Nursing Process 1 — Questions and Answers
Question 1: A nurse is admitting a client with pneumonia. The client has crackles in the right lower lobe, oxygen saturation of 91%, and a respiratory rate of 26 breaths/min. Which nursing diagnosis has the highest priority?
- Activity intolerance related to fatigue
- Impaired gas exchange related to alveolar inflammation (Correct answer)
- Deficient knowledge related to antibiotic therapy
- Anxiety related to hospitalization
Correct answer: Impaired gas exchange related to alveolar inflammation
Impaired gas exchange addresses an immediate physiological threat to life (SpO2 91%, RR 26). Using Maslow's hierarchy, oxygenation is the most fundamental physiological need. It must be addressed before activity, knowledge, or psychosocial concerns.
Question 2: During the assessment phase of the nursing process, the nurse obtains subjective data. Which is an example of subjective data?
- The client's blood pressure is 158/96 mmHg
- The client has pitting edema of 2+ in both ankles
- The client states, 'My chest feels tight and I am short of breath' (Correct answer)
- The client's respiratory rate is 22 breaths per minute
Correct answer: The client states, 'My chest feels tight and I am short of breath'
Subjective data is information reported by the client that cannot be directly observed or measured by others — symptoms such as pain, shortness of breath, and nausea. Objective data includes measurable, observable findings such as vital signs, lab values, and physical exam findings.
Question 3: A nurse has identified the nursing diagnosis 'Risk for infection related to impaired skin integrity.' In the planning phase, which outcome is written correctly using SMART criteria?
- The client will understand wound care before discharge
- The client will remain free of signs of wound infection as evidenced by no erythema, edema, or purulent drainage by day 3 (Correct answer)
- The nurse will change the wound dressing every day
- The client will have a better wound by the end of the week
Correct answer: The client will remain free of signs of wound infection as evidenced by no erythema, edema, or purulent drainage by day 3
A correctly written SMART nursing outcome is Specific, Measurable, Achievable, Relevant, and Time-bound. 'Free of signs of infection as evidenced by no erythema, edema, or purulent drainage by day 3' includes observable criteria and a timeline. Nurse-focused statements are not appropriate client outcomes.
Question 4: A nurse implements a turning schedule for a client with limited mobility. During evaluation, the nurse notes a new stage 2 pressure ulcer on the client's sacrum. What is the nurse's next action?
- Continue the current care plan because pressure ulcers can develop despite good care
- Document the finding and reassess the client at the next scheduled evaluation
- Revise the care plan to increase repositioning frequency and add a pressure-relief mattress (Correct answer)
- Discharge the client to a long-term care facility for wound management
Correct answer: Revise the care plan to increase repositioning frequency and add a pressure-relief mattress
Evaluation determines whether the care plan is effective. When a client develops a new complication despite existing interventions, the nurse must revise the plan of care. Increasing repositioning frequency and adding pressure-relief devices are evidence-based modifications.
Question 5: A nurse is collecting data on a newly admitted client. Which action is part of the assessment phase of the nursing process?
- Setting a goal that the client will ambulate 50 feet three times daily
- Administering prescribed antibiotics for a confirmed urinary tract infection
- Auscultating lung sounds and reviewing recent laboratory results (Correct answer)
- Teaching the client how to use an incentive spirometer postoperatively
Correct answer: Auscultating lung sounds and reviewing recent laboratory results
Assessment is the first step of the nursing process and involves systematic collection of subjective and objective data through physical examination, interview, and review of records. Planning, implementation (medication administration, teaching), and evaluation are subsequent steps.
Question 6: A nurse writes the following nursing diagnosis: 'Impaired physical mobility related to left hip pain as evidenced by inability to bear weight and refusal to ambulate.' Which part of this statement represents the defining characteristics?
- Impaired physical mobility
- Related to left hip pain
- Inability to bear weight and refusal to ambulate (Correct answer)
- The entire three-part PES statement
Correct answer: Inability to bear weight and refusal to ambulate
In a three-part nursing diagnosis (PES format), the Problem is the diagnosis label, the Etiology is introduced by 'related to,' and the Signs and Symptoms (defining characteristics) follow 'as evidenced by.' Defining characteristics are the observable data that validate the diagnosis.
Nursing Process 1
A nurse is admitting a client with pneumonia.
The client has crackles in the right lower lobe, oxygen saturation of 91%, and a respiratory rate of 26 breaths/min.
Which nursing diagnosis has the highest priority?