Medical-Surgical Nursing
Question 1
The nurse is instructing a patient on the role of diet, exercise, and medication to control type 2 diabetes. The nurse
is practicing which of the following core competencies for healthcare professionals?
1. provide patient-centered care
2. work in interdisciplinary teams
3. use evidence-based practice
4. apply quality improvement
Correct Answer: 1
Rationale 1: The nurse instructing the patient is an example of the competency provide patient-centered care.
Rationale 2: The core competency work in interdisciplinary teams involves collaboration between disciplines to
provide continuous and reliable care.
Rationale 3: Using best research when providing patient care is an example of the core competency use evidencebased practice.
Rationale 4: Identifying safety hazards and measuring quality is an example of the core competency apply quality
improvement.
Global Rationale: In 2003, the National Academy of Sciences proposed a set of five core competencies that all
healthcare professionals should possess to meet the needs of the twenty-first century. The nurse instructing the
patient is an example of the competency providing patient-centered care. Collaboration between disciplines to
provide continuous and reliable care is an example of the core competency work in interdisciplinary teams. Using
best research when providing patient care is an example of the core competency use evidence-based practice.
Identifying safety hazards and measuring quality are examples of the core competency apply quality
improvement.
Cognitive Level: Analyzing
Client Need: Safe Effective Care Environment
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 1. Describe the core competencies for healthcare professionals: provide patient-centered
care, work in interdisciplinary teams, use evidence-based practice, apply quality improvement, and use
informatics.
Question 2
Which of the following is an example of the nurse who is utilizing the core competency use informatics when
providing patient care?
1. searching through a database of articles to find current research on wound care
2. documenting the effectiveness of pain medication for a patient
3. discussing the effectiveness of bedside physical therapy with the therapist
4. changing the sharps container in a patient’s room
Correct Answer: 1
Rationale 1: Searching through a database of articles to find current research on wound care is an example of
using informatics.
Rationale 2: Documenting the effectiveness of pain medication for a patient is an example of providing patientcentered care.
Rationale 3: Discussing the effectiveness of bedside physical therapy with the therapist is an example of working
in interdisciplinary teams.
Rationale 4: Changing the sharp’s container is an example of applying quality improvement.
Global Rationale: Examples of the nurse using the core competency of using informatics include the use of
technology to communicate, manage knowledge, decrease errors, and support critical thinking activities. The
activity of searching through a database of articles to find current research on wound care is an example of the use
of informatics. Documenting the effectiveness of pain medication for a patient is an example of providing patientcentered care. Discussing the effectiveness of bedside physical therapy with the therapist is an example of
working in interdisciplinary teams. Changing the sharps container in a patient’s room is an example of applying
quality improvement.
Cognitive Level: Analyzing
Client Need: Safe Effective Care Environment
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 1. Describe the core competencies for healthcare professionals: provide patient-centered
care, work in interdisciplinary teams, use evidence-based practice, apply quality improvement, and use
informatics.
Question 3
The nurse who plans to implement evidence-based practice when providing patient care would include which of
the following activities?
Standard Text: Select all that apply.
1. Participate in education and research activities when possible.
2. Integrate research findings with clinical care to maximize patient outcomes.
3. Serve on the committee to create critical pathways for patient care.
4. Reinforce hand hygiene techniques with unlicensed assistive personnel.
5. Contact Environmental Services to inform of a malfunctioning infusion pump.
Correct Answer: 1,2
Rationale 1: Participate in education and research activities when possible. This is an example of an activity
when implementing evidence-based practice in the provision of patient care.
Rationale 2: Integrate research findings with clinical care to maximize patient outcomes. This is an example of an
activity when implementing evidence-based practice in the provision of patient care.
Rationale 3: Serve on the committee to create critical pathways for patient care. This is an example of work in
interdisciplinary teams.
Rationale 4: Reinforce hand hygiene techniques with unlicensed assistive personnel. This is an example of
applying quality improvement.
Rationale 5: Contact Environmental Services to inform of a malfunctioning infusion pump. This is an example of
applying quality improvement.
Global Rationale:
Client Need: Safe Effective Care Environment
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 1. Describe the core competencies for healthcare professionals: patient-centered care,
interdisciplinary teams, evidence-based practice, quality improvement, and informatics.
Question 4
Which of the following activities would the community health nurse implement to exemplify the core competency
provide patient-centered care?
1. smoking cessation classes and literature for members in the community
2. increasing the hours for the physician to see patients in the community
3. attending a continuing education program on clean water initiatives
4. evaluating the effectiveness of weight reduction strategies for community members
Correct Answer: 1
Rationale 1: Smoking cessation classes and literature for members in the community is an example of an activity
to provide patient-centered care.
Rationale 2: Increasing the hours for the physician to see patients in the community is an activity to support the
competency of working in interdisciplinary teams.
Rationale 3: Attending a continuing education program on clean water initiatives is an activity to support the
competency of using evidence-based practice.
Rationale 4: Evaluating the effectiveness of weight reduction strategies for community members is an activity to
support the competency of applying quality improvement.
Global Rationale: Activities to exemplify the core competency provide patient-centered care should be focused
on disease prevention, wellness, and promotion of healthy lifestyles. The activity “smoking cessation classes and
literature for members in the community” is an example of an activity to provide patient-centered care. Increasing
the hours for the physician to see patients in the community is an activity to support the competency of working in
interdisciplinary teams. Attending a continuing education program on clean water initiatives is an activity to
support the competency of using evidence-based practice. Evaluating the effectiveness of weight reduction
strategies for community members is an activity to support the competency of applying quality improvement.
Client Need: Safe Effective Care Environment
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 1. Describe the core competencies for healthcare professionals: provide patient-centered
care, work in interdisciplinary teams, use evidence-based practice, apply quality improvement, and use
informatics.
Question 5
The nurse, instructing a patient on weight reduction and smoking cessation, is implementing which of the
following codes of nursing practice?
1. International Council of Nurses Code for Nurses
2. American Nurses Association Standards of Professional Practice
3. American Nurses Association Code of Ethics for Nurses
4. State Board of Nursing
Correct Answer: 1
Rationale 1: The nurse who instructs a patient on weight reduction and smoking cessation is promoting health
and preventing illness which exemplifies the International Council of Nurses Code for Nursing.
Rationale 2: The American Nurses Association Standards of Professional Practice are standards, not a code, and
focus on specific behaviors to address quality practice, practice evaluation, education, collegiality, collaboration,
ethics, research, resource utilization, and leadership.
Rationale 3: The American Nurses Association Code of Ethics for Nurses has nine statements which address the
nurse’s professional relationships, commitment to patients, patient rights, nursing practice, competency,
conditions of employment, and contributions to the science of nursing, collaboration, and nursing values.
Rationale 4: The state boards of nursing do not publish codes for nursing.
Global Rationale: The International Council of Nurses Code for Nurses specifies what nurses are accountable for
in terms of people, practice, society, coworkers, and the profession. The philosophical base for this code is that
the nurse who instructs a patient on weight reduction and smoking cessation is promoting health and preventing
illness, which exemplifies the International Council of Nurses Code for Nursing. The American Nurses
Association Standards of Professional Practice are standards, not a code, and focus on specific behaviors to
address quality practice, practice evaluation, education, collegiality, collaboration, ethics, research, resource
utilization, and leadership. The American Nurses Association Code of Ethics for Nurses has nine statements
which address the nurse’s professional relationships, commitment to patients, patient rights, nursing practice,
competency, conditions of employment, and contributions to the science of nursing, collaboration, and nursing
values. The state boards of nursing do not publish codes for nursing.
Cognitive Level: Analyzing
Client Need: Safe Effective Care Environment
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 2. Explain the importance of nursing codes and standards as guidelines for clinical nursing
practice.
