I85PREP
⌘ K
UNB IDR Entrance study materials
UNB IDR Entrance study resources

UNB IDR Entrance practice questions

One question at a time. Build your UNB IDR Entrance understanding.

First 50 of 200 questions. Each one lists the choices, the correct answer, and an explanation. The checker at the top of this page saves progress in this browser when it is available.

Continue in the practice tool above to load more questions, 50 at a time.

Question 1Professional Practice, Ethics, and Legal Responsibilities

Under Canadian privacy law, what is the primary obligation of a regulated health professional when collecting a client's personal health information?

  1. Collect only the information reasonably necessary for the stated purpose Correct answer.
  2. Delegate collection decisions entirely to administrative staff
  3. Obtain a court order before any collection occurs
  4. Collect all available information in case it becomes useful later

Explanation

Privacy statutes require that collection of personal health information be limited to what is reasonably necessary for a purpose the client has been told about. Broad or speculative collection exceeds that authority and breaches the principle of data minimization.

Question 2Professional Practice, Ethics, and Legal Responsibilities

A client tells an interpreter, in confidence, about a plan to harm a specific named person. What is the most appropriate professional response?

  1. Record the disclosure and take no further action until a court orders it
  2. Ask the interpreter to keep the information secret from the care team
  3. Warn the identifiable third party and appropriate authorities as permitted by law Correct answer.
  4. Maintain confidentiality absolutely because the interpreter was told in trust

Explanation

Most Canadian jurisdictions permit or require disclosure where there is a credible risk of serious harm to an identifiable person. The duty to protect the public can override confidentiality in that narrow circumstance.

Question 3Professional Practice, Ethics, and Legal Responsibilities

What does the principle of informed consent require before a client agrees to an assessment procedure?

  1. A signature obtained after the procedure is complete
  2. Consent obtained from the client's employer rather than the client
  3. Disclosure of purpose, risks, benefits, alternatives, and the right to withdraw Correct answer.
  4. Only a verbal statement that the procedure is routine

Explanation

Valid informed consent requires that the client understand the nature, purpose, risks, benefits, and alternatives of the proposed service, and know that consent can be withdrawn. Consent must be obtained before the service, not after.

Question 4Professional Practice, Ethics, and Legal Responsibilities

A practitioner is asked to provide records in response to a subpoena. Which action best reflects professional and legal obligations?

  1. Send the complete file to any person who requested it informally
  2. Destroy the records to protect the client's privacy
  3. Ignore the subpoena because client records are confidential
  4. Verify the subpoena's validity and respond as the law requires while protecting confidentiality Correct answer.

Explanation

A subpoena is a legal demand that must be taken seriously; the practitioner should confirm it is properly issued and comply within legal limits. Confidentiality is preserved by disclosing only what is required and notifying the client where appropriate.

Question 5Professional Practice, Ethics, and Legal Responsibilities

Which statement best describes a regulated health professional's scope of practice?

  1. It is defined by legislation and controlled acts assigned to the profession Correct answer.
  2. It is identical for every health profession in a province
  3. It is set by the individual practitioner's personal training and comfort level
  4. It expands automatically whenever a client requests a new service

Explanation

Scope of practice is established in statute and regulation, which assign controlled acts and reserved titles to each profession. Individual competence determines whether a professional may perform an authorized act, but it does not expand the legal scope.

Question 6Professional Practice, Ethics, and Legal Responsibilities

A practitioner recognizes that a case exceeds their competence. What is the most appropriate ethical course of action?

  1. Refer the client to a qualified professional or consult a supervisor Correct answer.
  2. Proceed anyway to avoid inconveniencing the client
  3. Practise beyond scope but document the uncertainty
  4. Ask the client to sign a waiver releasing the practitioner from liability

Explanation

Professionals must practise within their competence and refer or consult when a matter falls outside it. A liability waiver does not cure the ethical duty to provide competent service.

Question 7Professional Practice, Ethics, and Legal Responsibilities

What is the primary purpose of maintaining professional boundaries with clients?

