NUR 514 / NUR514 EXAM 1. QUESTIONS AND ANSWERS WITH RATIONALES

NUR 514 EXAM 1 1. A client comes to the walk -in clinic with reports of abdominal pain and diarrhea. While taking the client's vital signs, the nurs e is implementing which phase of the nursing process? A. Assessment B. Diagnosis C. Planning D. Implementation 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. 2. Six Competencies of QSEN -Patient -Centered Care -Teamwork a nd Collaboration -Evidence -Based Practice -Quality Improvement -Safety -Informatics 3. 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." Rationale: Objective data is mea surable 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. 4. The J oint Commission 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 -emerge ncy preparedness (internal/external) 5. 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 defi ned 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 Rationale: Analysis of the clien t'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 r eading 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. 6. Patient Rights -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 7. 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. Rationale: Critical thinking in nursing is self -directed, supporting what nurses know and making clear what they do not know. It is important for nurses to recognize when they lack the knowledge they need to provide safe care for a client (option 1). Nurses must also utilize their resources to acquire the support they need to care for a client safely (option 5). Options 2, 3, and 4 do not demonstrate critical thinking. 8. Nurse's role in the informed consent process is: -Nurses witness informed consents -Ensure provider gave the necessary information -Ensure patient is competent and understood -Have patient sign the document -Notify the provider if the patient appears not to understand or still has questions 9. The nurse has documented the following outcome goal in the care plan: "The client will transfer from bed to chair with two -person assist." Th e charge nurse tells the nurse to add which of the following to complete the goal? A. Client behavior B. Conditions or modifiers C. Performance criteria D. Target time