Chapter_01.bnk
MULTIPLE CHOICE
1.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. What type of assessment data is this?
a. Objective
b. Reflective
c. Subjective
d. Introspective
ANS: a
Objective data is 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.
PTS: 1
DIF: Cognitive Level: Understanding (Comprehension)
MSC: Client Needs: Safe and Effective Care Environment: Management of
Care
2.A patient tells the nurse that he is very nervous, nauseous, and "feels
hot." What type of assessment data is this?
a. Objective
b. Reflective
c. Subjective
d. Introspective
ANS: c
Subjective data is what the person says about him or herself during
history taking. Objective data is 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.
,PTS: 1
DIF: Cognitive Level: Understanding (Comprehension)
MSC: Client Needs: Safe and Effective Care Environment: Management of
Care
3.What do the patient's record, laboratory studies, objective data, and
subjective data combine to form?
a. Database
b. Admitting data
c. Financial statement
d. Discharge summary
ANS: a
The objective and subjective data together with the patient's record and
laboratory studies, form the database. The other items are not part of the
patient's record, laboratory studies, or data.
PTS: 1
DIF: Cognitive Level: Remembering (Knowledge)
MSC: Client Needs: Safe and Effective Care Environment: Management of
Care
4.When listening to a patient's breath sounds, the nurse is unsure of a
sound that is heard. Which action would the nurse take next?
a. Notify the patient's physician.
b. Document the sound exactly as it was heard.
c. Validate the data by asking another nurse to listen to the breath
sounds.
d. Assess again in 20 minutes to note whether the sound is still present.
ANS: c
When unsure of a sound heard while listening to a patient's breath
sounds, the nurse validates the data to ensure accuracy by either
repeating the assessment themselves or asking another nurse to assess
the breath sounds. If the nurse has less experience analyzing breath
sounds, then he or she should ask an expert to listen. When unsure of a
sound heard while listening to a patient's breath sounds, the nurse should
,validate the data before documenting to ensure accuracy and before
notifying the patient's physician. To validate that data, the nurse either
repeats the assessment himself or herself or asks another nurse to assess
the breath sounds.
PTS: 1
DIF: Cognitive Level: Applying (Application)
MSC: Client Needs: Safe and Effective Care Environment: Management of
Care
5. The nurse is conducting a class for new graduate nurses. While
teaching the class, what would the nurse keep in mind regarding what
novice nurses, without a background of skills and experience from
which to draw upon, are more likely to base their decisions on?
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 to make
decisions. It takes time, perhaps a few years, in similar clinical situations
to achieve competency and it is functioning at the level of an expert
practitioner when intuition is included in making clinical decisions.
While information in journal articles and advice from supervisors may
assist in making decisions, novice nurses do not typically base their
decisions on them. It would also be important that if information from
journal articles and advice from supervisors were used, that they were
evidence based.
PTS: 1
DIF: Cognitive Level: Understanding (Comprehension)
MSC: Client Needs: General
6.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 clinician's
experience.
d. EBP does not consider the patient's own preferences as important.
ANS: c
EBP is a systematic approach to practice that emphasizes the use of
research evidence in combination with the clinician's expertise and
clinical knowledge (physical assessment), as well as patient values and
preferences, 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.
PTS: 1
DIF: Cognitive Level: Understanding (Comprehension)
MSC: Client Needs: Safe and Effective Care Environment: Management of
Care
7.The 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 distress
ANS: 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).
Postoperative pain, diabetic teaching for a patient newly diagnosed with
diabetes, and a small laceration on sole of the foot are not considered
first-level priority problems.
PTS: 1
DIF: Cognitive Level: Understanding (Comprehension)
MSC: Client Needs: Safe and Effective Care Environment: Management of
Care
, 8.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 signs
ANS: c
Abnormal laboratory values are a second-level priority problem.
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). Low
self-esteem and lack of knowledge are considered third-level priority as
although they are important to a patient's health, they can be addressed
after more urgent health problems are addressed. Severely abnormal
vital signs would be considered a first-level priority problem.
PTS: 1
DIF: Cognitive Level: Understanding (Comprehension)
MSC: Client Needs: Safe and Effective Care Environment: Management of
Care
9. 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 irrelevant
ANS: b
Clustering related cues involves clustering, or grouping together,
assessment data that appear to be associated, or related, and helps the
nurse see relationships among the data. Identifying gaps is looking for
missing information and validation involves ensuring accuracy, and
distinguishing relevant and irrelevant data involves identifying data the
fit, or support the problem, but none of those help the nurse to see