  1. To ensure the practitioner earns a higher fee
  2. To allow the practitioner to share personal problems with clients
  3. To prevent clients from asking questions about their care
  4. To protect the client from exploitation and preserve the therapeutic relationship Correct answer.

Explanation

Boundaries protect clients, who are in a position of relative vulnerability, from exploitation and confusion about the relationship. They also preserve objectivity and trust essential to professional service.

Question 8Professional Practice, Ethics, and Legal Responsibilities

A practitioner discovers a conflict of interest involving a referral arrangement. What should they do first?

  1. Increase fees to offset any perceived impropriety
  2. Disclose the conflict to the client and relevant parties and manage or avoid it Correct answer.
  3. Conceal the arrangement to avoid reputational harm
  4. Continue the arrangement because referrals benefit clients

Explanation

Conflicts of interest must be disclosed and managed so that client welfare and professional judgment are not compromised. Concealment or profit-driven responses worsen the ethical breach.

Question 9Professional Practice, Ethics, and Legal Responsibilities

Which of the following best reflects the duty of recordkeeping for a regulated professional?

  1. Records must be accurate, timely, and retained for the period required by law Correct answer.
  2. Records should be kept only until the client stops attending
  3. Records belong solely to the practitioner and may be withheld from clients
  4. Records may be altered later to reflect improved outcomes

Explanation

Records must be contemporaneous, accurate, and retained according to statutory retention periods. Altering records retroactively is falsification, and clients generally have a right of access to their own information.

Question 10Professional Practice, Ethics, and Legal Responsibilities

A client lacks decision-making capacity regarding a proposed service. What is the appropriate next step?

  1. Proceed on the practitioner's own judgment without further consultation
  2. Refuse all services permanently until capacity returns
  3. Identify the legally authorized substitute decision-maker and seek consent Correct answer.
  4. Ask another client to consent on the person's behalf

Explanation

Where a client lacks capacity, consent must be obtained from a legally authorized substitute decision-maker, following the applicable consent legislation. Treatment should not proceed on unilateral practitioner judgment alone.

Question 11Professional Practice, Ethics, and Legal Responsibilities

What is the role of a professional regulatory college in relation to public protection?

  1. To provide legal defence for any member accused of misconduct
  2. To set standards, license practitioners, and address complaints to protect the public Correct answer.
  3. To lobby government for lower professional fees
  4. To promote the commercial interests of its members above all else

Explanation

Regulatory colleges exist primarily to protect the public interest by setting entry and practice standards, issuing licences, and investigating complaints. Their mandate is public protection rather than member advocacy.

Question 12Professional Practice, Ethics, and Legal Responsibilities

A practitioner is considering a dual relationship with a current client. Which principle should guide the decision?

  1. Dual relationships are encouraged to strengthen rapport
  2. Dual relationships should be avoided when they risk impairing judgment or exploiting the client Correct answer.
  3. Dual relationships are only problematic if a fee is charged
  4. Dual relationships are acceptable whenever both parties agree

Explanation

Dual relationships are ethically risky because they can compromise objectivity and create power imbalances that enable exploitation. They should be avoided when they create foreseeable harm or impair professional judgment.

Question 13Professional Practice, Ethics, and Legal Responsibilities

Which action best demonstrates cultural humility in professional practice?

  1. Reflecting on one's own biases and adapting practice to the client's context Correct answer.
  2. Assuming all clients from a group share identical beliefs
  3. Avoiding any discussion of culture to remain neutral
  4. Applying one standard approach regardless of cultural context

Explanation

Cultural humility involves ongoing self-reflection about one's biases and a willingness to adapt practice to the client's cultural context. It avoids stereotyping and treats culture as relevant to care.

Question 14Professional Practice, Ethics, and Legal Responsibilities

A practitioner receives a request from a third party for information about a client without the client's consent. What is the appropriate response?

  1. Release only if the request is in writing
  2. Release the information but ask the third party to keep it secret
  3. Decline unless there is legal authority or valid consent to disclose Correct answer.
  4. Release the information because the third party asked politely

Explanation

Disclosure of personal health information requires the client's consent or a legal authority permitting it. The form of the request, written or oral, does not itself create authority to disclose.

