Question 1

Which of the following is not a component of the nursing process?

Accepted Answer

Answer reason: The nursing process is a structured framework for providing patient-centered care consisting of assessment, diagnosis, planning, implementation, and evaluation. “Prescription” pertains to medical orders written by a physician or authorized provider and is therefore not within the nursing process steps. Recognizing this distinction ensures that nurses practice within their defined scope and follow professional standards.

Question 2

Nurse Angela observes Joel, who is very apprehensive about the impending operation. The client is experiencing dyspnea and diaphoresis and asks many questions. Angela made a diagnosis of ANXIETY R/T INTRUSIVE PROCEDURE. What type of nursing diagnosis is this?

Accepted Answer

Answer reason: An actual nursing diagnosis is supported by observable signs and symptoms—here, anxiety manifested as dyspnea, diaphoresis, and verbal expression of fear. This distinguishes it from risk or possible diagnoses, which are anticipatory. Correct identification ensures appropriate care planning.

Question 3

In which phase of the nursing process does the nurse decide whether her actions have successfully treated the client's health problem?

Accepted Answer

Answer reason: The evaluation phase determines the effectiveness of interventions by comparing actual outcomes with expected goals. Based on this analysis, the nurse decides whether to continue, modify, or terminate the care plan. This step ensures accountability and continuous quality improvement.

Question 4

Where is revision of the nursing process done? During?

Accepted Answer

Answer reason: Revision of the care plan occurs during the evaluation phase, when outcomes are assessed and the plan is modified as needed.

Question 5

Which of the following is true with regard to Client Goals?

Accepted Answer

Answer reason: SMART criteria promote clarity and accountability in evaluating nursing outcomes.

Question 6

Once a nurse assesses a client's condition and identifies appropriate nursing diagnoses, a?

Accepted Answer

Answer reason: After assessment and nursing diagnosis, the next step in the nursing process is planning—developing the plan of care with goals and interventions. Options B and D are not the next step; C is a component of planning, but A states the overall step.

Question 7

When two nursing diagnoses appear closely related, what should the nurse do first to determine which diagnosis most accurately reflects the patient's needs?

Accepted Answer

Answer reason: To differentiate between similar nursing diagnoses, the nurse should compare the patient's assessment data with each diagnosis's defining characteristics and select the one that best matches.

Question 8

Which of the following is NOT a correct statement of an outcome criterion?

Accepted Answer

Answer reason: Outcome criteria should be specific, measurable, and time-limited. "Reestablishes a normal pattern of elimination" is vague and not measurable, whereas the other options are specific and observable.

Question 9

The following statements appear on a nursing care plan for a client after a mastectomy: Incision site approximated; absence of drainage or prolonged erythema at incision site; and client remains afebrile. These statements are examples of?

Accepted Answer

Answer reason: These are measurable criteria describing the client’s desired health state after care (incision well-approximated, no drainage/erythema, afebrile), which define expected outcomes—not interventions or broad goals.

Question 10

What is the primary goal of nursing research?

Accepted Answer

Answer reason: Nursing research aims to generate evidence that informs standards of care and enhances nursing practice, ultimately improving patient outcomes. It is not for diagnosing, raising costs, or replacing practice.

Question 11

The nurse hears a client calling out for help. The nurse hurries down the hallway to the client’s room and finds a client lying on the floor. The nurse performs a thorough assessment and assists the client back to bed. The nurse notifies the physician of the incident and completes an incident report. Which of the following would the nurse document on the incident report?

Accepted Answer

Answer reason: Incident reports should contain only objective, factual information without assumptions or blame. "The client was found lying on the floor" accurately describes the event. Other options make unverified assumptions.

Question 12

Documentation is a communication tool for exchange of information stored in records between nurses, patients, and other caregivers. Characteristics of good documentations are **EXCEPT** one?

Accepted Answer

Answer reason: High-quality nursing documentation must be factual, complete, accurate, timely, and legible. Lengthiness is not a desirable characteristic; documentation should be concise and relevant rather than overly long.

Question 13

When evaluating a client, the nurse focuses on?

Accepted Answer

Answer reason: Evaluation is the final step of the nursing process and centers on determining whether goals were met, partially met, or unmet, and deciding whether the plan of care needs to be continued, revised, or terminated.

Question 14

Which action by a nurse best demonstrates adherence to accepted standards of care?

