A nurse meets a newly admitted patient, asks about symptoms, reviews the medical record and listens to heart and lung sounds. Which step of the nursing process is the nurse performing?
Assessment
✓
Diagnosis
Planning
Implementation
Correct Answer
Assessment
Assessment is gathering data from the patient, family, records and physical examination. Diagnosis comes next, when the nurse analyzes the data to name problems. Planning sets outcomes and goals for those problems. Implementation carries out the planned interventions.
Category: Nursing Process Steps
Question 2
A nurse gives prescribed antibiotics, changes a surgical dressing and teaches the patient how to care for the wound at home. Which cognitive skill of the Clinical Judgment Measurement Model is the nurse using?
Recognize cues
Take action
✓
Prioritize hypotheses
Evaluate outcomes
Correct Answer
Take action
Taking action means carrying out interventions, which can include treatments, further assessment, monitoring and teaching. Recognizing cues is collecting and identifying relevant data. Prioritizing hypotheses is deciding which possible explanations are most likely and most urgent. Evaluating outcomes compares the patient's response with the expected results.
Category: Taking Action
Question 3
After giving a prescribed pain medication, the nurse returns to ask whether the patient's pain has eased as planned. Which step of the nursing process is this?
Diagnosis
Planning
Evaluation
✓
Implementation
Correct Answer
Evaluation
Evaluation determines whether actions worked and whether the expected outcome was met, and it may lead to changes in the plan. Diagnosis identifies the patient's problems from the data. Planning sets the outcomes and chooses interventions. Implementation is giving the medication itself, which happened before this check.
Category: Nursing Process Steps
Question 4
Which of these is a nursing diagnosis rather than a medical diagnosis?
Hypertension
Myocardial infarction
Pneumonia
Decreased activity tolerance
✓
Correct Answer
Decreased activity tolerance
A nursing diagnosis names the patient's response to a health problem, such as decreased activity tolerance in a patient with heart disease. Hypertension is a medical diagnosis of a disease. Myocardial infarction is a medical diagnosis made by the provider. Pneumonia is also a medical diagnosis of a specific disease.
Category: Nursing Process Steps
Question 5
Which finding is objective data?
Crackles heard in both lung bases
✓
The patient states feeling nauseated
The patient reports feeling anxious
The spouse says the patient was confused last night
Correct Answer
Crackles heard in both lung bases
Objective data are measurable or observable findings from the physical exam or tests, such as lung sounds the nurse hears. A patient stating nausea is a subjective report of a symptom. A patient reporting anxiety describes a feeling, which is subjective. A spouse's account of confusion is also subjective because it is a report rather than the nurse's own observation.
Category: Recognizing Cues
Question 6
Which organization developed the Clinical Judgment Measurement Model?
American Nurses Association
National Council of State Boards of Nursing
✓
The Joint Commission
World Health Organization
Correct Answer
National Council of State Boards of Nursing
The National Council of State Boards of Nursing created the model to teach and measure clinical judgment, and it shapes question types on the licensing exam. The American Nurses Association is a professional organization that sets standards of practice. The Joint Commission accredits health-care organizations. The World Health Organization directs international public health.
Category: Clinical Judgment Model
Question 7
A nurse identifies the expected outcomes for a patient and decides on a set of interventions that could achieve them. Which cognitive skill of the Clinical Judgment Measurement Model is this?
Analyze cues
Recognize cues
Generate solutions
✓
Evaluate outcomes
Correct Answer
Generate solutions
Generating solutions means identifying expected outcomes and planning the interventions that could reach them, based on the priority hypothesis. Analyzing cues links data to the patient's history and condition. Recognizing cues identifies which data are relevant. Evaluating outcomes compares the actual response with the expected one after actions are taken.
Category: Prioritizing and Planning
Question 8
A few days after knee replacement surgery, a patient's incision is red, warm and tender. The nurse also sees a new order to advance the patient's diet. Which action should the nurse take first?
