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Which traits of the nurse are most important for an assessment to be successful? A. Enthusiastic and aggressive B. Low-key and timid C. Trustworthy and confident D. Competent and forceful

C. Trustworthy and confident

A client comes to the emergency department reporting severe chest pain. The nurse asks the client questions and takes vital signs. Which step of the nursing process is the nurse demonstrating? A. Assessing B. Diagnosing C. Planning D. Implementing

A. Assessing

After conducting the initial assessment of a new resident of a long-term care facility, the nurse is preparing to terminate the interview. Which question is the most appropriate conclusion to the interview? A. "Is there anything else we should know in order to care for you better?" B. "What do you envision for your care while you're here at the facility?" C. "What practices have you found especially helpful in other settings?" D. "What are your expectations from us and from yourself in your care?"

A. "Is there anything else we should know in order to care for you better?"

A nurse is performing an assessment on a client. Which should the nurse record as subjective data? Select all that apply. A. "My leg hurts when I move." B. "I am so afraid of what my diagnosis is." C. Weight: 132 lb (60 kg) D. Blood pressure: 120/78 mm Hg E. "I am always anxious."

A. "My leg hurts when I move." B. "I am so afraid of what my diagnosis is." E. "I am always anxious."

A rapid onset of symptoms that lasts a relatively short time indicates which condition? A. A chronic illness B. An acute illness C. An actual risk factor D. A potential for wellness

B. An acute illness

Which question or statement would be an appropriate termination of the health history interview? A. "Well, I can't think of anything else to ask you right now." B. "Can you think of anything else you would like to tell me?" C. "I wish you could have remembered more about your illness." D. "Perhaps we can talk again sometime. Goodbye."

B. "Can you think of anything else you would like to tell me?"

Which statement made by the nurse indicates data that would be documented as part of an objective assessment? A. "The client's sister reports that the client has unrelieved pain." B. "The client's right leg is cold to the touch, from the knee to the foot." C. "The client reports nausea following eating." D. "The client reports having heartburn after breakfast."

B. "The client's right leg is cold to the touch, from the knee to the foot."

The older adult client is moving to another apartment. The nurse should encourage the client's family to take which action to reduce the older adult's risk of falling in the new home? A. Clear clutter in the walkways of the new home. B. Change the older adult's routine. C. Take walks outside. D. Use the stairs in the new home.

A. Clear clutter in the walkways of the new home.

The nurse is conducting a health assessment on a client. Which subjective data would the nurse gather about the client's sleep habits? A. Client reports only sleeping 2 hours per night B. Client frequently yawns C. Client has dark circles under the eyes D. Client has decreased attention span

A. Client reports only sleeping 2 hours per night

The nurse is preparing to interview several clients during clinic hours. What language difficulty(ies) might a nurse encounter while performing various interviews in a diverse population of clients? Select all that apply. A. Clients not being fluent in the same language as the nurse B. Clients having a limited education C. Clients speaking the same language as the nurse D. Clients demonstrating mild anxiety E. Clients fearing saying the wrong thing

A. Clients not being fluent in the same language as the nurse B. Clients having a limited education E. Clients fearing saying the wrong thing

The nurse is admitting a new client to the hospital and needs to determine the client's needs and current problems. Which action will the nurse do first? A. Complete a comprehensive assessment. B. Contact the health care provider. C. Review the client's past medical records. D. Perform a physical assessment.

A. Complete a comprehensive assessment.

What is the best way for a nurse to obtain a full set of data when performing an assessment of a client? A. Complete a systematic nursing history and nursing examination. B. Have a nursing student perform the assessment and report it back to the nurse. C. Make educated generalizations about the client's health to determine focused client problems. D. Make interpretations based on client behaviors.

