Complete Questions and Answers with Detailed
Rationales - Pass Guaranteed - A+ Graded
The Nursing Process, Critical Thinking & Documentation
Q1: When using the nursing process, which step involves the nurse collecting data
about the client's health status through interview, physical exam, and review of medical
records?
A. Diagnosis
B. Implementation
C. Assessment
D. Evaluation
Correct Answer: C
Rationale: Assessment is the first step of the nursing process where the nurse gathers
comprehensive subjective and objective data to establish a baseline for the client's care.
Q2: The nurse is caring for four clients. Which client should the nurse assess first?
A. A client 2 days post-op with stable vital signs and minimal incisional pain.
B. A client with type 2 diabetes reporting a blood glucose of 250 mg/dL who is alert.
C. A client with a history of asthma who is audibly wheezing and complaining of
shortness of breath.
D. A client admitted for dehydration who is requesting a fresh pitcher of water.
Correct Answer: C
Rationale: The nurse should prioritize the client with actual or potential airway/breathing
issues; wheezing and shortness of breath indicate respiratory distress requiring
immediate intervention.
Q3: The nurse evaluates the effectiveness of a client's pain medication. Which
statement indicates the goal has been met?
A. "The client asks for the medication at the scheduled time."
B. "The client reports their pain level is a 3 on a scale of 0 to 10, down from an 8."
C. "The client is sleeping quietly without being awakened."
D. "The medication was administered within 30 minutes of the scheduled time."
Correct Answer: B
,Rationale: Evaluation involves comparing the client's current status with the expected
outcome; a reduction in pain score directly indicates the medication was effective.
Q4: A nurse is preparing to communicate a change in a client's condition to the provider
using the SBAR tool. What does the "A" in this acronym stand for?
A. Assessment
B. Action
C. Analysis
D. Advice
Correct Answer: A
Rationale: In SBAR communication, "A" stands for Assessment, where the nurse
provides current data and recent findings about the client's condition.
Q5: Which task is appropriate for the nurse to delegate to the unlicensed assistive
personnel (UAP)?
A. Performing the initial admission assessment for a stable client.
B. Ambulating a client who is 1 day post-hip replacement using a gait belt.
C. Developing the teaching plan for a client going home on oxygen.
D. Administering a dose of insulin via subcutaneous injection.
Correct Answer: B
Rationale: Ambulating a stable client using a gait belt is a standard task that falls within
the scope of practice for a UAP, provided they have been trained on the specific
assistive device.
Q6: A client experiences a fall in their hospital room. The nurse completes an incident
report. Which statement best describes the primary purpose of this report?
A. To ensure the nurse involved is disciplined for the error.
B. To document the event for quality improvement and risk management purposes.
C. To serve as a legal document for the client to sue the hospital.
D. To assign blame to the staff member responsible for the client.
Correct Answer: B
Rationale: Incident reports are tools for quality improvement and risk management
designed to identify trends and prevent future harm, not to assign blame or serve as
legal evidence for lawsuits.
Q7: The nurse is documenting a client's response to pain medication. Which entry is the
most accurate and appropriate?
A. "Client seems better after the pill."
B. "Administered morphine 2 mg IV. Client states pain is 3/10."
, C. "Pain medication given as ordered."
D. "Client looks comfortable now."
Correct Answer: B
Rationale: Documentation should be objective, specific, and include the intervention
(medication given) and the client's response (pain score), rather than vague subjective
terms like "seems better."
Q8: The nurse plans care for a client with the nursing diagnosis "Impaired Physical
Mobility related to musculoskeletal surgery." Which intervention should the nurse
include?
A. Perform passive range-of-motion exercises twice daily.
B. Encourage the client to ambulate four times a day with assistance.
C. Restrict the client to bed rest for the first 48 hours post-op.
D. Apply sequential compression devices while the client is ambulating.
Correct Answer: B
Rationale: For impaired mobility, the nurse should plan interventions that maintain
function and prevent complications; supervised ambulation addresses the diagnosis
directly.
Q9: A client states, "I am afraid of the surgery tomorrow and I don't think I will wake up."
Which response by the nurse demonstrates critical thinking and therapeutic
communication?
A. "Don't worry, you are in good hands and the surgery is routine."
B. "You should tell the doctor about these feelings right away."
C. "Tell me more about what is worrying you regarding the anesthesia."
D. "You need to sleep now so you will be rested for the surgery."
Correct Answer: C
Rationale: Critical thinking involves assessing the client's concerns; this open-ended
response encourages the client to verbalize specific fears, allowing the nurse to provide
targeted education and support.
Q10: Which component of a nursing diagnosis label represents the etiology, or the
"related to" factor?
A. Problem statement
B. Risk factors
C. Etiology
D. Defining characteristics
Correct Answer: C