First nursing exam review: nursing process and assessment

Every question in this set, with the answer

Use this to review after you finish, or instead of the timed version if you would rather just read.

1. At 1845, near the end of your shift, you review the record after a treatment and notice the patient's vital signs and symptoms changed during the afternoon. Which entry best reflects the nurse's role described in this section?

   1. Save the details for verbal shift report and keep the written note brief.
   2. Document the patient's symptoms, vital signs, change in condition, and response to treatment.
   3. Write that the patient was “not quite at baseline” without the symptoms or vital signs.
   4. Chart only that treatment was completed, because evaluating response belongs to the provider.

   Answer: Document the patient's symptoms, vital signs, change in condition, and response to treatment.

   Nurses are described as assessing symptoms and vital signs, documenting changes, and evaluating response to treatment. The other entries omit the specific changes, omit response evaluation, or substitute a verbal handoff for the documented change described in the text.

2. At 0215, while reviewing a patient's vital signs and symptoms, you are the first health-care worker to recognize a new medical issue. Before waiting for morning rounds, what action best matches the nurse's professional role?

   1. Leave the concern for the next shift because the nurse remains with the patient during treatment.
   2. Immediately report the issue to the relevant provider.
   3. Ask the patient’s family to decide whether the provider should be notified.
   4. Continue monitoring until the provider asks for an update.

   Answer: Immediately report the issue to the relevant provider.

   The section states that the nurse who recognizes a medical issue must report it immediately to the relevant provider. Monitoring without reporting, leaving it for shift change, or shifting the decision to family delays the responsibility described in the text.

3. You accepted a nursing position in another state and are building an orientation checklist so you do not document or perform activities outside your permitted role. Which sources or actions belong on that checklist? Select all that apply.

   1. Rely on formal membership in a nursing organization as proof that the activity is permitted.
   2. Use only the scope rules from your prior state because nursing scope is uniform nationally.
   3. Identify where to find information on the limitations of practice in the state where you work.
   4. Review rules and regulations from that state's regulatory body, such as the state nursing board.
   5. Review that state's Nurse Practice Act.

   Answer: Identify where to find information on the limitations of practice in the state where you work., Review rules and regulations from that state's regulatory body, such as the state nursing board., Review that state's Nurse Practice Act.

   Scope is state-determined through the Nurse Practice Act and regulatory rules, and the nurse must know the limitations in the state of practice. Prior-state rules and professional organization membership do not establish the licensed scope described here.

4. A unit committee is selecting two documentation review topics that the section explicitly gives as examples of National Patient Safety Goals. Which topics should the committee choose? Select all that apply.

   1. Whether caregiver-to-caregiver communication is effective.
   2. Whether nurses have access to networking and specialty certification opportunities.
   3. Whether patient and family preferences are included in discharge planning.
   4. Whether records support accurate patient identification.
   5. Whether the unit's professional association activities support advocacy.

   Answer: Whether caregiver-to-caregiver communication is effective., Whether records support accurate patient identification.

   The section names patient identification accuracy and caregiver communication effectiveness as NPSG examples. Discharge planning and professional association activities appear elsewhere in the section, but they are not the NPSG examples cited.

5. In the section's Real RN Story, Mr. Marshall does not want heroic measures if his heart stops beating or he stops breathing. Which action by the nurse, Lisa, best shows the patient-centered care role of knowing what matters to the patient and honoring his directives?

   1. Record that the patient is noncompliant with the treatment plan and revisit his wishes after discharge.
   2. Ask the family to decide about resuscitation because they participate in the plan of care.
   3. Assume his wishes are unchanged from a prior admission and leave the record as it is.
   4. Confirm his wishes during each hospitalization and make sure the do-not-resuscitate order is filed in his medical record.

   Answer: Confirm his wishes during each hospitalization and make sure the do-not-resuscitate order is filed in his medical record.