Question 15Professional Practice, Ethics, and Legal Responsibilities

What is the professional obligation when a practitioner makes an error that affects a client's care?

  1. Disclose the error honestly to the client and take steps to address harm Correct answer.
  2. Blame the error on another team member
  3. Document the error only if the client notices it
  4. Conceal the error to avoid undermining client confidence

Explanation

Ethical practice requires honest disclosure of errors that affect care, along with appropriate steps to mitigate harm and prevent recurrence. Concealment or blame-shifting breaches the duty of candour and trust.

Question 16Professional Practice, Ethics, and Legal Responsibilities

Which statement about the duty to report impaired practice by a colleague is most accurate?

  1. Impairment is a private matter that never warrants reporting
  2. Reporting should occur only after a client is harmed
  3. Colleagues should cover for an impaired practitioner to protect team morale
  4. An impaired practitioner should be reported through appropriate channels to protect clients Correct answer.

Explanation

Professionals have a duty to protect clients by reporting impaired practice through the appropriate regulatory or workplace channels. Waiting for harm to occur defeats the preventive purpose of the duty.

Question 17Professional Practice, Ethics, and Legal Responsibilities

A practitioner wants to use a client's case details in a public presentation. What is required?

  1. De-identification or explicit consent, with attention to re-identification risk Correct answer.
  2. Nothing, because the case is educational
  3. Approval from the practitioner's employer alone
  4. Only a change of the client's first name

Explanation

Using client information for teaching or publication requires consent or adequate de-identification, taking care that details do not permit re-identification. Superficial changes such as altering a first name are insufficient.

Question 18Professional Practice, Ethics, and Legal Responsibilities

What is the most appropriate way to manage a gift from a client that could influence the professional relationship?

  1. Accept all gifts regardless of value to avoid offending the client
  2. Demand gifts as a sign of client appreciation
  3. Consider the value and context, and decline or discuss gifts that could create obligation Correct answer.
  4. Accept the gift but provide a discount on future services in return

Explanation

Gifts can create feelings of obligation or blur boundaries, so professionals should consider value, cultural meaning, and context. Declining or discussing a problematic gift preserves the integrity of the relationship.

Question 19Professional Practice, Ethics, and Legal Responsibilities

Which of the following best describes the concept of fiduciary duty in a professional relationship?

  1. A duty to act in the client's best interests ahead of the practitioner's own Correct answer.
  2. A duty that applies only when a written contract exists
  3. A duty to maximize the practitioner's income
  4. A duty owed only to the practitioner's employer

Explanation

Fiduciary duty requires the professional to place the client's interests above their own where the client relies on their judgment. It arises from the trust inherent in the relationship, not merely from a contract.

Question 20Professional Practice, Ethics, and Legal Responsibilities

A practitioner is asked to assess a former client in a legal dispute involving the practitioner's own family member. What is the most appropriate response?

  1. Accept but keep the family connection undisclosed
  2. Accept and charge a higher fee to reflect the complexity
  3. Decline due to a conflict of interest and refer to an independent practitioner Correct answer.
  4. Accept the case because the practitioner knows the client well

Explanation

A personal connection to a party in a dispute creates a clear conflict that can compromise objectivity and the appearance of fairness. The appropriate step is to decline and refer to an independent practitioner.

Question 21Professional Practice, Ethics, and Legal Responsibilities

What does the term 'mandatory reporting' most commonly refer to in health and social service practice?

  1. A legal duty to report specified circumstances such as suspected child abuse Correct answer.
  2. Reporting colleague absences to an employer
  3. Reporting fees to a regulatory college annually
  4. Reporting all client appointments to an insurer

Explanation

Mandatory reporting refers to statutory duties to report specified situations, most commonly suspected child abuse or neglect, to designated authorities. It is a legal obligation that can override confidentiality.

Question 22Professional Practice, Ethics, and Legal Responsibilities

A practitioner is asked to provide services in a jurisdiction where they are not licensed. What is the appropriate course of action?