Question 6
To practice within the American Nurses Association Standards of Professional Practice, the nurse would
implement which of the following activities?
1. Integrate research findings into practice.
2. Implement a patient’s plan of care.
3. Evaluate patient progress toward identified outcomes.
4. Analyze assessment data to determine issues.
Correct Answer: 1
Rationale 1: The nurse who is practicing within the American Nurses Association Standards of Professional
Practice would integrate research findings into practice. The standards focus on behaviors to address quality
practice, practice evaluation, education, collegiality, collaboration, ethics, research, resource utilization, and
leadership.
Rationale 2: Implementing a patient’s plan of care is an example of adhering to the American Nurses Association
Standards of Practice.
Rationale 3: Evaluating patient progress toward identified outcomes is an example of adhering to the American
Nurses Association Standards of Practice.
Rationale 4: Analyzing assessment data to determine issues is an example of adhering to the American Nurses
Association Standards of Practice.
Global Rationale: The American Nurses Association Standards of Professional Practice focus on behaviors to
address quality practice, practice evaluation, education, collegiality, collaboration, ethics, research, resource
utilization, and leadership. The nurse who is practicing within these standards would integrate research findings
into practice. The other activities would be implemented when the nurse is adhering to the American Nurses
Association Standards of Practice.
Client Need: Safe Effective Care Environment
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 2. Explain the importance of nursing codes and standards as guidelines for clinical nursing
practice.
Question 7
The nurse who prescribes strategies and alternatives to assist a patient achieve expected outcomes is practicing
within which of the American Nurses Association Standards of Practice?
1. planning
2. assessment
3. diagnosis
4. implementation
Correct Answer: 1
Rationale 1: The American Nurses Association Standards of Practice follow the nursing process. The nurse who
prescribes strategies and alternatives to assist a patient achieve expected outcomes is practicing within the
planning of the standards.
Rationale 2: Assessment activities include data collection.
Rationale 3: Diagnosis activities include the analyzing of data to determine issues.
Rationale 4: Implementation activities include implementation of the plan of care and coordination of care
delivery.
Global Rationale: The American Nurses Association Standards of Practice follow the nursing process. The nurse
who prescribes strategies and alternatives to assist a patient achieve expected outcomes is practicing within the
planning of the standards. Assessment activities include data collection. Diagnosis activities include the analyzing
of data to determine issues. Implementation activities include implementation of the plan of care and coordination
of care delivery.
Cognitive Level: Analyzing
Client Need: Safe Effective Care Environment
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 2. Explain the importance of nursing codes and standards as guidelines for clinical nursing
practice.
Question 8
A terminally ill patient says that the only thing he fears about dying is the pain. The nurse, following the
International Council of Nurses Code for Nurses, would plan which of the following for the patient?
1. measures to alleviate suffering
2. modified activities of daily living
3. enforcement of strict bed rest
4. dietary interventions to maximize strength
Correct Answer: 1
Rationale 1: Since the philosophical base for the International Council of Nurses Code for Nurses is the
responsibility to promote health, prevent illness, and alleviate suffering, the nurse should plan measures to
alleviate the patient’s suffering.
Rationale 2: Modified activities of daily living may not reduce the pain the terminally ill patient fears and would
be incorrect.
Rationale 3: Enforcement of strict bed rest may not reduce the pain the terminally ill patient fears and would be
incorrect.
Rationale 4: Dietary interventions to maximize strength may not reduce the pain the terminally ill patient fears
and would be incorrect.
Global Rationale: Since the philosophical base for the International Council of Nurses Code for Nurses is the
responsibility to promote health, prevent illness, and alleviate suffering, the nurse should plan measures to
alleviate the patient’s suffering. Modified activities of daily living, enforcement of strict bed rest, and dietary
interventions to maximize strength may not reduce the pain the terminally ill patient fears and would be incorrect.
Client Need: Safe Effective Care Environment
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 2. Explain the importance of nursing codes and standards as guidelines for clinical nursing
practice.
Question 9
A patient angrily tells the nurse that he has been waiting over an hour for pain medication. When applying critical
thinking, with which of the following should the nurse respond to this patient?
1. “I understand your anger and am sorry for the delay. I have your pain medication now.”
2. “I had other patients who needed my attention first so I did a few things before getting the pain medication.”
3. “I needed to find out what your medication is and if you can have more when you asked.”
4. “It seems that you always ask for pain medication when I am trying to do other things.”
Correct Answer: 1
Rationale 1: One behavior associated with critical thinking is having empathy and understanding why the patient
is angry when having to wait for pain medication. The best response for the nurse to make to the patient is “I
understand your anger and am sorry for the delay. I have your pain medication now.”
Rationale 2: “I had other patients who needed my attention first so I did a few things before getting the pain
medication” is not an example of a critical thinking behavior and would be incorrect or inappropriate for the nurse
to respond to the patient.
Rationale 3: “I needed to find out what your medication is and if you can have more when you asked” is not an
example of a critical thinking behavior and would be incorrect or inappropriate for the nurse to respond to the
patient.
Rationale 4: “It seems that you always ask for pain medication when I am trying to do other things” is not an
example of a critical thinking behavior and would be incorrect or inappropriate for the nurse to respond to the
patient.
Global Rationale: One behavior associated with critical thinking is having empathy and understanding why the
patient is angry when having to wait for pain medication. The best response for the nurse to make to the patient is
“I understand your anger and am sorry for the delay. I have your pain medication now.” The other choices are not
examples of critical thinking behaviors and would be incorrect or inappropriate for the nurse to respond to the
patient.
Client Need: Safe Effective Care Environment
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 3. Apply the attitudes, mental habits, and skills necessary for critical thinking when using
the nursing process in patient care.
Question 10
Which of the following should the nurse do with patient admission assessment data that would demonstrate
divergent thinking?
1. Identify abnormal data for further analyzing.
2. Focus on normal data to rule out health problems
3. Discriminate information as facts or guesses
4. Think about the information to determine solutions
Correct Answer: 1
Rationale 1: Divergent thinking, a critical-thinking skill, means having the ability to weigh the importance of
information. The nurse should sort out the data that are relevant from data that are irrelevant for the patient and
abnormal data are usually considered relevant.
Rationale 2: Normal data are helpful but may not change the care to provide to the patient. This is not divergent
thinking because it does not weigh the importance of the information.
Rationale 3: Discriminating information as facts or guesses describes the critical-thinking skill of reasoning.
Rationale 4: Thinking about the information to determine solutions describes the critical- thinking skill of
reflection.
Global Rationale: Divergent thinking, a critical-thinking skill, means having the ability to weigh the importance
of information. The nurse should sort out the data that are relevant from data that are irrelevant for the patient.
Abnormal data are usually considered relevant; normal data are helpful but may not change the care to provide to
the patient. Discriminating information as facts or guesses describes the critical-thinking skill of reasoning.
Thinking about the information to determine solutions describes the critical- thinking skill of reflection.
Client Need: Safe Effective Care Environment
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 3. Apply the attitudes, mental habits, and skills necessary for critical thinking when using
the nursing process in patient care.
Question 11
The nurse, utilizing critical-thinking behaviors when providing patient care, would demonstrate which of the
following?
Standard Text: Select all that apply.
1. think independently
2. creativity
3. make decisions based on feelings
4. easily influenced
5. find easy answers to problems
Correct Answer: 1,2
Rationale 1: Think independently. Critical thinking involves being able to think independently in order to
make sound clinical decisions based on sound thinking and judgment.
Rationale 2: Creativity. Nurses need to think of ways to provide quality patient care in the most costeffective manner.
