A patient with heart failure is taught to weigh daily. At teach-back he says: 'I weigh after breakfast in my clothes, and I call if I gain 5 kg in a week.' Which part of his statement shows a need for further teaching?

Both the weighing method and the gain he will report

Only the amount of weight gain he will report

No part, as his plan is acceptable for home use

Only the time of day he plans to weigh himself

A patient who has just been told she has had a miscarriage sits quietly in tears. The most therapeutic nursing approach is to:

Sit with her quietly and let her lead the conversation

Explain the common causes of miscarriage in detail

Leave her alone and return when she has stopped crying

Tell her she can try for another baby very soon

A newly admitted patient speaks only Bengali. For the admission assessment, the nurse should use:

Simple English and hand gestures

A ward cleaner who speaks Bengali

A nurse uses the PIE format to write a progress note. In this format, 'E' stands for:

Evaluation of the patient's response

Explanation given to the patient

Etiology of the nursing problem

A patient's goal was 'walks 30 metres with a frame by day 3'. On day 3 he walks only 10 metres before stopping, short of breath. The nurse should next:

Record the goal as not met and reassess the cause

Record the goal as met because he walked with a frame

Stop walking him and keep him on bed rest

Keep the same plan and goal for another 3 days

Nursing process, documentation and communication

42 Gulf Prometric RN (DHA, DOH, MOH, SCFHS) practice questions on Nursing process, documentation and communication, part of Fundamentals and Patient Safety. The first 25 are below; the first 5 with answers and explanations (tap Show answer after you have chosen), the rest in Learn with a free account.

