Nursing Process

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Sample questions from Nursing Process

This material has 90 questions with answers and rationales. Here are the first 5.

1. 1.At change of shift on a medical-surgical unit, a 72-year-old client admitted with pneumonia has new confusion and increasing oxygen needs. Refer to the client's chart. Which actions should the nurse take first? Select all that apply.

   • A.Reassess respiratory status and oxygen saturation immediately.
   • B.Document the change and reassess at the end of the shift.
   • C.Obtain a focused set of vital signs and assess mental status.
   • D.Notify the provider after gathering the immediate assessment findings.
   • E.Ask the unlicensed assistive personnel to assess breath sounds.

   Rationale: The change in mentation and oxygen need requires immediate reassessment of oxygenation, respiratory status, vital signs, and mental status. The nurse must assess the client rather than delegate breath-sound assessment, which requires nursing judgment. After gathering urgent findings, notifying the provider supports timely intervention; waiting until the end of the shift delays care.

2. 2.In a long-term care facility, an RN is assigning care for four clients at the start of the day shift. Which task is appropriate to delegate to an experienced unlicensed assistive personnel (UAP)?

   • A.Assess a new resident's swallowing ability before breakfast.
   • B.Obtain routine vital signs for a stable resident awaiting discharge.
   • C.Teach a resident how to use a walker after hip surgery.
   • D.Evaluate whether a newly prescribed analgesic relieved pain.

   Rationale: Routine vital signs for a stable resident are predictable data-gathering tasks that can be delegated to trained UAP, with the RN responsible for interpreting abnormal results. Swallowing assessment, evaluation of medication response, and teaching require nursing judgment and cannot be delegated. The RN should communicate parameters for reporting findings.

3. 3.A client states, "I do not understand why I need this operation," while completing a consent form in the preoperative area. The client is alert and has received no sedative. What should the nurse do?

   • A.Pause the process and notify the surgeon that the client needs further explanation.
   • B.Ask the client's spouse to sign because the client is uncertain.
   • C.Explain the risks and benefits of the operation and obtain the signature.
   • D.Document that the client is refusing surgery and prepare for discharge.

   Rationale: The surgeon or other provider performing the procedure is responsible for explaining its risks, benefits, and alternatives. The nurse should stop the consent process and notify the provider when the client indicates inadequate understanding. The nurse may witness the signature but should not provide the procedural disclosure or have a capable client's spouse sign.

4. 4.During rounds in an emergency department, a charge nurse must assign a client to a newly licensed RN. Which client is the most appropriate assignment?

   • A.A client receiving a titrated intravenous vasopressor infusion.
   • B.A client with chest pain whose blood pressure is falling.
   • C.A client with a new tracheostomy who has noisy respirations.
   • D.A client with a stable ankle sprain awaiting discharge instructions.

   Answer and rationale are in the full material.

5. 5.On a surgical unit, a 58-year-old client receiving postoperative opioids becomes difficult to arouse. Refer to the client's chart. Which nursing action has priority?

   • A.Document the sedation score and continue the current infusion.
   • B.Administer the next scheduled dose with food to prevent nausea.
   • C.Stop the opioid infusion and assess airway, breathing, and oxygenation.
   • D.Ask the UAP to return in 30 minutes to check the client.

   Answer and rationale are in the full material.