Rationale 3: Make decisions based on feelings. Critical thinking involves being able to listen and be fair and
making decisions based upon what is learned and not what is felt.
Rationale 4: Easily influenced. Critical thinking involves being able to think independently and not being
easily influenced by others’ comments and beliefs.
Rationale 5: Find easy answers to problems. Critical thinking involves discipline so that the nurse does not
stop at easy answers but rather searches for the best possible solutions.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Safe Effective Care Environment
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 3. Apply the attitudes, mental habits, and skills necessary for critical thinking when using
the nursing process in patient care.
Question 12
The nurse is identifying nursing diagnoses appropriate for a patient’s plan of care. Which of the following would
the nurse use to determine the nursing diagnoses?
1. diagnostic reasoning
2. effective communication techniques
3. identify outcome criteria
4. set priorities
Correct Answer: 1
Rationale 1: Making a diagnosis is a complex process and the nurse uses diagnostic reasoning to choose nursing
diagnoses that best define the individual patient’s health problems. Diagnostic reasoning is a form of clinical
judgment used to make decisions about which label, or diagnosis, best describes the patterns of data. Elements of
the clinical judgment process include data gathering and validation, data categorization, intuition, and prior
clinical experience.
Rationale 2: Effective communication techniques would be needed when conducting the assessment of the
patient.
Rationale 3: Identification of outcome criteria is a part of the planning phase of the nursing process.
Rationale 4: Setting priority is an activity conducted during the implementation phase of the nursing process.
Global Rationale: Making a diagnosis is a complex process and the nurse uses diagnostic reasoning to choose
nursing diagnoses that best define the individual patient’s health problems. Diagnostic reasoning is a form of
clinical judgment used to make decisions about which label, or diagnosis, best describes the patterns of data.
Elements of the clinical judgment process include data gathering and validation, data categorization, intuition, and
prior clinical experience. Effective communication techniques would be needed when conducting the assessment
of the patient. Identification of outcome criteria is a part of the planning phase of the nursing process. Setting
priority is an activity conducted during the implementation phase of the nursing process.
Cognitive Level: Analyzing
Client Need: Safe Effective Care Environment
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 3. Apply the attitudes, mental habits, and skills necessary for critical thinking when using
the nursing process in patient care.
Question 13
The nurse plans and implements care for a patient based upon nursing knowledge and skills. The nurse is
functioning within which of the following roles?
1. caregiver
2. advocate
3. educator
4. leader
Correct Answer: 1
Rationale 1: The caregiver role for the nurse today is both independent and collaborative. Nurses independently
make assessments and plan and implement patient care based on nursing knowledge and skills.
Rationale 2: The nurse functioning as a patient advocate actively promotes the patient’s rights to autonomy and
free choice.
Rationale 3: The nurse who is functioning in the role of educator nurse assesses learning needs, plans and
implements teaching methods to meet those needs, and evaluates the effectiveness of the teaching.
Rationale 4: The nurse functioning in the role of leader directs, delegates, and coordinates nursing activities.
Global Rationale: The caregiver role for the nurse today is both independent and collaborative. Nurses
independently make assessments and plan and implement patient care based on nursing knowledge and skills. The
nurse functioning as a patient advocate actively promotes the patient’s rights to autonomy and free choice. The
nurse who is functioning in the role of educator nurse assesses learning needs, plans and implements teaching
methods to meet those needs, and evaluates the effectiveness of the teaching. The nurse functioning in the role of
leader directs, delegates, and coordinates nursing activities.
Cognitive Level: Analyzing
Client Need: Safe Effective Care Environment
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 4. Explain the activities and characteristics of the nurse as caregiver, educator, advocate,
leader and manager, and researcher.
Question 14
A patient tells the nurse that he does not understand the surgical procedure the physician told him he needed.
Which of the following should the nurse do to advocate for this patient?
1. Contact the physician and ask that the procedure be explained to the patient.
2. Explain the procedure to the patient.
3. Document that the patient does not understand the proposed surgical procedure.
4. Instruct the patient in alternatives to the surgical procedure.
Correct Answer: 1
Rationale 1: The nurse as patient advocate actively promotes the patient’s rights to autonomy and free choice.
The nurse should protect the patient’s right to self-determination about the surgical procedure.
Rationale 2: The nurse should not explain the procedure to the patient. This is not patient advocacy.
Rationale 3: The nurse should not do anything beyond documenting the patient’s lack of understanding about the
procedure.
Rationale 4: The nurse should not provide alternatives to the surgical procedure.
Global Rationale: The nurse as patient advocate actively promotes the patient’s rights to autonomy and free
choice. The nurse should protect the patient’s right to self-determination about the surgical procedure. The nurse
should not explain the procedure to the patient. The nurse should not do anything beyond documenting the
patient’s lack of understanding about the procedure. The nurse should not provide alternatives to the surgical
procedure.
Client Need: Safe Effective Care Environment
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 4. Explain the activities and characteristics of the nurse as caregiver, educator, advocate,
leader and manager, and researcher.
Question 15
The nurse, instructing a patient newly diagnosed with type 2 diabetes, reminds the patient about an annual dilated
retinal eye examination in addition to annual urine tests to measure protein levels. The nurse is functioning within
which of the following roles with this patient?
1. educator
2. researcher
3. advocate
4. leader
Correct Answer: 1
Rationale 1: The nurse is functioning as an educator by instructing the patient on annual tests to maintain health.
Rationale 2: As a researcher, the nurse would have a goal to improve the care nurses provide to patients.
Rationale 3: As an advocate, the nurse actively promotes the patient’s rights to autonomy and free choice.
Rationale 4: As a leader, the nurse manages time, people, and resources by delegating, directing, and
coordinating nursing activities.
Global Rationale: The nurse is functioning as an educator by instructing the patient on annual tests to maintain
health. As a researcher, the nurse would have a goal to improve the care nurses provide to patients. As an
advocate, the nurse actively promotes the patient’s rights to autonomy and free choice. As a leader, the nurse
manages time, people, and resources by delegating, directing, and coordinating nursing activities.
Cognitive Level: Analyzing
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 4. Explain the activities and characteristics of the nurse as caregiver, educator, advocate,
leader and manager, and researcher.
Question 16
Which of the following leadership activities would the nurse perform when providing care within the primary
nursing care delivery model?
1. Communicate with patients, families, other care providers, and plans patient discharge.
2. Serve as the team leader by making assignments and being responsible for all care provided.
3. Make referrals and manages the quality of care to include timeliness and cost.
4. Manage a caseload of patients and the health team members providing care to the patients.
Correct Answer: 1
Rationale 1: When providing care to patients within the primary nursing care delivery model, leadership activities
of the nurse include communicating with patients, families, and other care providers, and planning the discharge
of the patients.
Rationale 2: In the team nursing care delivery model, leadership activities of the nurse include serving as the
team leader, making assignments, and being responsible for all care provider.
Rationale 3: In the case management care delivery model, leadership activities of the nurse include making
referrals and managing the quality of care to include timeliness and cost.
Rationale 4: In the case management care delivery model, leadership activities of the nurse include managing a
caseload of patients and managing the health team members providing care to the patients.
Global Rationale: When providing care to patients within the primary nursing care delivery model, leadership
activities of the nurse include communicating with patients, families, and other care providers, and planning the
discharge of the patients. In the team nursing care delivery model, leadership activities of the nurse include
serving as the team leader, making assignments, and being responsible for all care provider. In the case
management care delivery model, leadership activities of the nurse include making referrals, managing the quality
of care to include timeliness and cost, managing a caseload of patients, and managing the health team members
providing care to the patients.
Cognitive Level: Analyzing
Client Need: Safe Effective Care Environment
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 4. Explain the activities and characteristics of the nurse as caregiver, educator, advocate,
leader and manager, and researcher.