Question 1 · Hard
A patient with heart failure is taught to weigh daily. At teach-back he says: 'I weigh after breakfast in my clothes, and I call if I gain 5 kg in a week.' Which part of his statement shows a need for further teaching?
1. ABoth the weighing method and the gain he will report
2. BOnly the amount of weight gain he will report
3. CNo part, as his plan is acceptable for home use
4. DOnly the time of day he plans to weigh himself
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Answer: A · Both the weighing method and the gain he will report
Daily weights should be taken at the same time each morning, after voiding and before breakfast, in similar clothing, so the method is wrong. Patients are usually told to report a gain of about 1-1.5 kg in a day or 2 kg in a week, because 5 kg represents a large fluid build-up. Both errors would delay recognition of worsening heart failure. The nurse re-teaches both points and checks again.
- B: The weighing method is also incorrect.
- C: Waiting for a 5 kg gain risks a serious decompensation.
- D: Clothing also affects accuracy, not just the time of day.
Question 2 · Medium
A patient who has just been told she has had a miscarriage sits quietly in tears. The most therapeutic nursing approach is to:
1. AExplain the common causes of miscarriage in detail
2. BSit with her quietly and let her lead the conversation
3. CLeave her alone and return when she has stopped crying
4. DTell her she can try for another baby very soon
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Answer: B · Sit with her quietly and let her lead the conversation
Therapeutic silence and presence allow the patient to feel and express grief at her own pace. Sitting with her, perhaps offering a tissue or touch if appropriate, shows support without pressure. Talk of future pregnancies minimises her loss. Detailed facts can be given later when she is ready to ask.
- A: Detailed explanations now ignore her emotional needs.
- C: Leaving her alone may feel like abandonment at a time of grief.
- D: Talking about another baby minimises the current loss.
Question 3 · Easy
A newly admitted patient speaks only Bengali. For the admission assessment, the nurse should use:
1. AA trained medical interpreter
2. BSimple English and hand gestures
3. CThe patient's 12-year-old son
4. DA ward cleaner who speaks Bengali
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Answer: A · A trained medical interpreter
A trained medical interpreter translates accurately and neutrally and keeps the conversation confidential. Children and untrained staff may not know medical terms, may leave out sensitive details, and place a burden on the person interpreting. Phone or video interpreter services can be used when no one is on site. The nurse speaks directly to the patient, not to the interpreter.
- B: Gestures cannot give an accurate history or valid consent.
- C: A child should not interpret health information and may filter or misunderstand it.
- D: Untrained staff may translate inaccurately and break confidentiality.
Question 4 · Medium
A nurse uses the PIE format to write a progress note. In this format, 'E' stands for:
1. AEvaluation of the patient's response
2. BExpected outcome for the shift
3. CExplanation given to the patient
4. DEtiology of the nursing problem
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Answer: A · Evaluation of the patient's response
PIE stands for Problem, Intervention and Evaluation. The nurse names the problem, records what was done and then records how the patient responded. This links each note to the care plan and shows whether care is working. SOAP and DAR are other common problem-oriented formats.
- B: Expected outcomes belong in the care plan, not the 'E' of PIE.
- C: Patient explanation would be recorded as an intervention.
- D: Etiology is part of a nursing diagnosis, not the PIE note.
Question 5 · Medium
A patient's goal was 'walks 30 metres with a frame by day 3'. On day 3 he walks only 10 metres before stopping, short of breath. The nurse should next:
1. ARecord the goal as met because he walked with a frame
2. BRecord the goal as not met and reassess the cause
3. CStop walking him and keep him on bed rest
4. DKeep the same plan and goal for another 3 days
Show answerHide answer
Answer: B · Record the goal as not met and reassess the cause
Evaluation compares the patient's actual response with the expected outcome. Walking 10 of 30 metres with breathlessness means the goal was not met, so the nurse reassesses why, for example anaemia, hypoxia or pain. The plan or the goal is then revised. Repeating an unchanged plan ignores the new data.
- A: Walking with the frame does not meet the distance stated in the goal.
- C: Bed rest is a medical decision and would worsen deconditioning without assessment.
- D: Continuing unchanged ignores the evaluation and the new symptom.
Question 6 · Easy
In an SBAR report, the patient's admission diagnosis, relevant history and allergies belong in:
1. ASituation
2. BRecommendation
3. CBackground
4. DAssessment
Answer and explanation in LearnFree account
Question 7 · Medium
A newly diagnosed patient with heart failure has limited reading skills. The best discharge teaching strategy is to:
1. AFocus on two or three key points using plain words and pictures
2. BGive a detailed booklet to read at home before follow-up
3. CCover all medications and diet rules in one long session
4. DUse the correct medical terms so he can tell his doctor
Answer and explanation in LearnFree account
Question 8 · Medium
The daughter of a patient shouts at the nurse that her mother's call bell was ignored for 20 minutes. Which response is best?
1. AThat is not true, the bell was answered quickly.
2. BPlease calm down, or I will have to call hospital security now.
3. CThe ward is very busy and we have only two nurses.
4. DI can see you are upset. Let's talk about what happened.
Answer and explanation in LearnFree account
Question 9 · Medium
A nurse forgot to document a dressing change done at 10:00 and remembers at 15:00. The correct entry is to:
1. AWrite the note with a 10:00 time as if it had been written then
2. BLabel it a late entry, timed now, stating when care was given
3. CSqueeze the note in between the 09:00 and 11:00 entries
4. DLeave it out because the dressing will be changed again
Answer and explanation in LearnFree account
Question 10 · Medium
A main advantage of bedside handover at shift change compared with handover at the nurses' station is that:
1. AConfidential information is never overheard
2. BThe incoming nurse need not check the chart afterwards
3. CThe patient can take part and correct details
4. DIt takes less time than any other handover method
Answer and explanation in LearnFree account
Question 11 · Hard