   In the story, Lisa confirms during each hospitalization that Mr. Marshall does not want heroic measures and ensures the do-not-resuscitate order is filed in his medical record. The section lists knowing what is most important to the patient and honoring their directives as part of the nurse's role in patient-centered care. The other options delay, skip the confirmation, or shift the patient's decision to the family.

6. At 0900 in a cardiology clinic, you review the last three visit records and see the patient’s blood pressure has gradually risen to above normal values. You are completing the assessment portion of the nursing process. What is the best way to handle this finding?

   1. Identify the rising blood pressure as an unexpected pattern and use it to guide the nursing diagnosis and individualized plan of care.
   2. Treat the current blood pressure as the only usable finding because prior visits are not part of this assessment.
   3. Record the trend as routine and expected because gradual changes do not affect the nursing process.
   4. Skip assessment analysis and enter hypertension as the nursing diagnosis.

   Answer: Identify the rising blood pressure as an unexpected pattern and use it to guide the nursing diagnosis and individualized plan of care.

   Assessment is not just data collection; the nurse analyzes relevant data, notices unexpected findings, and looks for patterns. The other options ignore the trend, label it routine, or jump to a diagnosis without assessment analysis.

7. At 1100, after assessment data are reviewed, a patient receives a medical diagnosis of hypertension. You need to identify problem-based nursing diagnoses for the plan of care. Which entry best fits the nursing process described in the section?

   1. Open the blocked vessel to limit cardiac tissue damage.
   2. Hypertension.
   3. Gradual rise in blood pressure measurements over three clinic visits.
   4. Decreased cardiac output; risk for impaired cerebral tissue perfusion; activity intolerance.

   Answer: Decreased cardiac output; risk for impaired cerebral tissue perfusion; activity intolerance.

   Nursing diagnoses describe patient problems related to the medical condition and are broader than simply naming the condition. Hypertension is the medical diagnosis, the blood pressure trend is assessment data, and opening the blocked vessel is a planned outcome from the chest pain example.

8. At 1500, two nurses are reconciling a shared care plan before handoff. They want the plan to support consistent care rather than create duplicate work. Which uses of the nursing process match the section’s stated benefits? Select all that apply.

   1. Use the plan to avoid modifying care after evaluation.
   2. Use the plan to decrease omissions and duplications in care.
   3. Use the plan as a guide so all involved staff provide consistent and responsive care.
   4. Use the plan to keep each discipline working separately on the patient’s problems.
   5. Use the plan to reduce continuity between providers and institutions.

   Answer: Use the plan to decrease omissions and duplications in care., Use the plan as a guide so all involved staff provide consistent and responsive care.

   The section identifies fewer omissions and duplications and a guide for staff to provide consistent, responsive care as benefits. The other options contradict the described benefits: the process encourages collaboration, supports modification, and improves continuity.

9. At 1800, you evaluate a patient after giving the prescribed pain medication, and the patient’s pain is not relieved. According to the evaluation step, what should you do next in the plan of care?

   1. Replace the nursing diagnosis with the medical condition causing the pain.
   2. Continue the same plan unchanged because evaluation happens only after all diagnoses are resolved.
   3. Return to the plan and modify it with additional interventions, such as advocating for a medication order change or using nonpharmacological methods.
   4. Document that the expected outcome was achieved because the ordered medication was administered.

   Answer: Return to the plan and modify it with additional interventions, such as advocating for a medication order change or using nonpharmacological methods.

   Evaluation determines whether actions were effective; if the outcome is not achieved, the care plan may need modification. The other options confuse implementation with success, prevent needed revision, or substitute a medical diagnosis for nursing problem-solving.

10. At 1030 on a medical-surgical unit, a patient develops facial droop and dysarthria and cannot move their arm. Which actions from the section’s clinical judgment example should the nurse take? Select all that apply.

    1. Document only hygiene care and bed linen changes because those are the nurse’s main role.
    2. Wait to act until a physician gives orders, because nursing decisions are task-oriented.
    3. Treat the findings as expected data and continue the current plan without change.
    4. Notify the stroke emergency responders according to the institution’s policy.
    5. Perform a neurological assessment.

