1. After completing an initial assessment of a client, the registered nurse has charted that his respirations are
eupneic andhis pulse is 58 beats per minute. These types of data wouldbe:
a. Objective.
b. Reflective.
c. Subjective.
d. Introspective.
CORRECT ANSWER:- A
Objective data are what the healthcare practitioner observes by inspecting, percussing, palpating, and
auscultating during the physical examination. Subjective data is what the person says about him or herself
during historytaking. The terms reflective and introspective are not used to describe data.
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
2. A client tells the registered 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.
CORRECT ANSWER:- C
Subjective data are what the person says about him or herself during history taking. Objective data are what the
healthcare practitioner observes by inspecting, percussing, palpating, and auscultating during the physical
examination. The terms reflective and introspective are not used to describe data.
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
3. The clients record, laboratory studies, objective data, and subjective data combine to form the:
a. Data base.
b. Admitting data.
c. Financial statement.
,d. Discharge summary.
CORRECT ANSWER:- A
Together with the clients record and laboratory studies, the objective and subjective data form the data base.
The other items are not part of the clients record, laboratory studies, or data.
DIF: Cognitive Level: Remembering (Knowledge)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
4. When listening to a clients breath sounds, the registered nurse is unsure of a sound that is heard. The
registered nurses nextaction should be to:
a. Immediately notify the clients 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 present.
CORRECT ANSWER:- C
When unsure of a sound heard while listening to a clients breath sounds, the registered nurse validates the data to
ensureaccuracy. If the registered nurse has less experience in an area, then he or she asks an expert to listen.
DIF: Cognitive Level: Analyzing (Analysis)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
5. The registered nurse is conducting a class for new graduate registered nurses. During the teaching session,
the registered nurse should keep in mind that novice registered nurses, without a background of skills and
experience from which to draw, are more likelyto make their decisions using:
a. Intuition.
b. A set of rules.
c. Articles in journals.
d. Advice from supervisors.
CORRECT ANSWER:- B
Novice registered nurses operate from a set of defined, structured rules. The expert practitioner uses intuitive
6. Expert registered nurses learn to attend to a pattern of assessment data and act without consciously
labeling it. Theseresponses are referred to as:
a. Intuition.
b. The nursing process.
c. Clinical knowledge.
d. Diagnostic reasoning.
CORRECT ANSWER:- A
Intuition is characterized by pattern recognitionexpert registered nurses learn to attend to a pattern of
assessment data andact without consciously labeling it. The other options are not correct.
7. The registered nurse is reviewing information about evidence-based practice (EBP). Which statement
best reflectsEBP?
a. EBP relies on tradition for support of best practices.
b. EBP is simply the use of best practice techniques for the treatment of clients.
c. EBP emphasizes the use of best evidence with the clinicians experience.
d. The clients 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 client preferences and values, when making decisions about care and
treatment. EBP is more than simply using the best practice techniques to treat clients, and questioning
tradition is important when no compelling and supportive research evidence exists.
DIF: Cognitive Level: Applying (Application)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
8. The registered nurse is conducting a class on priority setting for a group of new graduate registered nurses.
Which is an exampleof a first-level priority problem?
a. Client with postoperative pain
b. Newly diagnosed client with diabetes who needs diabetic teaching
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