Question 17
The nurse is using a specific process to plan smoking cessation activities for a patient. Which of the following is
this nurse most likely using to plan the care for this patient?
1. nursing process
2. critical pathways
3. evidence-based practice
4. variance analyzing
Correct Answer: 1
Rationale 1: The nursing process is a series of critical-thinking activities that nurses use to provide care to
patients. The purpose of care may be to promote wellness, restore health, or facilitate coping with a disability or
death.
Rationale 2: The use of critical pathways is primarily used to manage disease conditions.
Rationale 3: The use of evidence-based practice is primarily used to manage disease conditions.
Rationale 4: The use of variance analyzing implies the use of statistical-based research.
Global Rationale: The nursing process is a series of critical-thinking activities that nurses use to provide care to
patients. The purpose of care may be to promote wellness, restore health, or facilitate coping with a disability or
death. The use of critical pathways and evidence-based practice are primarily used to manage disease conditions.
The use of variance analyzing implies the use of statistical-based research.
Client Need: Safe Effective Care Environment
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 2. Apply the attitudes, mental habits, and skills necessary for critical thinking when using
the nursing process in patient care.
Question 18
Which of the following best demonstrates a nurse using critical thinking when providing patient care?
1. A nurse lists alternative interventions available to provide patient care.
2. A nurse checks a laboratory manual before providing care.
3. A nurse is confused when the only planned intervention fails to help a patient.
4. A nurse checks every intervention with the charge nurse before providing care.
Correct Answer: 1
Rationale 1: Critical thinking is thinking about one’s own thinking. It is self-directed thinking that involves
attitudes and skills. The purpose of the thinking, level of knowledge, prejudices, information sources, option
identification, and personal values should all be considered with critical thinking.
Rationale 2: Although the nurse may use a laboratory manual when planning or providing care, it is not the best
selection.
Rationale 3: The nurse who is unable to employ alternative interventions lacks some of the basic characteristics
associated with critical thinking.
Rationale 4: The nurse who is unable to make independent decisions lacks some of the basic characteristics
associated with critical thinking.
Global Rationale: Critical thinking is thinking about one’s own thinking. It is self-directed thinking that involves
attitudes and skills. The purpose of the thinking, level of knowledge, prejudices, information sources, option
identification, and personal values should all be considered with critical thinking. Although the nurse may use a
laboratory manual when planning or providing care, it is not the best selection. The nurse who is unable to make
independent decisions or employ alternative interventions lacks some of the basic characteristics associated with
critical thinking.
Cognitive Level: Analyzing
Client Need: Safe Effective Care Environment
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 2. Apply the attitudes, mental habits, and skills necessary for critical thinking when using
the nursing process in patient care.
Question 19
A new nurse tells her mentor, “You always seem so poised when you interact with the patient. It is as if you
always know what to do. Can you teach me how to do that?” What characteristic does this mentor possess in
relation to critical thinking?
1. self-confidence
2. independent thinking
3. empathy
4. discipline
Correct Answer: 1
Rationale 1: Confidence in one’s own decisions is gained through the use of critical thinking.
Rationale 2: Independent thinking is demonstrated by the ability to make decisions with minimal input from
others.
Rationale 3: Empathy involves being able to relate in an understanding manner with others.
Rationale 4: Discipline involves self-control.
Global Rationale: Confidence in one’s own decisions is gained through the use of critical thinking. Independent
thinking is demonstrated by the ability to make decisions with minimal input from others. Empathy involves
being able to relate in an understanding manner with others. Discipline involves self-control.
Cognitive Level: Analyzing
Client Need: Safe Effective Care Environment
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 4. Explain the activities and characteristics of the nurse as caregiver, educator, advocate,
leader and manager, and researcher.
Question 20
The nurse stops to think about a previous patient care situation before providing care to a current patient. This
nurse is using what critical-thinking skill?
1. reflection
2. divergent thinking
3. reasoning
4. clarifying
Correct Answer: 4
Rationale 1: Reflection occurs when time is taken to think about a situation and compare it to other similar
situations.
Rationale 2: Divergent thinking involves thinking about multiple items simultaneously.
Rationale 3: Reasoning allows the nurse to use the powers of deduction.
Rationale 4: Clarifying is the use of thinking skills to enhance clarity and reduce confusion.
Global Rationale: Reflection occurs when time is taken to think about a situation and compare it to other similar
situations. Divergent thinking involves thinking about multiple items simultaneously. Reasoning allows the nurse
to use the powers of deduction. Clarifying is the use of thinking skills to enhance clarity and reduce confusion.
Client Need: Safe Effective Care Environment
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 2. Apply the attitudes, mental habits, and skills necessary for critical thinking when using
the nursing process in patient care.
Question 21
The nurse working on a quality improvement study wants to evaluate a patient care process. Which of the
following can the nurse use to evaluate this process?
1. nursing process
2. critical pathway
3. variance analyzing
4. evidence-based practice
Correct Answer: 1
Rationale 1: The nursing process can serve as a framework for the evaluation of quality care.
Rationale 2: The use of critical pathways would not provide the best, recommended means to evaluate a patient
care process.
Rationale 3: The use of variance analyzing would not provide the best, recommended means to evaluate a patient
care process.
Rationale 4: The use of evidence-based practice would not provide the best, recommended means to evaluate a
patient care process.
Global Rationale: The nursing process can serve as a framework for the evaluation of quality care. The use of
critical pathways, variance analyzing, and evidence-based practice would not provide the best, recommended
means to evaluate a patient care process.
Client Need: Safe Effective Care Environment
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 4. Explain the activities and characteristics of the nurse as caregiver, educator, advocate,
leader and manager, and researcher.
Question 22
The nurse is reviewing the outcome of patient care that was provided. Which of the following nursing process
steps should the nurse use next?
1. evaluation
2. assessment
3. implementation
4. planning
Correct Answer: 1
Rationale 1: The data gained during the evaluation of provided patient care serves as the assessment. The nurse
can then proceed to create a nursing diagnosis based upon this information. The steps in the nursing process are
interrelated, interdependent, and used cyclically.
Rationale 2: During the assessment phase, the nurse is actively collecting data.
Rationale 3: Implementation is the phase of the nursing process during which the nurse performs interventions.
Rationale 4: Determining the needs of patient and devising a plan of action take place during the planning phase.
Global Rationale: The data gained during the evaluation of provided patient care serves as the assessment. The
nurse can then proceed to create a nursing diagnosis based upon this information. The steps in the nursing process
are interrelated, interdependent, and used cyclically. During the assessment phase, the nurse is actively collecting
data. Implementation is the phase of the nursing process during which the nurse performs interventions.
Determining the needs of patient and devising a plan of action take place during the planning phase.
Client Need: Safe Effective Care Environment
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 2. Apply the attitudes, mental habits, and skills necessary for critical thinking when using
the nursing process in patient care.
Question 23
A patient tells the nurse, “I have pain in my leg when I stand too long.” This information would be considered
which of the following?
1. subjective data
2. evaluative data
3. qualitative data
4. objective data
Correct Answer: 1
Rationale 1: Information that is perceived only by the person experiencing it is called subjective data.
Rationale 2: Evaluative data is used to assess responses to care that are delivered.
Rationale 3: Qualitative data refers to the presence or absence of a factor.
Rationale 4: Objective data can be measured by someone or something other than the patient.
Global Rationale: Information that is perceived only by the person experiencing it is called subjective data.
Evaluative data is used to assess responses to care that are delivered. Qualitative data refers to the presence or
absence of a factor. Objective data can be measured by someone or something other than the patient.
Client Need: Safe Effective Care Environment
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 2. Apply the attitudes, mental habits, and skills necessary for critical thinking when using
the nursing process in patient care.
