1. What is a characteristic of the nursing process?

a. Asystematic
b. Goal-oriented
c. Inflexible
d. Stagnant

2. During the planning phase of the nursing process, which of the following is the
“product” developed?
a. Nursing care plan
b. Nursing diagnoses
c. Nursing history
d. Nursing notes

3. Objective data are also known as:

a. Covert data
b. Inferences
c. Overt data
d. Symptoms

4. Data or information obtained from the assessment of the patient is primarily used by
the nurse to:
a. Ascertain the patient’s responses to health problems
b. Assist in constructing the taxonomy of nursing interventions
c. Determine the effectiveness of the doctor’s orders
d. Identify the patient’s disease process

5. The primary source of data collection in the assessment phase of the nursing process is
the:
a. Chart
b. Patient
c. Doctor
d. Family

6. What is an example of subjective data?

a. Color of wound drainage
b. Odor of breath
c. Respirations of 14 breaths/ minute
d. The patient’s statement of “I feel sick to my stomach”

7. Two-year-old Jason’s mother states, “Jason vomited 8 ounces of his formula this
morning.” This statement is an example of:
 a. Objective data from a primary source
b. Objective data from a secondary source
c. Subjective data from a primary source
d. Subjective data from a secondary source

8. The nurse performs a neurologic exam on a patient. After the exam, which of the
following should be recorded as objective data?
a. +4 patellar reflexes in both of the patient’s legs
b. Patient’s description of ringing in his ears
c. Patient’s sensations of numbness in his right arm
d. Patient’s statement, “The room is spinning.”

9. Which finding obtained during an assessment is considered significant enough to

require immediate communication to another member of the health care team?
a. Change in a patient’s heart rate from 72 to 80
b. Diminished breath sounds in a patient with previously normal breath sounds
c. Relief noted by a patient from prescribed nausea medication
d. Weight loss of 2 lb (1 kg) in a 115-lb (52 kg) female patient

10. It is most important to identify the etiology (risk factors) of a nursing diagnosis because
doing so:
a. Assists in organizing nursing care of patients with a similar diagnosis
b. Describes the patient’s health problem or response in a few words
c. Gives direction to the required nursing interventions for the patient
d. Indicates the presence of a particular health problem in a patient

11. Mr. Bradley, a Jehovah’s Witness, refused any blood transfusions during his surgery,
became anemic after his operation, and is now tired. Mr. Bradley is more likely
experiencing:
a. A potential (risk) nursing diagnosis
b. A possible nursing diagnosis
c. A wellness diagnosis
d. An actual nursing diagnosis

12. Using Maslow’s hierarchy of basic human needs, which of the following nursing
diagnoses has the highest priority?
a. Anxiety related to impending surgery, as evidenced by insomnia
b. Impaired verbal communication related to tracheostomy, as evidenced by inability
to speak
c. Ineffective breathing pattern related to pain, as evidenced by shortness of breath
d. Risk for injury related to autoimmune dysfunction
13. When examining a patient’s eyes, the nurse considers the patient’s age. This action is an
example of:
a. Clustering data
b. Comparing data against standards and norms
c. Determining gaps in the data
d. Differentiating cues and inferences

14. Formulating a nursing diagnosis is a joint function of:

a. Patient and family
b. Nurse and patient
c. Nurse and doctor
d. Doctor and patient

15. Which statement indicates the most appropriate nursing intervention to determine
whether the goal of “The patient will demonstrate fluid balance, as evidenced by total
fluid intake equals total fluid output” has been met?
a. Determine the patient’s fluid preferences by the end of the shift.
b. Instruct the patient to drink 1500 mL of fluid every day.
c. Measure and record the patient’s total fluid intake and output every shift
d. Measure the specific gravity of the patient’s urine every shift

16. In the planning phase of the nursing process, the nurse:

a. Analyzes patient data
b. Carries out nursing interventions
c. Formulates a nursing diagnosis
d. Identifies patient goals

17. When should discharge planning commence?

a. 24 hours after discharge
b. The day before discharge
c. Upon admission
d. When the patient desires

18. The goal or expected outcome “Patient will maintain current weight of 165 pounds” can
be best evaluated by which of the following measures?
a. Determining the patient’s food preferences
b. Monitoring dietary intake for each meal
c. Restricting high-calories food
d. Weighing the patient on the same scale
19. The nurse makes the following entry in the patient’s record: “Goal not met; patient
refuses to attend smoking cessation classes.” Because this goal hasn’t been met, the
nurse should:
a. Develop a completely new nursing care plan
b. Assign the patient to a more experienced nurse
c. Critique the steps involved in the development of the goal
d. Transfer the patient to another facility

20. Collaborative nursing interventions:

a. Are based on the written instructions of another professional
b. Are determined solely by the nurse and patient
c. Reflect the overlapping responsibilities of health care personnel
d. Require supervision by the doctor

21. When assessing a patient’s level of pain, which type of nursing intervention is the nurse
performing?
a. Collaborative
b. Dependent
c. Independent
d. Professional

22. Which of the following behaviors by the nurse, Paula Smith, demonstrates that she
understands the elements of effective charting?
a. She documents giving a patient’s medication after administering the medication
b. She documents the following about her patient “appetite good this morning”
c. She signs her charting as follows: P. Smith
d. She writes in the nurses’ notes with a no. 2 pencil

23. What is a disadvantage of computerized documentation of the nursing process?

a. Accuracy
b. Concern for privacy
c. Legibility
d. Rapid communication

24. What should the nurse do after making a charting error in the nurses’ notes?
a. Draw a line through the error and write “Error” and her initials above it
b. Obliterate the mistake with a black felt pen
c. Recopy the page of nurses’ notes and start over
d. Report the incident immediately to the head nurse

25. Using the nursing process helps provide patient care that is:
 a. Individualized
b. Repetitious
c. Standardized
d. Unorthodox

26. Which statement does not describe an appropriate guideline for writing a nursing
diagnosis?
a. State the diagnosis in terms of a problem, not a need
b. Use medical terminology to describe the probable cause of the patient’s response
c. Use nursing terminology to describe the patient’s response
d. Use statements that assist in planning the independent nursing interventions

27. Which statement is the most appropriate goal for a nursing diagnosis of diarrhea?
a. “The patient will experience decreased frequency of bowel evacuation.”
b. “The patient will provide a stool specimen for culture and sensitivity.”
c. “The patient will receive antidiarrheal medication.”
d. “The patient will save all stools for inspection by the nurse.”

28. When selecting appropriate nursing interventions, the nurse must remember that
nursing interventions should be:
a. Achievable with resources available to the nurse and patient
b. Carried out under the supervision of a doctor
c. Choses disregarding the patient’s values and beliefs
d. Oriented primarily towards tasks and mechanical procedures