A. Complete a systematic nursing history and nursing examination.

Which nursing diagnoses are stated correctly? Select all that apply. A. Deficient Fluid Volume related to abnormal fluid loss B. Risk for Impaired Skin Integrity C. Grieving related to Body Image Disturbance D. Possible Chronic Low Self-Esteem E. Nutrition Deficit related to inability to eat a balanced diet F. Knowledge Deficit related to noncompliance with physical therapy routine

A. Deficient Fluid Volume related to abnormal fluid loss E. Nutrition Deficit related to inability to eat a balanced diet

A nurse asks a coworker about the condition of the nurse's next-door neighbor, who has been admitted to the unit. If the coworker shares the neighbor's client information with the nurse, the coworker could be held liable for committing which act? A. Invasion of privacy B. Negligence C. Assault D. Defamation of character

A. Invasion of privacy

A nurse is providing care to two clients who are sharing the same room. The nurse is preparing to give one of the clients a complete bed bath. Which action by the nurse would suggest liability related to invasion of the client's privacy? A. Keeping the curtain between the two clients in the room open B. Documenting a belief that the client was arrested C. Removing the client's clothing with some force D. Applying restraints to the client's arms to keep the client in bed

A. Keeping the curtain between the two clients in the room open

What is the ultimate goal of expanding nursing knowledge through nursing research? A. Learn improved ways to promote and maintain health B. Develop technology to provide hands-on nursing care C. Apply knowledge to become independent practitioners D. Become full-fledged partners with other care providers

A. Learn improved ways to promote and maintain health

A nurse in a wellness center is presenting a class on integrating holistic therapies with traditional health care. The nurse talks about the trend in health care to treat each client in a manner that reconnects the total being. Which would best be considered a holistic approach to health? A. Physical, emotional, and spiritual well-being B. Emotional and sexual contact C. Healthy work environment D. Financial success and post-secondary education

A. Physical, emotional, and spiritual well-being

The nurse is providing flu shots to older adult clients at a nurse-managed wellness center. This is an example of which aim of nursing? A. Preventing illness B. Restoring health C. Coping with disability D. Promoting health literacy

A. Preventing illness

A nurse who comments to coworkers at lunch that a client with a sexually transmitted infection has been sexually active in the community may be guilty of what tort? A. Slander B. Libel C. Fraud D. Assault

A. Slander

The nurse identifies which types of data when performing an assessment? Select all that apply. A.Subjective B. Intuition C. Objective D. Critical thinking E. Hunches

A. Subjective C. Objective

After a client falls out of bed, the nurse completes: A. a safety event report (incident report). B. a telephone call to hospital's attorney. C. a progress note stating event report was completed. D. a malpractice report.

A. a safety event report (incident report).

The correct progression of steps of the nursing process is: A. assessment, diagnosis, planning, implementation, and evaluation. B. planning, assessment, diagnosis, evaluation, and implementation. C. diagnosis, implementation, assessment, evaluation, and planning. D. implementation, planning, evaluation, assessment, and diagnosis.

A. assessment, diagnosis, planning, implementation, and evaluation.

When documenting subjective data, the nurse should: A. use the client's own words placed in quotation marks. B. paraphrase the information stated by the client. C. validate the information with the client's family prior to documentation. D. record the information using nonspecific words.

A. use the client's own words placed in quotation marks.

Which are examples of subjective data? Select all that apply. A nurse observes a client wringing the hands before signing a consent for surgery. A. A nurse observes redness and swelling at an intravenous site. B. A client describes pain as an 8 on the pain assessment scale. C. A client feels nauseated after eating breakfast. D. A client's blood pressure is elevated following physical activity. E. A client reports being cold and requests an extra blanket.

B. A client describes pain as an 8 on the pain assessment scale. C. A client feels nauseated after eating breakfast. E. A client reports being cold and requests an extra blanket.

For nursing students to be successful in their educational endeavors, they must A. Come to class having memorized the material in the textbook B. Be actively involved with the material in the text C. Save all questions for the end of the class D. Read the material after the class for understanding

B. Be actively involved with the material in the text

Which type of health problem requires both physician- and nurse-prescribed actions to address? A. Independent health problem B. Collaborative health problem C. Physician-developed problem D. Interdisciplinary health problem

B. Collaborative health problem

A nurse who obtains a license to practice nursing through self-misrepresentation is guilty of what tort? A. Slander B. Fraud C. Libel D. Assault