  1. Practise anyway because the client cannot find another provider
  2. Practise under the title of a licensed colleague
  3. Determine licensing requirements and obtain authorization or decline the engagement Correct answer.
  4. Provide services informally without any title or documentation

Explanation

Practising without required licensure is unlawful and can expose clients to harm and the practitioner to serious sanctions. The practitioner should confirm jurisdictional requirements and obtain authorization before providing services.

Question 23Professional Practice, Ethics, and Legal Responsibilities

Which behaviour best reflects the ethical principle of integrity when a practitioner is uncertain about a diagnosis?

  1. Present the uncertainty as the client's responsibility
  2. State the diagnosis confidently to reassure the client
  3. Acknowledge uncertainty, seek consultation, and communicate honestly with the client Correct answer.
  4. Omit the uncertainty from all documentation

Explanation

Integrity requires honesty about the limits of one's knowledge and appropriate consultation to reach a sound conclusion. False confidence and concealment of uncertainty mislead the client and undermine trust.

Question 24Professional Practice, Ethics, and Legal Responsibilities

What is the purpose of obtaining informed consent for the release of client information to a third party?

  1. To ensure the client understands and authorizes the specific disclosure Correct answer.
  2. To allow the practitioner to disclose unlimited future information
  3. To transfer ownership of the record to the third party
  4. To satisfy a requirement that applies only to verbal disclosures

Explanation

Consent for disclosure must be informed and specific, so the client understands what information will be shared, with whom, and for what purpose. Consent to one disclosure does not authorize unlimited future releases.

Question 25Nursing Process and Clinical Decision-Making

A client reports new shortness of breath. Which action represents the assessment step of the nursing process?

  1. Auscultating lung sounds and measuring respiratory rate Correct answer.
  2. Teaching the client pursed-lip breathing
  3. Documenting that the breathing problem is resolved
  4. Administering a prescribed bronchodilator

Explanation

Assessment is the systematic collection of data through observation, interview, and physical examination. Listening to lungs and counting respirations gather the subjective and objective cues that later steps depend on. Interventions and teaching belong to implementation, and judging resolution belongs to evaluation.

Question 26Nursing Process and Clinical Decision-Making

A nurse writes: "Client will ambulate to the bathroom with one assist within 24 hours." Which characteristic of a well-written outcome does this statement best demonstrate?

  1. It describes the nurse's actions
  2. It uses broad, holistic language
  3. It states the medical diagnosis
  4. It is measurable and time-bound Correct answer.

Explanation

A measurable outcome names an observable behavior, the conditions under which it occurs, and a timeframe for achievement. Ambulating to the bathroom with one assist can be observed and is bounded by 24 hours. Nurse-centered actions and medical diagnoses do not describe client outcomes.

Question 27Nursing Process and Clinical Decision-Making

During the planning step, which activity is the nurse's priority?

  1. Collecting a complete health history
  2. Establishing client-centered goals and selecting interventions Correct answer.
  3. Comparing current findings with expected outcomes
  4. Performing the prescribed dressing change

Explanation

Planning involves prioritizing problems, setting goals, and choosing interventions to achieve them. Data collection precedes planning, and comparing findings with outcomes is evaluation. Carrying out a procedure is implementation.

Question 28Nursing Process and Clinical Decision-Making

Which finding is an example of objective data?

  1. The client's statement of feeling dizzy
  2. Heart rate of 112 beats per minute Correct answer.
  3. A family member's description of the client's fatigue
  4. The client's report of pain rated 8 of 10

Explanation

Objective data are observable and measurable findings obtained through examination or monitoring. A recorded heart rate can be verified by another observer. Reports of symptoms and family descriptions are subjective data.

Question 29Nursing Process and Clinical Decision-Making

Which action best illustrates the evaluation step of the nursing process?

  1. Choosing a turning schedule for a bedbound client
  2. Revising the care plan before any intervention begins
  3. Collecting a blood pressure reading on admission
  4. Reviewing whether the client met the goal of independent ambulation Correct answer.

