Fundamentals of Nursing, Nursing
Process exam 2 with answers and
rationales
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 defined 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
A. Compare this reading against defined
Rationale: Analysis of the client'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
reading 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.
`•°
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.
A. Admitting not knowing how to do a procedure and requesting help
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.
A client comes to the walk-in clinic with reports of abdominal pain and
diarrhea. While taking the client's vital signs, the nurse is implementing
which phase of the nursing process?
A. Assessment
B. Diagnosis
C. Planning
D. Implementation
A. Assessment
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.
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."
B. The client's urine output was 450 mL.
Rationale: Objective data is measurable 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.
`•°
The nurse has documented the following outcome goal in the care plan: "The
client will transfer from bed to chair with two-person assist." The 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
D. Target time
Rationale: The outcome goal does not state the target timeframe for when
the nurse should expect to see the client behavior ("transfer"). The condition
or modifier is present ("with two assists"). The performance criterion is "from
bed to chair."
, `•°
The nurse who documents on the client's care plan the outcome goal
"Anxiety will be relieved within 20 to 40 minutes following administration of
lorazepam (Ativan)" is engaged in which step of the nursing process?
A. Assessment
B. Planning
C. Implementation
D. Evaluation
B. Planning
Rationale: The planning step of the nursing process involves formulating
client goals and designing the nursing interventions required to prevent,
reduce, or eliminate the client's health problems. Outcome goals are
documented on the client's care plan. Assessment data (option 1) is used to
help identify a client's human response, and once a plan is established, the
interventions are implemented (option 3) and evaluated (option 4).
When the client resists taking a liquid medication that is essential to
treatment, the nurse demonstrates critical thinking by doing which of the
following first?
A. Omitting this dose of medication and waiting until the client is more
cooperative
B. Suggesting the medication can be diluted in a beverage
C. Asking the nurse manager about how to approach the situation
D. Notifying the physician inability to give the client this medication
Process exam 2 with answers and
rationales
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 defined 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
A. Compare this reading against defined
Rationale: Analysis of the client'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
reading 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.
`•°
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.
A. Admitting not knowing how to do a procedure and requesting help
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.
A client comes to the walk-in clinic with reports of abdominal pain and
diarrhea. While taking the client's vital signs, the nurse is implementing
which phase of the nursing process?
A. Assessment
B. Diagnosis
C. Planning
D. Implementation
A. Assessment
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.
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."
B. The client's urine output was 450 mL.
Rationale: Objective data is measurable 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.
`•°
The nurse has documented the following outcome goal in the care plan: "The
client will transfer from bed to chair with two-person assist." The 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
D. Target time
Rationale: The outcome goal does not state the target timeframe for when
the nurse should expect to see the client behavior ("transfer"). The condition
or modifier is present ("with two assists"). The performance criterion is "from
bed to chair."
, `•°
The nurse who documents on the client's care plan the outcome goal
"Anxiety will be relieved within 20 to 40 minutes following administration of
lorazepam (Ativan)" is engaged in which step of the nursing process?
A. Assessment
B. Planning
C. Implementation
D. Evaluation
B. Planning
Rationale: The planning step of the nursing process involves formulating
client goals and designing the nursing interventions required to prevent,
reduce, or eliminate the client's health problems. Outcome goals are
documented on the client's care plan. Assessment data (option 1) is used to
help identify a client's human response, and once a plan is established, the
interventions are implemented (option 3) and evaluated (option 4).
When the client resists taking a liquid medication that is essential to
treatment, the nurse demonstrates critical thinking by doing which of the
following first?
A. Omitting this dose of medication and waiting until the client is more
cooperative
B. Suggesting the medication can be diluted in a beverage
C. Asking the nurse manager about how to approach the situation
D. Notifying the physician inability to give the client this medication