Question 24
While providing care to a patient, the nurse stops to assess a new patient problem. The assessment in this situation
would be which of the following?
1. a focused assessment
2. an initial assessment
3. an objective assessment
4. a subjective assessment
Correct Answer: 1
Rationale 1: Focused assessments enable the nurse to monitor the status of an actual or potential problem that
was previously identified.
Rationale 2: The initial assessment refers to the first interaction.
Rationale 3: Subjective assessment is not indicated in this scenario.
Rationale 4: Objective assessment is not indicated in this scenario.
Global Rationale: Focused assessments enable the nurse to monitor the status of an actual or potential problem
that was previously identified. The initial assessment refers to the first interaction. Subjective and objective
assessments are not indicated in this scenario.
Client Need: Safe Effective Care Environment
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 2. Apply the attitudes, mental habits, and skills necessary for critical thinking when using
the nursing process in patient care.
Question 25
At the completion of an assessment, the nurse chooses a nursing diagnosis that best defines the patient’s health
problems. Which type of clinical judgment will this nurse use?
1. diagnostic reasoning
2. evidence-based practice
3. critical pathway
4. nursing process
Correct Answer: 1
Rationale 1: Diagnostic reasoning is a form of clinical judgment used to make decisions about which diagnostic
label best describes the patterns of patient data.
Rationale 2: Evidence-based practice refers to the implementation of care initiatives which have been supported
by research.
Rationale 3: A critical pathway is a health care plan developed to provide care with a multidisciplinary, managed
action focus.
Rationale 4: The nursing process is a systematic method of critically thinking used to promote wellness, maintain
health, restore health, or facilitate coping with disability and death.
Global Rationale: Diagnostic reasoning is a form of clinical judgment used to make decisions about which
diagnostic label best describes the patterns of patient data. Evidence-based practice refers to the implementation
of care initiatives which have been supported by research. A critical pathway is a healthcare plan developed to
provide care with a multidisciplinary, managed action focus. The nursing process is a systematic method of
critically thinking used to promote wellness, maintain health, restore health, or facilitate coping with disability
and death.
Client Need: Safe Effective Care Environment
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 2. Apply the attitudes, mental habits, and skills necessary for critical thinking when using
the nursing process in patient care.
Question 26
The nurse is creating outcome criteria for the nursing diagnoses for a patient. Which of the following should the
nurse include when creating the criteria?
1. They should be written to address the patient, and be time-specific and measurable.
2. They should be written as nursing goals.
3. They should be written as statements.
4. .They should be written as psychomotor only.
Correct Answer: 1
Rationale 1: Outcome criteria for nursing diagnoses are patient-centered, time-specific, and measurable. They are
classified into three domains: cognitive, affective, and psychomotor.
Rationale 2: The focus of the outcome criteria is the patient not upon the nurse.
Rationale 3: While the outcome criteria are often written as statements, this option does not encompass all of the
criteria the way the correct answer does.
Rationale 4: Outcome criteria are not limited to psychomotor skills; they may also be cognitive or affective.
Global Rationale: Outcome criteria for nursing diagnoses are patient-centered, time-specific, and measurable.
They are classified into three domains: cognitive, affective, and psychomotor. The focus of the outcome criteria is
the patient not upon the nurse. While the outcome criteria are often written as statements, this option does not
encompass all of the criteria the way the correct answer does. Outcome criteria are not limited to psychomotor
skills; they may also be cognitive or affective.
Client Need: Safe Effective Care Environment
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 2. Apply the attitudes, mental habits, and skills necessary for critical thinking when using
the nursing process in patient care.
Question 27
The nurse is implementing a plan of care for a patient. After providing care, what should the nurse do as the final
step in the process?
1. Document.
2. Reassess the patient.
3. Nothing.
4. Give the charge nurse a report.
Correct Answer: 1
Rationale 1: Documenting interventions is the final component of implementation as well as being a legal
requirement.
Rationale 2: Ongoing assessment of the patient is an essential component of implementation but it is not the final
step.
Rationale 3: Nursing action is required after the completion of care.
Rationale 4: Providing report is an ongoing process and not necessarily completed after implementing the plan of
care.
Global Rationale: Documenting interventions is the final component of implementation as well as being a legal
requirement. Ongoing assessment of the patient is an essential component of implementation but it is not the final
step. Nursing action is required after the completion of care. Providing report is an ongoing process and not
necessarily completed after implementing the plan of care.
Client Need: Safe Effective Care Environment
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 2. Apply the attitudes, mental habits, and skills necessary for critical thinking when using
the nursing process in patient care.
Question 28
A patient care issue has been raised about the actions taken by a nurse who was asked to provide care to a patient
whose healthcare decisions were considered controversial. The unit’s nurse manager is concerned that care was
not appropriately provided. Which of the following should be consulted to protect the patient and to evaluate the
care in question?
1. nursing code of ethics
2. hospital quality improvement guidelines
3. nurse practice act
4. critical pathway
Correct Answer: 1
Rationale 1: An established code of ethics is one criterion that defines a profession. Ethics are principles of
conduct. Codes of ethics for nurses provide a frame of reference for ideal nursing behaviors that are congruent
with the principles expressed in the Code for Nurses.
Rationale 2: Quality improvement efforts are used to assess and ensure care is provided and as a means to
identify needed changes in care practices.
Rationale 3: The nurse practice act provides the standards for an individual state’s stance on the nurse’s scope of
practice.
Rationale 4: A critical pathway is a healthcare plan developed to provide care with a multidisciplinary, managed
action focus.
Global Rationale: An established code of ethics is one criterion that defines a profession. Ethics are principles of
conduct. Codes of ethics for nurses provide a frame of reference for ideal nursing behaviors that are congruent
with the principles expressed in the Code for Nurses. Quality improvement efforts are used to assess and ensure
care is provided and as a means to identify needed changes in care practices. The nurse practice act provides the
standards for an individual state’s stance on the nurse’s scope of practice. A critical pathway is a healthcare plan
developed to provide care with a multidisciplinary, managed action focus.
Cognitive Level: Analyzing
Client Need: Safe Effective Care Environment
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 3. Explain the importance of nursing codes and standards as guidelines for clinical nursing
practice.
Question 29
A patient tells the nurse, “I have an advance directive that I want you to follow.” Which of the following will this
document provide for the nurse?
1. the patient’s preferences for health care should the patient become mentally incapacitated
2. a complete plan of care for the patient
3. the answers to any care dilemmas for the patient
4. directions regarding when to use universal precautions for the patient
Correct Answer: 1
Rationale 1: An advance directive, or living will, is a document in which a patient formally states preferences for
health care in the event that he or she later becomes mentally incapacitated.
Rationale 2: The patient’s care plan is a hospital-based source of information.
Rationale 3: Patient care dilemmas will be decided on a case-by-case basis and do not relate to the information in
this question
Rationale 4: Information regarding the use of universal precautions is a hospital-based source of information.
Global Rationale: An advance directive, or living will, is a document in which a patient formally states
preferences for health care in the event that he or she later becomes mentally incapacitated. The patient’s care
plan and information regarding the use of universal precautions are hospital-based sources of information. Patient
care dilemmas will be decided on a case-by-case basis and do not relate to the information in this question.
Client Need: Safe Effective Care Environment
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 3. Explain the importance of nursing codes and standards as guidelines for clinical nursing
practice.
Question 30
The nurse is preparing a patient to go home. Which of the following skills are the most important for the nurse in
order to adequately prepare this patient?