Explanation

Evaluation compares the client's actual status with the expected outcomes set during planning. Determining whether the ambulation goal was met is a direct comparison of results to goals. Revising the plan and choosing schedules are planning activities, and admission vital signs are assessment.

Question 30Nursing Process and Clinical Decision-Making

A nurse uses a standard tool to rate a client's risk of falling. Which step of the nursing process does this represent?

  1. Assessment Correct answer.
  2. Diagnosis
  3. Planning
  4. Implementation

Explanation

Assessment includes the use of validated instruments to gather data about the client's condition. A fall-risk score is data collected to inform later clinical judgments. Diagnosis interprets the data, planning sets goals, and implementation carries out interventions.

Question 31Nursing Process and Clinical Decision-Making

Which statement is a correctly written nursing diagnosis?

  1. Acute pain related to surgical incision as evidenced by guarding Correct answer.
  2. Pneumonia related to bacterial infection
  3. Incision care every shift with sterile technique
  4. Client will report pain below 3 of 10 within one hour

Explanation

A nursing diagnosis has a problem label, an etiology (related to), and defining characteristics (as evidenced by). Acute pain with a surgical etiology and observed guarding fits this structure. Medical diagnoses, interventions, and outcomes use different formats.

Question 32Nursing Process and Clinical Decision-Making

A client is short of breath and cannot speak in full sentences. Which action should the nurse take first?

  1. Schedule a teaching session about inhalers
  2. Prepare discharge paperwork
  3. Obtain a detailed dietary history
  4. Assess the airway and breathing Correct answer.

Explanation

Physiologic needs, especially airway and breathing, take priority over other concerns. A client unable to speak in full sentences shows significant respiratory distress that must be assessed and addressed first. History taking, teaching, and discharge tasks can wait until the client is stable.

Question 33Nursing Process and Clinical Decision-Making

A nurse collects data, identifies a problem, sets a goal, performs an intervention, and then compares results with the goal. Which step comes immediately after comparing results?

  1. Restarting the entire process from assessment
  2. Documenting only the original goal
  3. Modifying the care plan as indicated Correct answer.
  4. Discharging the client

Explanation

The nursing process is cyclic, so evaluation feeds back into planning. When results differ from expected outcomes, the nurse revises the plan or interventions. Restarting from the beginning, limiting documentation, or discharging the client does not follow from the comparison alone.

Question 34Nursing Process and Clinical Decision-Making

A nurse notices a colleague about to give a medication by the wrong route. Which response reflects appropriate clinical decision-making?

  1. Document the incident only if the client reacts
  2. Report the colleague to the manager after the dose is given
  3. Stop the colleague and clarify the order before administration Correct answer.
  4. Say nothing because the colleague is more experienced

Explanation

Client safety requires the nurse to intervene before a known error reaches the client. Verifying the order and route prevents harm and is a professional obligation. Waiting for harm to occur or deferring to experience ignores the duty to protect the client.

Question 35Nursing Process and Clinical Decision-Making

A client with a new colostomy says, "I will never be able to manage this at home." Which nursing diagnosis is most appropriate?

  1. Impaired skin integrity related to stoma output
  2. Risk for infection related to surgical incision
  3. Anxiety related to change in body function as evidenced by expressed inability to cope Correct answer.
  4. Imbalanced nutrition related to decreased appetite

Explanation

The defining cue is the client's expressed inability to cope with a changed body function, which supports an anxiety or coping-related diagnosis. The other options describe risks or problems for which no supporting cues are given. Matching the diagnosis to the actual cue keeps the plan individualized.

Question 36Nursing Process and Clinical Decision-Making

A client is admitted with dehydration and also reports mild anxiety about hospitalization. Which problem should the nurse address first?

  1. The dehydration Correct answer.
  2. Whichever the client prefers
  3. The anxiety
  4. Both equally at the same time

Explanation

Priority setting follows physiologic stability, with actual fluid imbalance threatening circulation and organ function before mild anxiety. Anxiety is important but not immediately life-threatening and can be addressed after stabilization. Client preference informs care but does not override physiologic priorities.

