NR-224 Fundamentals – Skills - Set 1 - Part 1

Correct Answer: "I should quote the client's own words about the symptom."

Subjective data are recorded as a direct quotation wherever the exact wording carries meaning. Chest pain and a description of an elephant sitting on the chest are not the same picture, and quoting preserves the difference. Option b is incorrect because translating a description into a diagnostic term interprets it before anyone has analyzed the data. Writing palpitations in place of what the client said has already decided what the symptom is. Option c is incorrect because an impression is the nurse's inference, and the record needs the cue instead. Charting what someone probably meant introduces a judgment that a later reader cannot separate from the client's actual words. Option d is incorrect because unmeasurable reports are often the only route to a problem. No instrument detects nausea or itching, so discarding what cannot be verified would erase much of the health history.

Correct Answer: Have the assistive personnel enter them before leaving

Staff document only the care they personally performed, and every entry made under a login is legally attributed to the owner of that login. The person who took the measurements enters them and signs for them. Option a is incorrect because adding a note about who obtained the readings does not repair the attribution problem. The nurse would be signing for measurements never seen, and any error in them would belong to the nurse. Option b is incorrect because typing under a colleague's name is impersonation within the record system, and the audit trail will still show the nurse's session. Credentials are never shared or borrowed for any reason. Option d is incorrect because measurements parked on paper are invisible to everyone reading the chart, including the nurse who takes over tonight. Delaying the entry leaves a gap that an auditor reads as vital signs never taken.

Correct Answer: Analyzing cues to determine their meaning

Analyzing cues assigns meaning to findings that have already been sorted as relevant and links them to a likely condition. Naming atelectasis as the explanation for the cluster is precisely that interpretive step. Option a is incorrect because recognizing cues is the sorting move that decides which findings matter, such as noticing that the saturation has fallen below baseline. Sorting stops short of saying what the change means. Option b is incorrect because generating solutions comes later, once the problem is ranked, and produces desired outcomes and candidate interventions such as upright positioning and incentive spirometry. No intervention has been proposed here. Option c is incorrect because evaluating outcomes requires an action to have been taken and a target to compare against. This nurse has only reached an explanation, and nothing has yet been done or measured.

Correct Answer: Record the client's exact words in quotation marks

The reason for seeking care is recorded in the client's own words inside quotation marks. Fluttering with near fainting is a fuller clinical picture than palpitations, and quoting keeps the nurse's interpretation out of the record. Option a is incorrect because translating the account into terminology discards information. Palpitations covers a fluttering, a pounding and a skipped beat equally, and the words the client chose carry detail the label throws away. Option b is incorrect because an interpretation is an inference, not data. Charting what the nurse concluded rather than what the client said puts a judgement into the one section of the history that must stay verbatim. Option d is incorrect because diagnosing is outside the scope of this entry and may simply be wrong. A recorded diagnosis then follows the client through the chart, and everyone downstream treats it as established fact.

Correct Answer: An opinion that the daughter is impossible to please

Personal judgments about a client or family have no place in hand-off, and at the bedside the client and family can hear them. The receiving nurse needs the facts about the family's concerns and what was done about them. Option b is incorrect because wound dimensions are objective data the oncoming nurse will compare against tonight's dressing change. Handing over a measurement is exactly what a hand-off should carry, so nothing needs redirecting. Option c is incorrect because code status and fall risk sit near the top of the required content list. Safety information and resuscitation preferences must transfer with accountability, and omitting either would be the real error. Option d is incorrect because medications given and their effect are standard hand-off content, especially for as-needed doses. Without it the oncoming nurse cannot judge when the next dose is due or whether the current regimen is working.

Correct Answer: Go to the room and assess the client

Assistive personnel may report what they observed, but interpreting a change in condition and assessing the client belong to the nurse. A new episode of exertional dyspnea requires the nurse's own evaluation at the bedside. Option a is incorrect because charting the event preserves a record without anyone examining the client. Documentation follows assessment, and delegating the write-up leaves an unexplained change in condition unaddressed at the moment it matters. Option b is incorrect because one delegated number cannot substitute for a nursing evaluation of respiratory effort, breath sounds, color and level of consciousness. A saturation is useful data, gathered as part of the nurse's own assessment. Option c is incorrect because restricting activity treats a symptom whose cause is still unknown and may hide worsening cardiac or pulmonary function. Activity limits are also a change in the plan, which the nurse decides.

Correct Answer: Overall appearance, behaviour, posture, gait and hygiene

The general survey is the nurse's overall impression formed on first contact. It captures appearance and behaviour, body build and posture, gait and movement, hygiene and grooming, speech, mood and any obvious distress, plus vital signs and measurements. Option a is incorrect because those findings come from a focused abdominal examination performed with the client positioned and draped. None of them can be gathered while a client walks down a corridor. Option b is incorrect because laboratory results are objective data from a secondary source, retrieved from the record rather than observed. They may explain a survey finding later, but they are not part of it. Option d is incorrect because auscultated sounds and palpated pulses require a stethoscope, the nurse's fingertips and a quiet room. The general survey precedes that hands-on examination and relies on what the eye takes in.