1. familiarity with adult learning principles
2. the ability to follow written orders
3. the ability to use critical thinking
4. the ability to support patient decision making
Correct Answer: 1
Rationale 1: The nurse will function as an educator when preparing a patient for discharge. In order to do this
adequately, the nurse will need to have some level of familiarity of adult learning principles to effectively provide
and evaluate the outcome of patient education.
Rationale 2: Following written orders considered a basic caregiver skill.
Rationale 3: Using critical thinking would be considered a basic caregiver skill.
Rationale 4: The ability to support patient decision making relates to the role of patient advocate.
Global Rationale: The nurse will function as an educator when preparing a patient for discharge. In order to do
this adequately, the nurse will need to have some level of familiarity of adult learning principles to effectively
provide and evaluate the outcome of patient education. Following written orders and using critical thinking would
be considered basic caregiver skills. The ability to support patient decision making relates to the role of patient
advocate.
Client Need: Safe Effective Care Environment
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 4. Explain the activities and characteristics of the nurse as caregiver, educator, advocate,
leader and manager, and researcher.
Question 31
The nurse is preparing to provide patient care information to a group of unlicensed assistive personnel. Which
type of care delivery system is this nurse most likely using to provide patient care?
1. team nursing
2. functional nursing
3. primary nursing
4. case management
Correct Answer: 1
Rationale 1: Team nursing is practiced by teams of healthcare providers with various levels of education,
including unlicensed assistive personnel. The concept of team nursing utilizes variously educated healthcare team
members. The team works together and provides the care for which they are individually trained.
Rationale 2: Functional nursing is not a recognized term.
Rationale 3: In primary nursing, total nursing care is provided by the assigned nurse.
Rationale 4: The focus of case management involves meeting the needs and care of a group of patients, with
concurrent goals of maximized outcomes combined with cost containment.
Global Rationale: Team nursing is practiced by teams of healthcare providers with various levels of education,
including unlicensed assistive personnel. The concept of team nursing utilizes variously educated healthcare team
members. The team works together and provides the care for which they are individually trained. Functional
nursing is not a recognized term. In primary nursing, total nursing care is provided by the assigned nurse. The
focus of case management involves meeting the needs and care of a group of patients, with concurrent goals of
maximized outcomes combined with cost containment.
Client Need: Safe Effective Care Environment
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 4. Explain the activities and characteristics of the nurse as caregiver, educator, advocate,
leader and manager, and researcher.
Question 32
A nurse has delegated the collection of vital signs, including blood pressure readings, to two unlicensed assistive
personnel. The delegation of this work means the nurse is
1. accountable for the care that was delegated.
2. not responsible for these vital signs.
3. not accountable for these vital signs.
4. responsible to re-measure all of the vital signs.
Correct Answer: 1
Rationale 1: When the nurse delegates nursing care activities to another person, that person is authorized to act in
the place of the nurse, while the nurse retains the accountability for the activities performed.
Rationale 2: The nurse retains responsibility/accountability for the vital signs.
Rationale 3: The nurse is accountable for reviewing the data collected and ensuring it is done appropriately.
Rationale 4: The purpose of delegation is to share tasks appropriately, not to increase the work load of the
primary nurse.
Global Rationale: When the nurse delegates nursing care activities to another person, that person is authorized to
act in the place of the nurse, while the nurse retains the accountability for the activities performed. The nurse
retains responsibility/accountability for the vital signs. The nurse is accountable for reviewing the data collected
and ensuring it is done appropriately. The purpose of delegation is to share tasks appropriately, not increase the
workload of the primary nurse.
Client Need: Safe Effective Care Environment
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 1. Describe the core competencies for healthcare professionals: provide patient-centered
care, work in interdisciplinary teams, use evidence-based practice, apply quality improvement, and use
informatics.
Question 33
The nurse is consulting a critical pathway to help make patient care decisions. Which type of care delivery model
is this nurse most likely using to provide patient care?
1. case management
2. primary nursing
3. functional nursing
4. team nursing
Correct Answer: 1
Rationale 1: Critical pathways are often used in conjunction with case management models and/or quality
improvement efforts. Both critical pathways and case management involve providing care or overseeing care to a
group of patients having similar diagnoses.
Rationale 2: Primary nursing refers to the provision of all nursing care by a single assigned nurse.
Rationale 3: Functional nursing is not a recognized term.
Rationale 4: In team nursing, the care is provided based upon the education level of the team members.
Global Rationale: Critical pathways are often used in conjunction with case management models and/or quality
improvement efforts. Both critical pathways and case management involve providing care or overseeing care to a
group of patients having similar diagnoses. Primary nursing refers to the provision of all nursing care by a single
assigned nurse. Functional nursing is not a recognized term. In team nursing, the care is provided based upon the
education level of the team members.
Client Need: Safe Effective Care Environment
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 1. Describe the core competencies for healthcare professionals: provide patient-centered
care, work in interdisciplinary teams, use evidence-based practice, apply quality improvement, and use
informatics.
Question 34
Patient chart audits provide the nurses with information that impacts the future outcomes of patient care. What
should the nurses do with this information?
1. Use the information to create an action plan to address any negative findings.
2. Nothing.
3. Submit it to the agency’s accrediting body.
4. Place it in a file to compare with the next set of audits.
Correct Answer: 1
Rationale 1: Data from chart audits or the result of quality assurance audits can be used to develop a plan of
action to resolve differences or issues with patient care. The nurses are expected to use the information if it will
have a positive impact on the nursing practice.
Rationale 2: Obtaining information and then failing to use it has no useful purpose.
Rationale 3: While the accrediting body of an institution may encourage quality improvement activities, there is
no reason to provide the chart audit results.
Rationale 4: The nurses are expected to use the information if it will have a positive impact on the nursing
practice.
Global Rationale: Data from chart audits or the result of quality assurance audits can be used to develop a plan of
action to resolve differences or issues with patient care. The nurses are expected to use the information if it will
have a positive impact on the nursing practice. Obtaining information and then failing to use it has no useful
purpose. While the accrediting body of an institution may encourage quality improvement activities, there is no
reason to provide the chart audit results.
Client Need: Safe Effective Care Environment
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 1. Describe the core competencies for healthcare professionals: provide patient-centered
care, work in interdisciplinary teams, use evidence-based practice, apply quality improvement, and use
informatics.
Question 35
A graduate nurse is attending a seminar regarding the role of the nurse as a patient advocate. After the session, the
students engage in a discussion. Which of the following statements by the graduate nurse indicates the need for
further education?
1. “Patient advocates have the authority to make decisions for the patient.”
2. “Being a patient advocate entails making efforts to improve patient outcomes.”
3. “Providing education to the patient and family is a key way to be a positive patient advocate.”
4. “Communicating patient needs to the members of the healthcare team is a role of the patient advocate.”
Correct Answer: 1
Rationale 1: The nurse who serves as a patient advocate may assist and support the patient in decision making.
The nurse cannot make decisions for the patient.
Rationale 2: This is an element of being a successful patient advocate.
Rationale 3: This is an element of being a successful patient advocate.
Rationale 4: This is an element of being a successful patient advocate.
Global Rationale: The nurse who serves as a patient advocate may assist and support the patient in decision
making. The nurse cannot make decisions for the patient. The remaining answer choices are elements of being a
successful patient advocate.
Cognitive Level: Analyzing
Client Need: Safe Effective Care Environment
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 4. Explain the activities and characteristics of the nurse as caregiver, educator, advocate,
leader and manager, and researcher.
Question 36
Core competencies in nursing are essential to meet the challenges of upcoming patient populations and expanding
technologies to provide safe and effective nursing care. All of the following choices are parts of core
competencies. Choose the best description that designates the competency of providing patient centered-care.
1. Design and test interventions to change processes and systems of care, with the objective of improving quality.
2. Communicate, manage knowledge, decrease error, and support. Decision-making (critical thinking) using
information technology.