Question 37Nursing Process and Clinical Decision-Making

A nurse delegates vital signs on a stable client to assistive personnel. Which action is most appropriate?

  1. Allow the assistant to decide whether to recheck
  2. Specify what to report and verify the findings Correct answer.
  3. Transfer accountability for the assessment
  4. Delegate the interpretation of abnormal values

Explanation

Delegation transfers tasks, not accountability, so the nurse clarifies expectations and validates reported data. Interpretation of findings and clinical judgments remain with the registered nurse. Accountability for assessment cannot be transferred to assistive personnel.

Question 38Nursing Process and Clinical Decision-Making

A client's blood pressure drops suddenly and the client becomes confused. Which action should the nurse take first?

  1. Continue the current plan and reassess at shift end
  2. Document the finding and recheck in one hour
  3. Ask the client to complete a satisfaction survey
  4. Perform a focused assessment and notify the provider Correct answer.

Explanation

An acute change with mental status alteration signals instability that requires immediate focused assessment and escalation. Early recognition and communication allow timely intervention. Delaying reassessment or continuing an unchanged plan risks deterioration.

Question 39Nursing Process and Clinical Decision-Making

A nurse is uncertain whether a new order is appropriate for the client. What is the best action?

  1. Hold the order indefinitely without notifying anyone
  2. Clarify the order with the prescribing provider Correct answer.
  3. Administer the medication as written without question
  4. Ask another client's family for an opinion

Explanation

When an order is unclear or questionable, the nurse must seek clarification from the prescriber before acting. Administering blindly risks harm, and indefinitely withholding without communication abandons the client. Consultation with the prescriber resolves the uncertainty safely.

Question 40Nursing Process and Clinical Decision-Making

A client reports pain rated 8 of 10 one hour after receiving an analgesic. Which action reflects the evaluation step?

  1. Administering the next scheduled dose early
  2. Documenting the original pain score only
  3. Changing the client's diagnosis without reassessment
  4. Reassessing the pain and comparing it with the expected outcome Correct answer.

Explanation

Evaluation requires reassessing the client and comparing the result with the expected outcome of the intervention. Reassessing pain after analgesia provides the data needed to judge effectiveness. Giving medication early or altering the diagnosis without data bypasses that comparison.

Question 41Nursing Process and Clinical Decision-Making

Which approach best reflects evidence-based clinical decision-making?

  1. Combining best evidence with clinical expertise and client preferences Correct answer.
  2. Relying only on tradition and unit routine
  3. Using the most recent opinion heard in the break room
  4. Applying the same intervention to every client

Explanation

Evidence-based practice integrates current best evidence, clinician expertise, and the client's values and preferences. Relying on tradition, informal opinion, or uniform interventions ignores evidence and individual needs. This triad supports sound, individualized decisions.

Question 42Nursing Process and Clinical Decision-Making

A nurse gathers data and then writes "Risk for falls related to impaired mobility." What is the most important next step?

  1. Reassess the client only at discharge
  2. Wait for the client to fall before intervening
  3. Plan interventions that address the identified risk Correct answer.
  4. Remove the diagnosis because it is only a risk

Explanation

After a risk diagnosis is identified, planning targets prevention through specific interventions such as fall precautions. Waiting for harm contradicts the purpose of a risk diagnosis. Reassessment occurs continuously, not only at discharge.

Question 43Nursing Process and Clinical Decision-Making

A client's condition changes and the original care plan no longer fits. What should the nurse do?

  1. Discard all documentation of the previous plan
  2. Revise the care plan based on the new assessment data Correct answer.
  3. Wait for the next scheduled care conference
  4. Continue the original plan to maintain consistency

Explanation

The nursing process is dynamic, and plans must be updated when assessment data change. Revising the plan keeps interventions relevant to the client's current needs. Rigid adherence or waiting for a conference delays appropriate care.

Question 44Nursing Process and Clinical Decision-Making

A nurse is caring for a client with an acute asthma exacerbation and a second client requesting a snack. Which action demonstrates sound clinical judgment?