Correct Answer: Respiratory rate rising with shallow chest movement

A rising respiratory rate with shallow movement points to a breathing problem, and breathing outranks every other finding here. The pattern fits splinting from incisional pain, which can progress to collapsed alveoli and falling oxygenation. Option b is incorrect because sluggish bowel sounds are expected the day after bowel surgery, when peristalsis has not yet returned. The finding is worth tracking across the next several shifts but demands nothing right now. Option c is incorrect because moderate incisional pain on the first postoperative day is an expected response that ordered analgesia addresses. Pain still matters, and treating it supports deeper breathing, yet it is not the most urgent finding. Option d is incorrect because clear yellow urine in adequate amounts describes normal renal perfusion and normal elimination. Nothing about this finding is unexpected, so the nurse records it and moves on to the abnormal data.

Correct Answer: "I will use a heating pad over the patch."

Heat over a transdermal patch increases absorption and can deliver far more drug than intended, which is dangerous with an analgesic. The client needs to keep heating pads, hot baths and direct sun away from the site. Option a is incorrect because removing the old patch first is exactly right. An overlooked patch left in place is a classic cause of double dosing, so this statement shows the client understood a key safety step. Option b is incorrect because labeling the patch with the date and time is standard practice. The marking tells anyone who looks when the patch went on and when it is due to come off. Option c is incorrect because site rotation is taught with every patch prescription. Moving to a new area of clean, dry, hairless skin each time protects against irritation and breakdown under the adhesive.

Correct Answer: Contact the prescriber to have the order rewritten

Each of these appears on the prohibited list because it has caused tenfold and wrong-frequency errors. The nurse does not translate an unsafe order; the prescriber rewrites it so the record itself carries the unambiguous version. Option b is incorrect because rewriting someone else's order is interpretation, and the nurse may guess wrong about whether the frequency meant daily or four times a day. The original ambiguous order also stays in the record. Option c is incorrect because insulin is a high-alert drug and the dose itself is in doubt. A trailing zero read without its decimal point turns the ordered amount into ten times as much. Option d is incorrect because no colleague can supply what the prescriber intended. Passing the question sideways adds a person to the chain without resolving the ambiguity, and the nurse who administers the dose still carries responsibility for it.

Correct Answer: The right circumstance for this client

Right circumstance asks whether the client is stable and the outcome predictable. A client who deteriorated overnight fails that test, so the measurement becomes part of the nurse's ongoing assessment and cannot be handed to assistive personnel. Option a is incorrect because right task addresses whether the activity itself is delegatable and appears in the delegatee's job description. Measuring vital signs qualifies; the problem in this scenario lies with the client's condition instead. Option b is incorrect because right person points at the delegatee, asking whether this worker has the training and demonstrated competence for the task. Nothing in the situation suggests the assistive personnel lacked skill. Option d is incorrect because supervision and evaluation cover what happens after the handover, meaning checking back, reviewing data and giving feedback. The decision went wrong before any of that, at the moment the task was assigned.

Correct Answer: "You sound frightened. Tell me what worries you most."

Reflecting the feeling and then probing with an open invitation names what the client is experiencing and opens the actual content of the fear, which may be pain, anaesthesia, or who will care for the family. Option b is incorrect because false reassurance answers a feeling with a statistic. It comforts the nurse rather than the client, and it closes the topic before anything useful about the fear is said. Option c is incorrect because why questions demand justification. The client now has to defend being afraid instead of describing the fear, and the word routine minimises an experience that feels anything but routine. Option d is incorrect because turning to paperwork changes the subject. Consent verification is a legitimate task at another moment, but here it signals that the disclosure just made does not interest the nurse.

Correct Answer: Assess the client and check the blood glucose

The client comes before the paperwork and the phone call. A rapid-acting insulin can drop the glucose quickly, so the nurse goes to the bedside, evaluates the client's status, and obtains a blood glucose to guide everything that follows. Option a is incorrect because notification is the step that follows assessment, not the one that precedes it. The prescriber will ask for the current glucose and the client's condition, and the nurse cannot answer without looking. Option b is incorrect because the occurrence report belongs at the very end of the sequence, after the client is safe and the provider has been told. Filing a form does nothing for a falling blood glucose. Option c is incorrect because charting records what already happened and protects no one right now. Documentation of the drug given, the findings and the notifications is required, but it waits until the client has been evaluated and treated.