3. Identify, respect and communicate patient’s differences, values, preferences, and expressed needs.
4. Clarify roles and responsibilities of team members, collaborating and integrating care.
5. Use organizational systems to report near misses and errors.
Correct Answer: 3
Rationale 1: The nurse uses critical thinking to collect and interpret information, consider the patient’s needs, and
determine appropriate interventions. Option 1 is under the competency of applying quality improvement.
Rationale 2: The nurse uses critical thinking to collect and interpret information, consider the patient’s needs, and
determine appropriate interventions. Option 2 is under the competency of using informatics.
Rationale 3: The nurse uses critical thinking to collect and interpret information, consider the patient’s
needs, and determine appropriate interventions.
Rationale 4: The nurse uses critical thinking to collect and interpret information, consider the patient’s
needs, and determine appropriate interventions. Option 4 is under the working in interdisciplinary teams
and Option 5 is under promoting safety.
Rationale 5: The nurse uses critical thinking to collect and interpret information, consider the patient’s
needs, and determine appropriate interventions. Option 5 is under promoting safety.
Global Rationale: The nurse uses critical thinking to collect and interpret information, consider the patient’s
needs, and determine appropriate interventions. Option 1 is under the competency of applying quality
improvement. Option 2 is under the competency of using informatics, Option 4 is under the working in
interdisciplinary teams and Option 5 is under promoting safety.
Client Need: Physiological Integrity
Client Need Sub: Basic Care and Comfort
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 1. Describe the core competencies for healthcare professionals: provide patient-centered
care, work in interdisciplinary teams, use evidence-based practice, apply quality improvement, promote safety,
and use informatics.
Question 37
Choose the questions or results which would best represents divergent thinking on the part of a nurse doing an
initial intake assessment for a patient complaining of pain in his or her back.
Standard Text: Select all that apply.
1. “Tell me about your dietary practices.”
2. “When did the pain start and can you tell me on a scale of 1-10, with 10 being the worst, what your pain rating
is now?”
3. The nurse notes a cluster of blisters on patient’s scapula.
4. “When is the last time you had a physical?”
5. “Does your eyesight affect your ability to see the insulin that you are taking?”
Correct Answer: 2,3,5
Rationale 1: “Tell me about your dietary practices.” Normal data are helpful but may not change the care the
nurse provides.
Rationale 2: “When did the pain start and can you tell me on a scale of 1-10, with 10 being the worst, what your
pain rating is now?” Divergent thinking is the ability to weigh the importance of information. This means that
when the nurse collects data from a patient, he or she can sort out the data that are relevant for care from the data
that is not relevant.
Rationale 3: The nurse notes a cluster of blisters on patient’s scapula. Divergent thinking is the ability to weigh
the importance of information. This means that when the nurse collects data from a patient, he or she can sort out
the data that are relevant for care from the data that is not relevant.
Rationale 4: “When is the last time you had a physical?” Normal data are helpful but may not change the care the
nurse provides.
Rationale 5: “Does your eyesight affect your ability to see the insulin that you are taking?” Divergent thinking is
the ability to weigh the importance of information. This means that when the nurse collects data from a patient, he
or she can sort out the data that are relevant for care from the data that is not relevant.
Global Rationale: Divergent thinking is the ability to weigh the importance of information. This means that
when the nurse collects data from a patient, he or she can sort out the data that are relevant for care from the data
that is not relevant. Normal data are helpful but may not change the care the nurse provides.
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 2. Apply the attitudes, mental habits, and skills necessary for critical thinking when using
the nursing process in patient care.
Question 38
Arrange in order the steps the nurse would take to create a focused assessment for a patient with type II diabetes.
Standard Text: Click and drag the options below to move them up or down.
Choice 1. Nurse notes patient is reluctant to draw up insulin in syringe.
Choice 2. Nurse assesses what the patient already knows.
Choice 3. Nurse has patient practice drawing up insulin.
Choice 4. Nurse calls in diabetic educator.
Choice 5. Nurse notes patient is not aware of differences of hypo- and hyperglycemia.
Correct Answer: 3,1,5,4,2
Rationale 1:
Rationale 2:
Rationale 3:
Rationale 4:
Rationale 5:
Global Rationale: Focused assessments are ongoing and continuous. Data is used to evaluate nursing actions and
make decisions about whether to continue or change interventions to meet outcomes. Assessments also provide
structure for documenting nursing care, enable responses to a disease process or treatment, and to identify new
problems (Alfaro-LeFevre, 2009).
Client Need: Physiological Integrity
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 2. Apply the attitudes, mental habits, and skills necessary for critical thinking when using
the nursing process in patient care.
Question 39
Evaluate the following scenarios and choose the one that best describes an ethical nursing dilemma.
1. A 20-year-old male patient comes in the hospital with an opportunistic disease and has HIV. He is sexually
irresponsible and is sleeping with two girls and does not want this information given out.
2. You are a charge nurse and the patient ratio is greater than 5:1.
3. You are assigned to a cardiac unit but are not capable of interpreting EKG results. You take the assignment
anyway.
4. You drop the patient’s medication on the floor but give it to the patient anyway.
5. A co-worker has hung the wrong antibiotic on the patient. You find the error.
Correct Answer: 1
Rationale 1: A dilemma is a choice between two unpleasant, ethically troubling alternatives. Nurses who provide
medical-surgical nursing care face dilemmas almost daily. Many commonly experienced dilemmas involve
confidentiality, patient rights, and issues of dying and death.
Rationale 2: The rest of the answers 2, 3, 4, and 5 do not fall under the definition of dilemma, although they are
violating standards of care, codes of ethics and standards of practice.
Rationale 3: The rest of the answers 2, 3, 4, and 5 do not fall under the definition of dilemma, although they are
violating standards of care, codes of ethics and standards of practice.
Rationale 4: The rest of the answers 2, 3, 4, and 5 do not fall under the definition of dilemma, although they are
violating standards of care, codes of ethics and standards of practice.
Rationale 5: The rest of the answers 2, 3, 4, and 5 do not fall under the definition of dilemma, although they are
violating standards of care, codes of ethics and standards of practice.
Global Rationale: A dilemma is a choice between two unpleasant, ethically troubling alternatives. Nurses who
provide medical-surgical nursing care face dilemmas almost daily. Many commonly experienced dilemmas
involve confidentiality, patient rights, and issues of dying and death. The rest of the answers 2, 3, 4, and 5 do not
fall under the definition of dilemma, although they are violating standards of care, codes of ethics, and standards
of practice.
Cognitive Level: Evaluating
Client Need: Psychosocial Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 3. Explain the importance of nursing codes and standards as guidelines for clinical nursing
practice.
Question 40
A nurse has met a patient who can provide season passes for the upcoming football season at a discounted price.
The nurse offers to provide home care for one week in exchange for the discounted tickets as a present to her
boyfriend. The nurse is in violation of which standard(s)?
Standard Text: Select all that apply.
1. HIPPA
2. ANA standards
3. professional boundaries
4. state nurse practice acts
5. standards pertinent to specific hospital protocols
Correct Answer: 3,4
Rationale 1: Answer 1 is a violation of patient confidentiality.
Rationale 2: Answer 2 is a violation of ethics in the ANA Standards of Care and would not apply here.
Rationale 3: Professional boundaries are the borders between the vulnerability of the patient and the power of the
nurse.
Rationale 4: Professional boundaries are the borders between the vulnerability of the patient and the power of the
nurse.
Rationale 5: Hospital protocols are not specified in the question; however, the nurse’s action violates a
professional boundary.