B. Fraud

A client is being prepared for cardiac catheterization. The nurse performs an initial assessment and records the vital signs. Which data collected can be classified as subjective data? A. Blood pressure B. Nausea C. Heart rate D. Respiratory rate

B. Nausea

A nurse has just taken vital signs on a newly admitted client. Vital signs would be entered on the client record as which type of data? A. Subjective B. Objective C. Intuitive D. Hunches

B. Objective

A nurse working on a medicine unit is mentoring a new graduate. The new nurse asks why it is necessary to perform an assessment on the same client twice during a 12-hour shift. What would be the nurse's best response to the new graduate? A. It is policy and we have to follow the facility's rules. B. Ongoing data collection is critical to the deletion or modification of old problems and finding new ones. C. We have always done it this way for as long as I have worked here. D. It will give you lots of chances to practice your assessment skills.

B. Ongoing data collection is critical to the deletion or modification of old problems and finding new ones.

A nurse is collecting data from a home care client. In addition to information about the client's health status, which is another critical observation the nurse should make? A. Number of rooms in the house B. Safety of the immediate environment C. Frequency of home visits to be made D. Friendliness of the client and family

B. Safety of the immediate environment

A nurse assesses a client, obtaining the information from a primary source. The nurse has gathered the information from which source? A. The client's spouse B. The client C. The client's health care records D. A primary care health care provider

B. The Client

A nurse is assessing a new older adult client's level of activity and exercise. What data should the nurse prioritize? A. The client's resting heart rate B. The client's ability to perform activities of daily living C. The quality of the client's diet D. The client's lying, sitting and standing blood pressures

B. The client's ability to perform activities of daily living

The nurse is preparing to begin a health assessment with a new client. Which nursing consideration will help to establish a safe and appropriate environment for conducting the health assessment? A. There is adequate time to perform the assessment. B. The room is private, quiet, warm, and has adequate light. C. Family members are present to answer specific questions. D. The assessment should be conducted after all tests and procedures.

B. The room is private, quiet, warm, and has adequate light.

The nurse has entered the client's room to ask questions and complete the nursing admission database. The client is wearing a hearing aid in the left ear. Noise is emanating from the television set. What action will the nurse take to facilitate obtaining the history? A. Speak into the client's left ear. B. Turn off the television with permission. C. Use a loud voice to speak with the client. D. Stand about 1 ft (0.3 m) of the client.

B. Turn off the television with permission.

While doing an assessment, the nurse identifies questionable data. Which should the nurse do first? A. Disregard the questionable data. B. Validate the questionable data. C. Inform the physician of the questionable data. D. Inform the client that the data are not correct.

B. Validate the questionable data.

A 2-year-old child arrives at the emergency department of a local hospital with difficulty breathing from an asthmatic attack. What is the priority nursing intervention? A. giving the child a favorite stuffed animal to hold B. assessing respirations and administering oxygen C.raising the side rails and restraining the child's arms D. asking the child's parent about favorite foods

B. assessing respirations and administering oxygen

When planning nursing interventions, the nurse must review the etiology of the problem statement. The etiology: A. identifies the unhealthy response preventing desired change. B. identifies factors causing undesirable response and preventing desired change. C. suggests client goals to promote desired change. D. identifies client strengths.

B. identifies factors causing undesirable response and preventing desired change.

The nurse is conducting an interview with a newly admitted client. Which listening behavior should the nurse implement to have a successful interview? A. Focus mainly on verbal comments. B. Fill in the words for the client. C Avoid the impulse to interrupt. D. Fill in quiet spaces and pauses.

C Avoid the impulse to interrupt.

Which question or statement would be appropriate for eliciting further information when conducting a health history interview? A. "Why didn't you go to your health care provider when you began to have this pain?" B. "Are you feeling better now than you did during the night?" C. "Tell me more about what caused your pain." D. "If I were you, I would not wait to get help next time."