Correct Answer: Assessment, where data are collected and validated

Assessment is the deliberate, systematic collection of data along with its validation, and it happens before any problem is named. Listening, counting and reading the record all gather the information that the later steps require. Option a is incorrect because diagnosis begins after the data exist, when the nurse clusters findings and names the client's response. The stem states plainly that no problem has been identified yet. Option b is incorrect because planning sets priorities, writes measurable outcomes with the client and selects interventions. None of that can occur until the data have produced a named problem. Option d is incorrect because evaluation compares a client's actual response with an expected outcome that was written earlier. Without a plan in place there is no expected outcome to serve as the comparison.

Correct Answer: Evaluation, because the outcome is judged

Rechecking pain after giving the analgesic measures the client's actual response against the expected outcome, which is evaluation. The physical act resembles assessment, but the purpose is to judge whether the intervention worked. Option a is incorrect because assessment gathers data before a problem has been named, building the database the diagnosis rests on. Here the problem was already identified and treated, so the purpose of the visit differs. Option b is incorrect because diagnosis is the analysis that clusters findings and names the client's response, such as acute pain. That naming happened before the analgesic was given rather than afterward. Option c is incorrect because implementation covers the act of giving the medication itself, which the nurse had already completed. Returning to the room to check the result belongs to the step that follows.

Correct Answer: "I notice you are holding your side. Tell me about that."

Sharing the observation and inviting the client to explain it checks the nurse's tentative interpretation against the primary source. The conflict between the denial and the guarding is itself a finding that must be resolved before planning. Option a is incorrect because telling the client what the client is feeling replaces the report rather than confirming it. The wording also invites a defensive yes or no instead of an explanation. Option b is incorrect because contacting the surgeon acts on an unconfirmed interpretation. The nurse has two data sets that disagree, and the gap belongs to the client to explain before anyone else is called. Option d is incorrect because a generalization about most people gathers nothing from this client and can imply that the denial is being doubted. Validation asks about the specific behavior the nurse actually saw.

Correct Answer: Assess the respiratory rate and oxygen saturation

Restlessness in a client with a respiratory problem is treated as hypoxia until proven otherwise, because hypoxia and anxiety look almost identical. Checking respiratory rate and saturation tests the dangerous explanation before any comfort measure is chosen. Option a is incorrect because dimming the lights acts on an inference the nurse has not yet checked. Comfort measures are reasonable once oxygenation has been ruled out, and premature reassurance can delay recognition of a falling saturation. Option c is incorrect because sedating a client whose oxygenation is unknown can blunt respiratory drive and deepen the very problem causing the restlessness. Medication is never the first response to an unexplained change in behavior. Option d is incorrect because family presence supports a client but collects no data about the change. The spouse has already supplied the useful cue, which is that this behavior differs from the client's baseline.

Correct Answer: Coarse crackles noted in the lower lobes

Crackles are heard by the nurse through a stethoscope, which makes them a measurable observation any second listener could confirm. Sounds perceived by the examiner are objective, while the other entries are all client reports. Option b is incorrect because breathlessness is a sensation the client alone experiences. No instrument detects it, so the nurse can chart only what the client says about it, and that makes the entry subjective. Option c is incorrect because a description of how the chest feels comes from the client's own perception. Quality words such as constant and dull belong to the symptom the client reports rather than to any measurement. Option d is incorrect because fatigue cannot be seen, counted or verified by another observer. It ranks with nausea and dizziness as an experience the client must supply, so it is filed as subjective.

Correct Answer: Verifying the order and product without any prompting

An independent double check means the second nurse works from the original order and the product in hand, reaching her own conclusion before the two compare answers. Prompting from the first nurse turns the check into confirmation bias. Option a is incorrect because agreeing with a number someone has already announced is the failure the word independent was chosen to prevent. Hearing the answer first steers the second nurse toward it rather than away from an error. Option b is incorrect because observing a colleague program the pump verifies only that the keystrokes matched what she believed. If the first nurse read the concentration wrong, a spectator repeats that mistake instead of catching it. Option c is incorrect because a signature documents that a check occurred; it is not the check. Heparin sits on the high-alert list precisely because a paperwork gesture will not stop a bleeding event.

Correct Answer: The spouse present at the bedside

Family become the primary source when the client cannot give a history, as with an intubated adult. The spouse now supplies the account the client would otherwise give, and the nurse verifies details against the record. Option b is incorrect because a transfer note is written by another clinician and belongs among the secondary sources. It tells the nurse what was found earlier and still has to be checked at the bedside. Option c is incorrect because a written list is a document rather than a person who can be questioned. Useful as it is, a list cannot describe symptoms, adherence or the reason a drug was stopped. Option d is incorrect because an intubated client has no way to give a history, which is the one condition that shifts the primary role to family. Ability to communicate, not preference, decides the question.