Call dietary services about the new diet
Teach the patient about home exercises
Update the patient's activity schedule
Notify the provider about the incision findings
✓
Correct Answer
Notify the provider about the incision findings
Redness, warmth and tenderness at the incision suggest infection, which can become severe and life-threatening, so it is addressed before routine tasks. Calling dietary services about the new diet is needed but can wait. Teaching the patient about home exercises is a lower priority than a possible infection. Updating the activity schedule is routine and does not address the urgent cue.
Category: Prioritizing and Planning
Question 9
While eating lunch, a patient suddenly develops facial droop, slurred speech and arm weakness. Which nursing action protects the patient from aspiration?
Withhold all food and fluids until swallowing is checked
✓
Offer thickened liquids to ease swallowing
Encourage the patient to finish the meal slowly
Give small sips of water to clear the mouth
Correct Answer
Withhold all food and fluids until swallowing is checked
Sudden stroke signs can impair swallowing, so withholding all food and fluids prevents aspiration until a swallow screen is done, while the nurse completes a neurologic assessment and activates stroke responders. Offering thickened liquids still puts material in the mouth before swallowing is known to be safe. Encouraging the patient to finish the meal raises the aspiration risk. Giving sips of water is unsafe because thin liquids are the easiest to aspirate.
Category: Taking Action
Question 10
Which goal is a short-term goal?
The patient completes cardiac rehabilitation after discharge
The patient demonstrates a blood glucose check before discharge
✓
The patient's chronic wound heals over the coming months
The patient maintains a healthy weight in the years ahead
Correct Answer
The patient demonstrates a blood glucose check before discharge
Short-term goals are reached over a short period, often before discharge, and let the nurse evaluate a new treatment or skill. Completing cardiac rehabilitation after discharge is a long-term goal. Healing a chronic wound over months is long-term. Maintaining a healthy weight in the years ahead is also a long-term goal focused on quality of life.
Category: Prioritizing and Planning
Question 11
Which outcome statement is written in SMART form?
The patient will feel better soon
The patient will understand diabetes
The patient will walk to the nurses' station and back with a walker before discharge
✓
The patient will improve mobility
Correct Answer
The patient will walk to the nurses' station and back with a walker before discharge
A SMART outcome is specific, measurable, attainable, relevant and timely, and walking a set distance with a walker before discharge meets all of these. Feeling better soon is vague and cannot be measured. Understanding diabetes does not state an observable behavior. Improving mobility names no specific measure or time frame.
Category: Prioritizing and Planning
Question 12
After a patient's first physical therapy session following knee replacement, which outcome is realistic?
Walking the full hallway unassisted
Climbing a flight of stairs alone
Returning to jogging outdoors
Walking a few steps with assistance
✓
Correct Answer
Walking a few steps with assistance
Realistic outcomes are reasonable and attainable for this patient at this point, and a few assisted steps fits early recovery. Walking the full hallway unassisted is too much after one session. Climbing a flight of stairs alone is far beyond early recovery. Returning to jogging is a goal for much later, if at all.
Category: Prioritizing and Planning
Question 13
A patient with type 2 diabetes says the medication is taken faithfully, yet blood glucose stays high and the patient avoids talking about meals. What should the nurse explore next?
The patient's eating patterns and diabetes knowledge
✓
The patient's preferred sleeping position
The blood types of family members
The brand of glucose meter the patient owns
Correct Answer
The patient's eating patterns and diabetes knowledge
Reluctance to discuss diet and high glucose despite reported adherence are cues that medication is not the whole story, so the nurse gathers more data on meals and understanding of diabetes care. The patient's preferred sleeping position does not explain the glucose readings. The blood types of family members have no bearing on glucose control. The brand of glucose meter does not address the likely gap in knowledge and eating habits.
Category: Analyzing Cues
Question 14
A nurse notes that a patient with heart failure has increasing shortness of breath and new leg swelling and concludes that the heart failure is worsening. What is this conclusion called?
