year old with pneumonia who needs to be started on intravenous (IV) antibiotics
D. A 50-year old with asthma who complains of shortness of breath after using a
bronchodilator
D. A 50-year old with asthma who complains of shortness of breath after using a
bronchodilator
Rationale:
The patient with asthma did not achieve relief from shortness of breath after using the
bronchodilator and is at risk for respiratory complications. This patient's needs are
urgent. The other patients need to be assessed as soon as possible, but none of their
situations are urgent. in COPD patients pulse oximetry oxygen saturations of more than
90% are acceptable.
