This is a comprehensive and detailed practice material/testbank that contains practice questions and answers on chapter 16; Nursing Assessment for Nur 130.
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1. The nurse is using critical thinking skills during the first phase of the nursing process. Which
action indicates the nurse is in the first phase?
a. Completes a comprehensive database
b. Identifies pertinent nursing diagnoses
c. Intervenes based on priorities of patient care
d. Determines whether outcomes have been achieved
ANS: A
The assessment phase of the nursing process involves data collection to complete a thorough
patient database and is the first phase. Identifying nursing diagnoses occurs during the diagnosis
phase or second phase. The nurse carries out interventions during the implementation phase
(fourth phase), and determining whether outcomes have been achieved takes place during the
evaluation phase (fifth phase) of the nursing process.
2. A nurse is using the problem-oriented approach to data collection. Which action will the nurse
take first?
a. Complete the questions in chronological order.
b. Focus on the patient’s presenting situation.
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c. Make accurate interpretations of the data.
d. Conduct an observational overview.
ANS: B
A problem-oriented approach focuses on the patient’s current problem or presenting situation
rather than on an observational overview. The database is not always completed using a
chronological approach if focusing on the current problem. Making interpretations of the data is
not data collection. Data interpretation occurs while appropriate nursing diagnoses are assigned.
The question is asking about data collection.
3. After reviewing the database, the nurse discovers that the patient’s vital signs have not been
recorded by the nursing assistive personnel (NAP). Which clinical decision should the nurse
make?
Administer scheduled medications assuming that the NAP would have reported abnormal
a. vital signs.
Have the patient transported to the radiology department for a scheduled x-ray, and review
b. vital signs upon return.
c. Ask the NAP to record the patient’s vital signs before administering medications.
d. Omit the vital signs because the patient is presently in no distress.
ANS: C
The nurse should ask the nursing assistive personnel to record the vital signs for review before
administering medicines or transporting the patient to another department. The nurse should not
make assumptions when providing high-quality patient care, and omitting the vital signs is not an
appropriate action.
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