Accepted Answer

Answer reason: Accurate, timely documentation is a core component of nursing standards of care. It ensures continuity, supports clinical decision-making, and provides a legal record of the care delivered. Failing to verify orders, improper delegation, or delaying response to condition changes violate accepted standards.

Question 15

When working in a facility that uses focus charting, the nurse will use which of the following as a focus of care?

Accepted Answer

Answer reason: Focus charting (often DARP: Data, Action, Response, Plan) centers documentation around the client’s current needs, responses, and priorities rather than a problem list. The “focus” can be a concern, symptom, behavior, significant event, or strength that guides nursing care for that shift. Therefore, emphasizing the client’s concerns and strengths best matches the intent of focus charting. Options that emphasize the initial assessment problem list or predefined goals are more consistent with problem-oriented documentation than focus charting.

Question 16

The nurse documenting patient care should?

Accepted Answer

Answer reason: Documentation should be accurate, factual, and completed promptly after the care/intervention is provided. Charting personal opinions and using unapproved abbreviations increase risk of miscommunication and are not best practice. Records should never be altered; errors are corrected per policy (e.g., single line through the error with date/time/initials in paper chart or an electronic addendum), not by changing the original entry.

Question 17

The nurse documenting patient care should?

Accepted Answer

Answer reason: Nursing documentation must be accurate, objective, and completed after the care or intervention is provided. Personal opinions and pre-charting are inappropriate, and documentation errors should be corrected according to agency policy without altering the original entry.

Question 18

Which statement best explains the importance of standards of practice in the nursing profession?

Accepted Answer

Answer reason: They define minimum professional expectations for assessment, planning, implementation, and evaluation so nursing care is consistent and safe. These standards guide clinical judgment, support accountability, and provide a benchmark for evaluating performance and quality of care. They apply across practice settings and help reduce variability that could lead to errors or harm.

Question 19

Which of the following professional organizations best supports critical care nursing practice?

Accepted Answer

Answer reason: This organization is the primary professional body dedicated specifically to critical care nursing and provides evidence-based practice resources, education, and specialty certification support for nurses in ICU/critical care settings. It issues clinical practice guidelines and promotes standards that directly shape bedside critical care nursing. The other organizations are valuable but are broader (general nursing) or focus more on cardiovascular care or multidisciplinary critical care rather than nursing practice specifically.

Question 20

In Community Health Nursing, despite the availability and use of many equipment and devices to facilitate the job of the community health nurse, the best tool any nurse should be well be prepared to apply is a scientific approach ensuring quality of care even at the community setting. This is nursing par balance nothing less than the?

Accepted Answer

Answer reason: It describes the systematic, scientific method nurses use to deliver consistent, high-quality care: assessment, diagnosis, planning, implementation, and evaluation. This framework applies across settings, including community health, to identify needs, plan interventions, and evaluate outcomes. The other options are components or supports of practice (e.g., diagnosis is a step; protocols and research guide care) but are not the overarching scientific approach used for all nursing care.

Question 21

Which of the following best defines a "procedure"?

Accepted Answer

Answer reason: A procedure operationalizes a policy by outlining the step-by-step actions required to implement it consistently. Policies state the organization’s official position or guiding principle, while procedures describe how staff should carry it out in practice. Clear procedures promote standardized care delivery, reduce variability, and support safety and accountability. This distinction is common in healthcare facility administration and nursing management.

Question 22

What document should be in guiding the care of this client?

Accepted Answer

Answer reason: Nursing care must be based on authorized provider prescriptions and current orders to ensure interventions are legally permitted, clinically appropriate, and accurately individualized to the client’s condition. These orders direct medications, treatments, activity level, diet, and diagnostic monitoring, which are the immediate guides for day-to-day care planning. Clinical pathways are standardized tools that support care coordination but do not replace client-specific prescriptions or accommodate all clinical variations.

Question 23

It is the professionally desired norms against which staff performance will be compared?

Accepted Answer

Answer reason: They provide measurable criteria for comparison during audits, peer review, and competency assessment. Job descriptions outline duties and role expectations but are not the normative professional benchmark for quality of care. Surveys and flow charts are tools for data collection or process mapping rather than the authoritative norms used to judge performance.

Question 24

Which of the following would prove that nursing action carried out met the standards of care on falls?