Global Rationale: Professional boundaries are the borders between the vulnerability of the patient and the power
of the nurse. Answer 1 is a violation of patient confidentiality and 2 is a violation of ethics in the ANA Standards
of Care and would not apply here.
Cognitive Level: Evaluating
Client Need: Psychosocial Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 3. Explain the importance of nursing codes and standards as guidelines for clinical nursing
practice.
Question 41
Nurse Lynn has been in the profession for over 10 years. When students come on the medical-surgical unit, Lynn
is often grumpy, mean, and non-compliant when it comes to helping the students stating, “I had to pay my dues,
they must pay theirs.” She does not want the students on the floor and is often obstructive in having them gain
experiences or sharing insights that may benefit them. Nurse Lynn is guilty of violating which standard?
1. ICN Code of Ethics
2. ANA Standards of Practice
3. ANA Code of Ethics
4. state practice acts
5. APNA Code of Ethics
Correct Answer: 2
Rationale 1: The ICN Code of Ethics for Nurses (2006) helps guide nurses in setting priorities, making
judgments, and taking action when they face ethical dilemmas in clinical practice.
Rationale 2: Collegiality, from the ANA Standards of Practice: The registered nurse interacts with and
contributes to the professional development of peers and colleagues.
Rationale 3: Response 3 deals with the standards of self-care, collaboration and association involvement.
Rationale 4: Response 4 deals with the laws to define the scope of nursing in each state
Rationale 5: Response 5 has to do with the American Psychiatric Nurse Association.
Global Rationale: Collegiality, from the ANA Standards of Practice: The registered nurse interacts with and
contributes to the professional development of peers and colleagues. Option1: The ICN Code of Ethics for Nurses
(2006) helps guide nurses in setting priorities, making judgments, and taking action when they face ethical
dilemmas in clinical practice. Option 3 deals with the standards of self-care, collaboration and association
involvement. Option 4 deals with the laws to define the scope of nursing in each state and Option 5 has to do with
the American Psychiatric Nurse Association.
Cognitive Level: Evaluating
Client Need: Psychosocial Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 3. Explain the importance of nursing codes and standards as guidelines for clinical nursing
practice.
Question 42
The nurse attends multidisciplinary meetings to discuss the plan of care for a trauma patient who has been
transferred to the medical-surgical unit. In this role the nurse is acting in the role of which of the following?
1. caregiver
2. team leader
3. delegate
4. advocate
5. manager
Correct Answer: 4
Rationale 1: The caregiver role does not fit the description of advocate above. The caregiver works independently
and collaboratively with the patient.
Rationale 2: Team leaders and delegates are nurses who are participating in roles of leadership in that they
manage time, people, resources, and the environment to ensure that staff is able to provide the proper care to
children.
Rationale 3: Team leaders and delegates are nurses who are participating in roles of leadership in that they
manage time, people, resources, and the environment to ensure that staff is able to provide the proper care to
children.
Rationale 4: The nurse as advocate will attend meetings with others on the healthcare team so that the advocate is
able to mediate between the patient and other persons on the team such as the physician, social worker, and case
manager.
Rationale 5: A manager’s role is to oversee the operation of their perspective nursing floors. They must be aware
of daily activities and the roles and quality assurances needed to implement safe and effective patient care.
Global Rationale: The nurse as advocate will attend meetings with others on the healthcare team so that the
advocate is able to mediate between the patient and other persons on the team such as the physician, social
worker, and case manager.
Client Need: Physiological Integrity
Client Need Sub: Basic Care and Comfort
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 4. Explain the activities and characteristics of the nurse as caregiver, educator, advocate,
leader and manager, and researcher.
Question 43
To ensure the quality and safety of patient care the nurse must understand the following concepts.
Standard Text: Select all that apply.
1. training, experience and competence of each member of the healthcare team
2. monitor care provided and give constructive evaluation
3. ensure quality and safety that patients receive
4. the demographics of the patient
5. the number of previous hospitalizations and satisfaction scores
Correct Answer: 1,2,3
Rationale 1: All nurses must be prepared to understand, take seriously, and participate in quality and safety
improvement strategies, which include training, experience, monitoring of care and quality and safety assurance.
Rationale 2: All nurses must be prepared to understand, take seriously, and participate in quality and safety
improvement strategies, which include training, experience, monitoring of care and quality and safety assurance.
Rationale 3: All nurses must be prepared to understand, take seriously, and participate in quality and safety
improvement strategies, which include training, experience, monitoring of care and quality and safety assurance.
Rationale 4: Information specific to the geographic region or the patient may have some impact on care but does
not generally pertain to the concepts.
Rationale 5: Information specific to the geographic region or the patient may have some impact on care but does
not generally pertain to the concepts.
Global Rationale: All nurses must be prepared to understand, take seriously, and participate in quality and safety
improvement strategies, which include training, experience, monitoring of care and quality and safety assurance.
Information specific to the geographic region or the patient may have some impact on care but do not generally
pertain to the concepts.
Client Need: Safe Effective Care Environment
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 4. Explain the activities and characteristics of the nurse as caregiver, educator, advocate,
leader and manager, and researcher.
Question 44
A nurse would like to do a research project that determines that patients are able to walk to the beverage vending
machine and have choices that fulfill their needs. This research project is
1. valid but not realistic.
2. not valid and not pertinent.
3. a nice idea and should be explored further.
4. realistic but not valid.
5. does not contribute to patient care and therefore is not a good research project.
Correct Answer: 5
Rationale 1: To be relevant, nursing research must have a goal to improve the care that nurses provide patients.
This means that all nurses must consider the researcher role to be integral to nursing practice. Validity, pertinence,
and an interesting idea have nothing to do with improving patient care.
Rationale 2: To be relevant, nursing research must have a goal to improve the care that nurses provide patients.
This means that all nurses must consider the researcher role to be integral to nursing practice. Validity, pertinence,
and an interesting idea have nothing to do with improving patient care.
Rationale 3: To be relevant, nursing research must have a goal to improve the care that nurses provide patients.
This means that all nurses must consider the researcher role to be integral to nursing practice. Validity, pertinence,
and an interesting idea have nothing to do with improving patient care.
Rationale 4: Realistic attempts to do research are based on the need to promote patient care in nursing practice.
Rationale 5: To be relevant, nursing research must have a goal to improve the care that nurses provide patients.
This means that all nurses must consider the researcher role to be integral to nursing practice.
Global Rationale: To be relevant, nursing research must have a goal to improve the care that nurses provide
patients. This means that all nurses must consider the researcher role to be integral to nursing practice. Validity,
pertinence, and an interesting idea have nothing to do with improving patient care. We are speaking to the
outcome of the study and the rationale for the attempt. Realistic attempts to do research are based on the need to
promote patient care in nursing practice.
Cognitive Level: Evaluating
Client Need: Physiological Integrity
Client Need Sub: Basic Care and Comfort
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 4. Explain the activities and characteristics of the nurse as caregiver, educator, advocate,
leader and manager, and researcher.
Question 45
Put the process of making a nursing diagnosis in the correct order.
Standard Text: Click and drag the options below to move them up or down.
Choice 1. Choose the standardized problem label.
Choice 2. Draw conclusions about the present health status.
Choice 3. Compare data to standards and norms.
Choice 4. Cluster clues to look for patterns and relationships.
Choice 5. Identify the problem.
Correct Answer: 5,3,1,2,4
Rationale 1:
Rationale 2:
Rationale 3:
Rationale 4:
Rationale 5:
Global Rationale: The nurse analyzes assessment data to support appropriate nursing diagnoses. During
analyzing, the nurse organizes or categorizes data so that it can be used to identify actual or potential health
problems.
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Basic Care and Comfort
Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 2. Apply the attitudes, mental habits, and skills necessary for critical thinking when using
the nursing process in patient care.