NUR 245 Exam 1 Test Preparation
Questions and Correct Answers
After completing an initial assessment of a patient, the nurse has charted that his
respirations are eupneic and his pulse is 58 beats per minute. These types of data
would be:
a. Objective.
b. Reflective.
c. Subjective.
d. Introspective.ANS: A
Objective data are what the health professional observes by inspecting, percussing,
palpating, and auscultating during the physical examination. Subjective data is what the
person says about him or herself during history taking. The terms reflective and
introspective are not used to describe data.
A patient tells the nurse that he is very nervous, is nauseated, and feels hot. These
types of data would be:
a. Objective.
b. Reflective.
c. Subjective.
d. Introspective.ANS: C
Subjective data are what the person says about him or herself during history taking.
Objective data are what the health professional observes by inspecting, percussing,
palpating, and auscultating during the physical examination. The terms reflective and
introspective are not used to describe data.
The patients record, laboratory studies, objective data, and subjective data combine to
form the:
a. Data base.
b. Admitting data.
c. Financial statement.
d. Discharge summary.ANS: A
Together with the patients record and laboratory studies, the objective and subjective
data form the data base. The other items are not part of the patients record, laboratory
studies, or data.
When listening to a patients breath sounds, the nurse is unsure of a sound that is heard.
The nurses next action should be to:
a. Immediately notify the patients physician.
b. Document the sound exactly as it was heard.
c. Validate the data by asking a coworker to listen to the breath sounds.
d. Assess again in 20 minutes to note whether the sound is still presentANS: C
,When unsure of a sound heard while listening to a patients breath sounds, the nurse
validates the data to ensure accuracy. If the nurse has less experience in an area, then
he or she asks an expert to listen.
The nurse is conducting a class for new graduate nurses. During the teaching session,
the nurse should keep in mind that novice nurses, without a background of skills and
experience from which to draw, are more likely to make their decisions using:
a. Intuition.
b. A set of rules.
c. Articles in journals.
d. Advice from supervisors.ANS: B
Novice nurses operate from a set of defined, structured rules. The expert practitioner
uses intuitive links.
Expert nurses learn to attend to a pattern of assessment data and act without
consciously labeling it. These responses are referred to as:
a. Intuition.
b. The nursing process.
c. Clinical knowledge.
d. Diagnostic reasoning.ANS: A
Intuition is characterized by pattern recognitionexpert nurses learn to attend to a pattern
of assessment data and act without consciously labeling it. The other options are not
correct.
The nurse is reviewing information about evidence-based practice (EBP). Which
statement best reflects EBP?
a. EBP relies on tradition for support of best practices.
b. EBP is simply the use of best practice techniques for the treatment of patients.
c. EBP emphasizes the use of best evidence with the clinicians experience.
d. The patients own preferences are not important with EBP.ANS: C
EBP is a systematic approach to practice that emphasizes the use of best evidence in
combination with the clinicians experience, as well as patient preferences and values,
when making decisions about care and treatment. EBP is more than simply using the
best practice techniques to treat patients, and questioning tradition is important when no
compelling and supportive research evidence exists.
he nurse is conducting a class on priority setting for a group of new graduate nurses.
Which is an example of a first-level priority problem?
a. Patient with postoperative pain
b. Newly diagnosed patient with diabetes who needs diabetic teaching
c. Individual with a small laceration on the sole of the foot
d. Individual with shortness of breath and respiratory distressANS: D
First-level priority problems are those that are emergent, life threatening, and immediate
(e.g., establishing an airway, supporting breathing, maintaining circulation, monitoring
abnormal vital signs)
,When considering priority setting of problems, the nurse keeps in mind that second-
level priority problems include which of these aspects?
a. Low self-esteem
b. Lack of knowledge
c. Abnormal laboratory values
d. Severely abnormal vital signsANS: C
Second-level priority problems are those that require prompt intervention to forestall
further deterioration (e.g., mental status change, acute pain, abnormal laboratory
values, risks to safety or security
Which critical thinking skill helps the nurse see relationships among the data?
a. Validation
b. Clustering related cues
c. Identifying gaps in data
d. Distinguishing relevant from irrelevantANS: B
Clustering related cues helps the nurse see relationships among the data.
The nurse knows that developing appropriate nursing interventions for a patient relies
on the appropriateness of the __________ diagnosis.
a. Nursing
b. Medical
c. Admission
d. CollaborativeANS: A
An accurate nursing diagnosis provides the basis for the selection of nursing
interventions to achieve outcomes for which the nurse is accountable. The other items
do not contribute to the development of appropriate nursing interventions.
The nursing process is a sequential method of problem solving that nurses use and
includes which steps?
a. Assessment, treatment, planning, evaluation, discharge, and follow-up
b. Admission, assessment, diagnosis, treatment, and discharge planning
c. Admission, diagnosis, treatment, evaluation, and discharge planning
d. Assessment, diagnosis, outcome identification, planning, implementation, and
evaluationANS: D
The nursing process is a method of problem solving that includes assessment,
diagnosis, outcome identification, planning, implementation, and evaluation.
A newly admitted patient is in acute pain, has not been sleeping well lately, and is
having difficulty breathing. How should the nurse prioritize these problems?
a. Breathing, pain, and sleep
b. Breathing, sleep, and pain
c. Sleep, breathing, and pain
d. Sleep, pain, and breathingANS: A
First-level priority problems are immediate priorities, remembering the ABCs (airway,
breathing, and circulation), followed by second-level problems, and then third-level
problems.
, Which of these would be formulated by a nurse using diagnostic reasoning?
a. Nursing diagnosis
b. Medical diagnosis
c. Diagnostic hypothesis
d. Diagnostic assessmentANS: C
Diagnostic reasoning calls for the nurse to formulate a diagnostic hypothesis; the
nursing process calls for a nursing diagnosis.
Barriers to incorporating EBP include:
a. Nurses lack of research skills in evaluating the quality of research studies.
b. Lack of significant research studies.
c. Insufficient clinical skills of nurses.
d. Inadequate physical assessment skills.ANS: A
As individuals, nurses lack research skills in evaluating the quality of research studies,
are isolated from other colleagues who are knowledgeable in research, and often lack
the time to visit the library to read research. The other responses are not considered
barriers.
What step of the nursing process includes data collection by health history, physical
examination, and interview?
a. Planning
b. Diagnosis
c. Evaluation
d. AssessmentANS: D
Data collection, including performing the health history, physical examination, and
interview, is the assessment step of the nursing process
During a staff meeting, nurses discuss the problems with accessing research studies to
incorporate evidence-based clinical decision making into their practice. Which
suggestion by the nurse manager would best help these problems?
a. Form a committee to conduct research studies.
b. Post published research studies on the units bulletin boards.
c. Encourage the nurses to visit the library to review studies.
d. Teach the nurses how to conduct electronic searches for research studies.ANS: D
Facilitating support for EBP would include teaching the nurses how to conduct
electronic searches; time to visit the library may not be available for many nurses.
Actually conducting research studies may be helpful in the long-run but not an
immediate solution to reviewing existing research.
When reviewing the concepts of health, the nurse recalls that the components of holistic
health include which of these?
a. Disease originates from the external environment.
b. The individual human is a closed system.
c. Nurses are responsible for a patients health state.
d. Holistic health views the mind, body, and spirit as interdependent.ANS: D