Accepted Answer

Answer reason: Using the nursing process ensures fall risk is identified, individualized interventions are selected (e.g., alarms, assistive devices, toileting plan), and outcomes are reassessed and adjusted, which directly aligns with professional standards. Documentation is important for communication and legal record, but it does not by itself prove the care provided met the clinical standard. Simply executing a provider order or doing an assessment alone is incomplete without the full cycle of planning, implementing, and evaluating preventive care.

Question 25

Total no of steps in nursing process is?

Accepted Answer

Answer reason: It is classically taught as ADPIE: assessment, diagnosis, planning, implementation, and evaluation, which are the core iterative steps used to guide clinical judgment and care delivery. This sequence ensures data are collected and interpreted before interventions are chosen, and that outcomes are reassessed to revise the plan as needed. Options with fewer steps omit essential phases (e.g., nursing diagnosis or evaluation), while more steps typically reflect expanded sub-steps rather than the standard count.

Question 26

It is the professionally desired norms against which a staff performance will be compared?

Accepted Answer

Answer reason: These benchmarks are used to objectively compare what staff did versus what should be done in a role or clinical process. Job descriptions outline duties and responsibilities, but they are not the professional norms used to judge quality of practice. Surveys and flow charts are tools for data collection or process mapping rather than criteria for evaluating competency and performance.

Question 27

Which of the following is a core measure set developed by the Joint Commission?

Accepted Answer

Answer reason: The Joint Commission core measures include standardized, evidence-based performance measures for conditions such as heart failure, acute myocardial infarction, pneumonia, and stroke. These sets are used to evaluate and improve quality of care. The other options are not recognized core measure sets.

Question 28

What provides direction for individualized care and assures the delivery of accurate, safe care through a definitive pathway that promotes the client’s and the support persons’ progress toward positive outcomes?

Accepted Answer

Answer reason: The nursing care plan organizes individualized patient care based on assessment, diagnosis, planning, implementation, and evaluation. It ensures coordinated, safe, and goal-directed care delivery.

Question 29

A survey asks you a question. Which of the following statements would be a good answer?

Accepted Answer

Answer reason: Professional and safe practice requires honesty, accountability, and a commitment to finding accurate information. Admitting uncertainty while taking responsibility to obtain the correct answer reflects adherence to standards of care and patient safety. The other responses demonstrate unsafe, non-evidence-based, or unprofessional attitudes.

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Which of the following is not a component of the nursing process?

Nurse Angela observes Joel, who is very apprehensive about the impending operation. The client is experiencing dyspnea and diaphoresis and asks many questions. Angela made a diagnosis of ANXIETY R/T INTRUSIVE PROCEDURE. What type of nursing diagnosis is this?

In which phase of the nursing process does the nurse decide whether her actions have successfully treated the client's health problem?

Where is revision of the nursing process done? During?

Which of the following is true with regard to Client Goals?

Once a nurse assesses a client's condition and identifies appropriate nursing diagnoses, a?

When two nursing diagnoses appear closely related, what should the nurse do first to determine which diagnosis most accurately reflects the patient's needs?

Which of the following is NOT a correct statement of an outcome criterion?

The following statements appear on a nursing care plan for a client after a mastectomy: Incision site approximated; absence of drainage or prolonged erythema at incision site; and client remains afebrile. These statements are examples of?

What is the primary goal of nursing research?

Documentation is a communication tool for exchange of information stored in records between nurses, patients, and other caregivers. Characteristics of good documentations are EXCEPT one?

When evaluating a client, the nurse focuses on?

Which action by a nurse best demonstrates adherence to accepted standards of care?

When working in a facility that uses focus charting, the nurse will use which of the following as a focus of care?

The nurse documenting patient care should?

The nurse documenting patient care should?

Which statement best explains the importance of standards of practice in the nursing profession?

Which of the following professional organizations best supports critical care nursing practice?

Which of the following best defines a "procedure"?

What document should be in guiding the care of this client?

It is the professionally desired norms against which staff performance will be compared?

Which of the following would prove that nursing action carried out met the standards of care on falls?

Total no of steps in nursing process is?

It is the professionally desired norms against which a staff performance will be compared?

Which of the following is a core measure set developed by the Joint Commission?

What provides direction for individualized care and assures the delivery of accurate, safe care through a definitive pathway that promotes the client’s and the support persons’ progress toward positive outcomes?

A survey asks you a question. Which of the following statements would be a good answer?

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