  1. Delay both requests until the next medication round
  2. Ask assistive personnel to manage the asthma exacerbation
  3. Attend to the client with breathing difficulty before the snack request Correct answer.
  4. Give the snack first to keep the second client satisfied

Explanation

Clinical judgment requires ranking needs by urgency, and impaired breathing is a higher priority than a nonurgent request. Delegating care of an unstable client to assistive personnel is inappropriate because it requires nursing assessment and judgment. Delaying both requests ignores the urgent need.

Question 45Nursing Process and Clinical Decision-Making

A client with confusion repeatedly tries to climb out of bed. Which nursing action reflects the safest decision-making?

  1. Implement fall precautions and reassess the cause of agitation Correct answer.
  2. Apply restraints immediately without an order
  3. Document the behavior without intervening
  4. Ask the family to stay without providing instructions

Explanation

Safety interventions should be the least restrictive and based on assessment of the cause of agitation. Applying restraints without an order violates legal and safety standards. Involving family requires clear instruction, and documenting without acting fails to protect the client.

Question 46Nursing Process and Clinical Decision-Making

A nurse receives conflicting information: the client reports severe pain while the monitor and vital signs are normal. What is the best interpretation?

  1. The pain is not real because vital signs are normal
  2. The monitor should be trusted over the client
  3. The client should be asked to wait until signs appear
  4. Pain is subjective and the client's report should guide care Correct answer.

Explanation

Pain is a subjective experience, and the client's self-report is the most reliable indicator. Normal vital signs do not exclude significant pain because physiologic responses vary. Discounting the report or waiting for signs delays appropriate comfort care.

Question 47Nursing Process and Clinical Decision-Making

Two clients both report pain. One is one day postoperative and the other has chronic back pain and requests an early refill. How should the nurse prioritize?

  1. Follow the order in which requests were received regardless of acuity
  2. Treat only the client with visible signs of pain
  3. Assess both clients and address the acute postoperative pain promptly Correct answer.
  4. Assume the chronic pain request is drug-seeking and delay it

Explanation

Priority is based on assessment of acuity, not assumptions about the nature of pain. Acute postoperative pain has a clear physiologic cause and warrants prompt attention, while the chronic pain client still requires assessment. Judging by visible signs or request order ignores individual needs.

Question 48Nursing Process and Clinical Decision-Making

A nurse is caring for multiple clients and must decide which task can be delegated to assistive personnel.

  1. Evaluating whether a pain goal was met
  2. Assessing a new client's breath sounds
  3. Teaching a client to self-administer insulin
  4. Measuring intake and output for a stable client Correct answer.

Explanation

Tasks that are routine, standardized, and do not require nursing judgment may be delegated to assistive personnel. Measuring intake and output fits these criteria for a stable client. Teaching, assessment, and evaluation require the registered nurse's knowledge and judgment.

Question 49Nursing Process and Clinical Decision-Making

A nurse is reviewing a care plan and notices the goal states "client will feel better." What is the best revision?

  1. Client will report pain below 3 of 10 within one hour of analgesia Correct answer.
  2. Nurse will administer analgesia as ordered
  3. Client will be comfortable
  4. Client will feel improved by the end of the shift

Explanation

Goals must be measurable, specific, and time-bound to allow evaluation. A pain rating target with a timeframe can be objectively assessed. Vague comfort statements and nurse-focused actions cannot be measured as client outcomes.

Question 50Nursing Process and Clinical Decision-Making

A nurse is documenting care and writes the following: "Client will ambulate to the bathroom with a walker three times daily by discharge." Which component of the nursing process does this statement represent?

  1. Implementation
  2. Planning Correct answer.
  3. Evaluation
  4. Assessment

Explanation

A goal or outcome statement describes a measurable target the client should reach, and goals are established during the planning phase of the nursing process. Assessment collects data, implementation carries out interventions, and evaluation compares results with the goal. Because this statement specifies a behavior, a condition, and a timeframe, it belongs to planning.