    Answer: Notify the stroke emergency responders according to the institution’s policy., Perform a neurological assessment.

    The example states that the nurse uses clinical judgment to assess neurologic status and notify stroke responders per policy. Waiting passively, treating new deficits as expected, or reducing the nurse’s role to basic tasks contradicts the section’s description of contemporary nursing judgment.

11. At 0700 at the beginning of a medical-surgical shift, you perform a systematic head-to-toe review instead of limiting the exam to one complaint. Which documentation heading best matches what you did?

    1. Focused Physical Assessment: chief-complaint system only
    2. Bedside Physical Assessment: systematic exam of patient body systems
    3. Safety/Surroundings Assessment: environment and potential risks only
    4. Comprehensive Health History: detailed interview about history and lifestyle

    Answer: Bedside Physical Assessment: systematic exam of patient body systems

    A bedside assessment is the systematic exam of patient body systems used in this setting. A focused assessment is limited to the chief complaint, a comprehensive health history is an interview, and safety/surroundings documentation addresses environmental and risk concerns.

12. At 0800, you are filling in the General Survey subsection after seeing a patient. Which entries belong there? Select all that apply.

    1. Height and weight
    2. PERRLA, visual acuity, and conjunctivae
    3. Physical appearance and personal hygiene
    4. Cardiac rhythm, heart sounds, and capillary refill
    5. Chronic wounds and general behavior

    Answer: Height and weight, Physical appearance and personal hygiene, Chronic wounds and general behavior

    Height, weight, appearance, chronic wounds, hygiene, and behavior are listed as General Survey content. PERRLA and visual acuity belong with HEENT, while rhythm, sounds, and capillary refill fit the cardiac assessment.

13. At 0900 during the HEENT portion of assessment, the patient says they usually use hearing aids, but none are in their ears. Which documentation best follows the section?

    1. Neuro-muscular: hearing aid status documented with gait and extremity strength
    2. Ears: no hearing documentation needed if the patient answers questions verbally
    3. General survey: possible communication issue noted; omit ear-specific hearing aid status
    4. Ears: document hearing loss or difficulty and whether hearing aids are worn or with the patient

    Answer: Ears: document hearing loss or difficulty and whether hearing aids are worn or with the patient

    The HEENT ear assessment includes hearing difficulty and whether hearing aids are being worn or are with the patient. The other entries either omit the ear-specific documentation or place it in the wrong assessment area.

14. At 1000, you are completing the safety/surroundings documentation for a hospitalized medical-surgical patient. Which risks or observations belong in this assessment? Select all that apply.

    1. Fall risk
    2. Domestic and family violence risk or suicidal ideation
    3. Use of ambulatory aids
    4. Bowel sounds and stool
    5. Environmental concerns in the room
    6. Pupils equal, round, reactive to light and accommodation

    Answer: Fall risk, Domestic and family violence risk or suicidal ideation, Use of ambulatory aids, Environmental concerns in the room

    The safety/surroundings assessment includes fall risk, ambulatory aids, environmental concerns, violence risk, and suicidal ideation. Bowel sounds and stool are abdominal assessment items, and PERRLA belongs in HEENT.

15. At 1300, the patient’s stated reason for seeking care is a sore throat. You need to document the assessment most aligned with a focused assessment. Which entry is best?

    1. Bedside assessment: all major body systems documented because focused assessments do not begin with the complaint
    2. Comprehensive health history only: past medical, family, medication, allergy, and lifestyle history documented without physical findings
    3. Focused assessment: HEENT findings documented because the exam is centered on the sore-throat complaint
    4. Safety/surroundings assessment: bed position, side rails, and call bell documented as the assessment for the sore throat

    Answer: Focused assessment: HEENT findings documented because the exam is centered on the sore-throat complaint

    A focused assessment centers the exam on the patient’s chief complaint, and the section specifically connects sore throat with HEENT. The other options describe broader or different assessment types rather than the focused documentation for this complaint.