C. "Tell me more about what caused your pain."

After graduating from an accredited program in nursing and successfully passing the NCLEX, the nurse must take which action to obtain the legal right to practice? A. Enroll in an advanced degree program B. File NCLEX results in the county of residence C. Be licensed by the State Board of Nursing D. Submit a signed letter confirming graduation

C. Be licensed by the State Board of Nursing

Which group of terms best describes the nursing process? A. Nursing goals, medical terminology, linear B. Nurse-centered, single focus, blended skills C. Client-centered, systematic, outcome-oriented D. Family-centered, single point in time, intuitive

C. Client-centered, systematic, outcome-oriented

Which is the most appropriate reason for a nurse to ask a client what the client would like to be called? A. It signifies that the nurse wants to be friendly. B. It allows the client to control the situation. C. It communicates respect for the client. D. It ignores the policies of the facility.

C. It communicates respect for the client.

A nurse realizes that the dosage of the medication administered to the client has been entered incorrectly into the client paper record. Which action would be most appropriate for the nurse to do? A. Completely erase or delete the erroneous entry if possible. B. Use a highlighter to mark the incorrect entry and place initials next to it. C. Strike out the entry with a single line, place initials next to it, and write the correct entry. D. Black out the erroneous entry with a dark pen or marker.

C. Strike out the entry with a single line, place initials next to it, and write the correct entry.

Which practice by the nurse indicates that the nurse is a professional? A. Doing things the way they have always been done B. Using intuition to make decisions about client care C. Using evidence-based practice interventions D. Submitting an article to a local newspaper

C. Using evidence-based practice interventions

The nurse is assessing the client's abdominal wound and notes yellow-green purulent wound drainage. The nurse recognizes that the drainage is an example of: A. a judgment. B. an inference. C. objective data. D. subjective data.

C. objective data.

A nurse is conducting an interview with a client. Which example best demonstrates use of open-ended questions in an interview? A. "Are you feeling well?" B. "Do you smoke?" C. "Do you use any illicit drugs?" D. "How are you feeling?"

D. "How are you feeling?"

A nurse has been named as a defendant in a lawsuit. With whom should the nurse discuss the case? A. Colleagues B. Reporters C. Plaintiff D. Attorney

D. Attorney

A nurse is arrested for possession of illegal drugs. What kind of law is involved with this type of activity? A. Civil B. Private C. Public D. Criminal

D. Criminal

When should a health care facility determine its disaster preparedness plan for delivering care in the event of an emergency or disaster? A. As soon as the disaster is announced publicly B. When officially informed that a disaster has occurred C. After the first disaster has been experienced D. In advance of a possible emergency or disaster

D. In advance of a possible emergency or disaster

A client presents to an outpatient health care office for the first time. What step would the nurse take first, prior to taking a health assessment from the client? A. Ask a family member to be present for the assessment. B. Tell the client the amount of time planned for the assessment. C. Inform the client of the procedures done in the assessment. D. Introduce oneself to the client.

D. Introduce oneself to the client.

A nurse is using the assistance of an interpreter. When interviewing a client who does not speak the dominant language, what should the nurse do? A. Assess the client's vital signs at the beginning of the assessment. B. Prioritize objective data over subjective data. C. Inspect the symmetry of the facial features. D. Observe the client's body language.

D. Observe the client's body language.

A nurse is preparing to conduct a health history for a client who is confined to bed. How should the nurse position oneself? A. Standing at the end of the bed B. Standing at the side of the bed C. Sitting at least 6 feet from the beside D. Sitting at a 45-degree angle to the bed

D. Sitting at a 45-degree angle to the bed

A client gets out of bed following hip surgery, falls, and re-injures the hip. The nurse caring for the client knows that it is the nurse's duty to make sure an incident report is filed. Which statement accurately describes the correct procedure for filing an incident report? A. The health care provider in charge should fill out the report. B. The names of the staff involved should not be included. C. The reports are used for disciplinary action against the staff. D. The report should contain all the variables related to the incident.

D. The report should contain all the variables related to the incident.

A nurse does not assist with ambulation of a postoperative client on the first day after surgery. The client falls and fractures a hip. What charge might be brought against the nurse? A. assault B. battery C. Fraud D. negligence

D. negligence

A nurse does not assist with ambulation of a postoperative client on the first day after surgery. The client falls and fractures a hip. What charge might be brought against the nurse? A. assault B. battery C. fraud D. negligence

D. negligence


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