Cue
Inference
✓
Outcome
Intervention
Correct Answer
Inference
An inference is a conclusion drawn from significant clues in the data. The shortness of breath and leg swelling themselves are the cues. An outcome is the desired result of a plan of care. An intervention is an action the nurse takes in response.
Category: Analyzing Cues
Question 15
Which item is an individual factor related to the nurse in the Clinical Judgment Measurement Model?
The unit's staffing levels
The equipment available on the unit
The nurse's level of experience
✓
The patient's insurance coverage
Correct Answer
The nurse's level of experience
Individual factors are characteristics of the nurse, such as specialty, knowledge, skills, attitudes, experience and cognitive load. The unit's staffing levels are an environmental resource factor. The equipment available on the unit is also an environmental factor. The patient's insurance coverage is not a characteristic of the nurse, so it is not an individual factor.
Category: Clinical Judgment Model
Question 16
During an admission interview, which statement by the patient is a cue the nurse should explore further?
I like to read before bed
I prefer the window shade open
My favorite food is pasta
My father had a heart attack at a young age
✓
Correct Answer
My father had a heart attack at a young age
Cues include subtle details such as a family history of disease, which can signal risk and shape assessment and teaching. Liking to read before bed is a routine preference. Preferring the window shade open is a comfort preference with no health concern attached. A favorite food is ordinary information unless it relates to a diet problem.
Category: Recognizing Cues
Question 17
A patient's pain remains severe after the prescribed medication and repositioning. What should the nurse do next?
Revise the plan of care with the provider
✓
Continue the current plan without changes
Stop all pain interventions
Record the pain goal as met
Correct Answer
Revise the plan of care with the provider
When interventions are not fully effective, the plan must be revised, for example by advocating for a medication change or adding other nondrug measures. Continuing the current plan without changes leaves the pain uncontrolled. Stopping all pain interventions abandons the problem. Recording the goal as met would be inaccurate.
Category: Evaluating Outcomes
Question 18
The morning after cataract surgery, a patient is unusually quiet, reports pressure in the operated eye and keeps it closed. The eye is redder and more swollen than expected. What should the nurse do?
Reassure the patient that this is expected
Notify the ophthalmologist of the findings
✓
Advise the patient to wait and recheck later
Apply a warm compress and continue routine care
Correct Answer
Notify the ophthalmologist of the findings
Increased redness, swelling and pressure beyond the expected course suggest a complication such as infection or increased eye pressure, so the surgeon must be told promptly. Reassuring the patient that this is expected ignores abnormal cues. Advising the patient to wait delays treatment of a possible complication. Applying a warm compress and continuing routine care does not address the underlying problem.
Category: Taking Action
Question 19
A nurse lists possible explanations for a patient's new confusion and ranks them by how likely and how urgent each one is. Which cognitive skill of the Clinical Judgment Measurement Model is the nurse using?
Recognize cues
Take action
Prioritize hypotheses
✓
Evaluate outcomes
Correct Answer
Prioritize hypotheses
Prioritizing hypotheses means weighing the possible explanations for the cues and ranking them by likelihood, seriousness and urgency so the most pressing one is addressed first. Recognizing cues is gathering data and spotting what is relevant, which comes earlier. Taking action carries out interventions once a plan is set. Evaluating outcomes compares the patient's response with the expected results afterward.
Category: Clinical Judgment Model
Question 20
A nurse is caring for several patients on a surgical unit. Which finding should the nurse follow up on first?
Stable chronic knee pain in a patient with arthritis
A request for an extra blanket
A question about the visitor policy
New confusion in a patient the day after surgery
✓
Correct Answer
New confusion in a patient the day after surgery
A sudden change in mental status after surgery is an acute finding that may signal a serious complication such as low oxygen or infection, and acute problems come before chronic, stable ones. Stable chronic knee pain is ongoing and expected. A request for an extra blanket is a comfort need. A question about the visitor policy can be answered after urgent needs are met.
Category: Prioritizing and Planning