NUR 514 Final Exam Questions & correct
Answers & Rationale’s Already verified &
Graded A+
When prioritizing care using Maslow's Hierarchy of Needs, which client need is addressed first? correct
answers
A. Fear of surgery
B. Social isolation
C. Dehydration
D. Low self-esteem
C. Dehydration
Rationale: Dehydration is a physiological need, which is the foundation of Maslow's hierarchy. It takes
precedence over emotional or psychological needs.
Which of the following cues should the nurse prioritize based on the ABC framework? correct answers
A. Blood pressure of 138/86
B. Respiratory rate of 8 breaths per minute
C. Complaints of knee pain
D. Report of fatigue
B. Respiratory rate of 8 breaths per minute
Rationale: Airway and breathing issues come before circulation and other complaints. A respiratory rate
of 8 is critically low and requires immediate intervention.
During assessment, a nurse observes a surgical wound with purulent drainage. This is best classified as:
,A. Subjective data
B. Objective data
C. Inferred data
D. Psychosocial data
B. Objective data
Rationale: Objective data includes observable findings like purulent drainage, which the nurse can
directly see and assess.
A client with chronic hypertension begins exhibiting confusion and slurred speech. What should the
nurse do first? correct answers
A. Document findings
B. Notify the healthcare provider
C. Reassess blood pressure
D. Administer prescribed antihypertensives
C. Administer prescribed antihypertensives
Rationale: The nurse should reassess and gather more objective data (e.g., BP, neuro status) before
notifying the provider to ensure accurate reporting.
The nurse identifies a sudden drop in a patient's oxygen saturation and rapid breathing. These findings
are:
A. Unrelated cues
,B. Part of subjective data
C. Expected findings in a stable patient
D. Relevant objective cues
D. Relevant objective cues
Rationale: These are measurable clinical signs (objective data) and are relevant cues that may indicate
respiratory distress.
Which of the following represents the 'Analyze Cues' step in the Clinical Judgment Measurement
Model? correct answers
A. Comparing client assessment findings to normal values
B. Asking the client to rate their pain
C. Administering pain medication
D. Collaborating with physical therapy
A. Comparing client assessment findings to normal values
Rationale: Analyzing cues involves comparing clinical data to norms to identify abnormalities and
determine the client's needs.
A nurse is caring for a post-op client complaining of abdominal pain. Which action reflects "Take Action"
in the CJMM? correct answers
A. Administering prescribed analgesic
B. Documenting pain level
C. Asking the client to rate the pain
D. Calling the surgeon
A. Administering prescribed analgesic
, Rationale: "Take Action" involves implementing nursing or interdisciplinary interventions to address
client problems. Giving the analgesic is a direct intervention.
Which framework helps the nurse prioritize care for a client with multiple needs? correct answers
A. Nursing scope and standards
B. Airway-Breathing-Circulation (ABC)
C. Professional Code of Ethics
D. Time management model
B. Airway-Breating-Circulation (ABC)
Rationale: The ABC framework is used to prioritize life-threatening conditions, especially when dealing
with multiple clinical concerns.
What action reflects the "Evaluate Outcomes" step in the CJMM? correct answers
A. Giving discharge instructions
B. Creating a care plan
C. Calling a rapid response team
D. Reviewing a client's response to a new medication
D. Reviewing the client''s response to a new medication
Rationale: Evaluation involves determining whether a nursing intervention achieved the desired
outcome, such as assessing how a client responded to a medication.
Answers & Rationale’s Already verified &
Graded A+
When prioritizing care using Maslow's Hierarchy of Needs, which client need is addressed first? correct
answers
A. Fear of surgery
B. Social isolation
C. Dehydration
D. Low self-esteem
C. Dehydration
Rationale: Dehydration is a physiological need, which is the foundation of Maslow's hierarchy. It takes
precedence over emotional or psychological needs.
Which of the following cues should the nurse prioritize based on the ABC framework? correct answers
A. Blood pressure of 138/86
B. Respiratory rate of 8 breaths per minute
C. Complaints of knee pain
D. Report of fatigue
B. Respiratory rate of 8 breaths per minute
Rationale: Airway and breathing issues come before circulation and other complaints. A respiratory rate
of 8 is critically low and requires immediate intervention.
During assessment, a nurse observes a surgical wound with purulent drainage. This is best classified as:
,A. Subjective data
B. Objective data
C. Inferred data
D. Psychosocial data
B. Objective data
Rationale: Objective data includes observable findings like purulent drainage, which the nurse can
directly see and assess.
A client with chronic hypertension begins exhibiting confusion and slurred speech. What should the
nurse do first? correct answers
A. Document findings
B. Notify the healthcare provider
C. Reassess blood pressure
D. Administer prescribed antihypertensives
C. Administer prescribed antihypertensives
Rationale: The nurse should reassess and gather more objective data (e.g., BP, neuro status) before
notifying the provider to ensure accurate reporting.
The nurse identifies a sudden drop in a patient's oxygen saturation and rapid breathing. These findings
are:
A. Unrelated cues
,B. Part of subjective data
C. Expected findings in a stable patient
D. Relevant objective cues
D. Relevant objective cues
Rationale: These are measurable clinical signs (objective data) and are relevant cues that may indicate
respiratory distress.
Which of the following represents the 'Analyze Cues' step in the Clinical Judgment Measurement
Model? correct answers
A. Comparing client assessment findings to normal values
B. Asking the client to rate their pain
C. Administering pain medication
D. Collaborating with physical therapy
A. Comparing client assessment findings to normal values
Rationale: Analyzing cues involves comparing clinical data to norms to identify abnormalities and
determine the client's needs.
A nurse is caring for a post-op client complaining of abdominal pain. Which action reflects "Take Action"
in the CJMM? correct answers
A. Administering prescribed analgesic
B. Documenting pain level
C. Asking the client to rate the pain
D. Calling the surgeon
A. Administering prescribed analgesic
, Rationale: "Take Action" involves implementing nursing or interdisciplinary interventions to address
client problems. Giving the analgesic is a direct intervention.
Which framework helps the nurse prioritize care for a client with multiple needs? correct answers
A. Nursing scope and standards
B. Airway-Breathing-Circulation (ABC)
C. Professional Code of Ethics
D. Time management model
B. Airway-Breating-Circulation (ABC)
Rationale: The ABC framework is used to prioritize life-threatening conditions, especially when dealing
with multiple clinical concerns.
What action reflects the "Evaluate Outcomes" step in the CJMM? correct answers
A. Giving discharge instructions
B. Creating a care plan
C. Calling a rapid response team
D. Reviewing a client's response to a new medication
D. Reviewing the client''s response to a new medication
Rationale: Evaluation involves determining whether a nursing intervention achieved the desired
outcome, such as assessing how a client responded to a medication.