After handover, a nurse has four patients. Which should she assess first? (A) Day 2 after cholecystectomy, pain 4/10. (B) Diabetic, glucose 11 mmol/L (198 mg/dL) before breakfast. (C) Pneumonia patient, RR 30/min, SpO2 88% on 2 L/min. (D) Patient due for discharge, awaiting teaching.
1. AThe pneumonia patient with falling oxygen saturation
2. BThe patient due for discharge teaching
3. CThe diabetic patient with a raised glucose level
4. DThe cholecystectomy patient with moderate pain
Answer and explanation in LearnFree account
Question 12 · Easy
Which statement is a nursing diagnosis rather than a medical diagnosis?
1. ALeft femoral neck fracture
2. BCommunity-acquired pneumonia
3. CType 2 diabetes mellitus with neuropathy
4. DRisk for impaired skin integrity
Answer and explanation in LearnFree account
Question 13 · Hard
On day 2 after a myocardial infarction, a patient reports chest pain 6/10 and says he is too worried about his job to concentrate. HR 104/min, BP 150/92 mmHg. The plan is to teach him a low-salt diet today. What should the nurse do first?
1. ATreat his pain and defer the diet teaching
2. BGive him the diet leaflet to read on his own
3. CStart the diet teaching while he is awake
4. DTeach his wife the diet instead of him
Answer and explanation in LearnFree account
Question 14 · Medium
On the way to theatre, a patient who signed consent yesterday says, 'I've changed my mind, I don't want this operation.' The nurse should first:
1. AContinue, as he has already signed consent
2. BAsk the family to persuade him to continue
3. CGive the prescribed premedication to calm him
4. DStop the transfer and inform the surgeon
Answer and explanation in LearnFree account
Question 15 · Hard
A nurse finds that an hour ago she entered blood glucose and vital signs into the electronic record of the wrong patient. Both patients are stable. What is the correct action?
1. ADelete the wrong entries so that no trace of the error is left
2. BLeave the wrong entries and add the correct values in a free-text note
3. CAsk IT staff to remove the entries from the record overnight
4. DMark the entries in error in the EHR and re-enter them correctly
Answer and explanation in LearnFree account
Question 16 · Easy
Which finding recorded on admission is subjective data?
1. AHer temperature is 38.4 °C on the tympanic thermometer
2. BThe patient says she has felt nauseated since morning
3. CHer skin is pale and cool to touch
4. DShe vomited 150 mL of bile-stained fluid
Answer and explanation in LearnFree account
Question 17 · Medium
A nurse photographs a patient's unusual wound on her personal phone to show colleagues at a teaching session. This action:
1. AIs acceptable if the patient's face is not shown
2. BIs acceptable because it is for staff education
3. CBreaches policy only if the photo is posted online
4. DBreaches the patient's privacy and confidentiality
Answer and explanation in LearnFree account
Question 18 · Medium
On the evening before surgery a patient says, 'I keep thinking something will go wrong tomorrow.' Which response is most therapeutic?
1. AWhy do you think something is going to go wrong?
2. BEveryone feels like this, so try to get a good night's sleep.
3. CYou sound worried about the operation. Tell me more.
4. DDon't worry, your surgeon does this every day.
Answer and explanation in LearnFree account
Question 19 · Hard
A 66-year-old man is listed for elective surgery tomorrow. He speaks only Urdu. The consent form was signed after the surgeon explained the procedure in English while his 15-year-old grandson translated. That evening he asks the nurse, through a phone interpreter, which leg is being operated on. What should the nurse do?
1. ATell him which leg it is and reassure him that consent is complete
2. BDocument his question and continue with tomorrow's preparation
3. CAsk the grandson to come back and explain the operation again
4. DInform the surgeon so consent is retaken with a trained interpreter
Answer and explanation in LearnFree account
Question 20 · Easy
Which question is an open-ended question?
1. AWhat has your pain been like since the operation?
2. BIs your pain worse now than it was earlier this morning?
3. CWould you rate your pain as more than five?
4. DDid you take your pain tablet at noon today?
Answer and explanation in LearnFree account
Question 21 · Hard
Day 1 after a laparotomy, a 58-year-old man has these findings: pain 6/10, SpO2 89% on room air with coarse crackles and a weak cough, temperature 37.6 °C, and he is asking anxiously when he can eat. Which finding needs the nurse's action first?
1. AA pain score of 6/10 on movement
2. BSpO2 89% with crackles and a weak cough
3. CHis anxious questions about eating
4. DA temperature of 37.6 °C
Answer and explanation in LearnFree account
Question 22 · Hard
A nurse calls the doctor about a patient on day 2 after hip replacement: HR 124/min, BP 86/50 mmHg, RR 26/min, temperature 38.9 °C, new confusion; history of diabetes; on IV cefazolin prophylaxis that ended yesterday. Which is the best opening Situation statement?
1. APlease come now and consider blood cultures, lactate and IV fluids
2. BI think she may be developing sepsis from a wound or other source
3. CShe is 70, diabetic and had a right hip replacement two days ago
4. DBed 6 hip patient: low BP, fast pulse, fever and new confusion
Answer and explanation in LearnFree account
Question 23 · Medium
A patient with type 2 diabetes on insulin plans to fast during Ramadan. Which advice is correct?
1. ATake the usual full insulin doses at the usual daytime times
2. BCheck blood glucose during the fast and break it if it falls below 3.9 mmol/L
3. CAvoid glucose checks while fasting because they break the fast
4. DBreak the fast only if glucose falls below 2.2 mmol/L
Answer and explanation in LearnFree account
Question 24 · Medium
The son of an elderly Arab patient asks the nurse not to tell his father that his biopsy shows cancer. The best initial action is to:
1. AAvoid the topic until the son changes his mind
2. BFind out from the patient how much he wishes to know
3. CTell the son that his father must be told today
4. DAgree to the son's request and inform the doctor of the plan
Answer and explanation in LearnFree account
Question 25 · Easy
A male nurse is admitting a conservative Muslim woman. When greeting her, it is most respectful to:
1. AShake her hand firmly to build trust and rapport
2. BTouch her shoulder to show warmth
3. CGreet her husband and not speak to her
4. DWait for her to offer a handshake first
Answer and explanation in LearnFree account

17 more Nursing process, documentation and communication questions

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Nursing process, documentation and communication

A patient with heart failure is taught to weigh daily. At teach-back he says: 'I weigh after breakfast in my clothes, and I call if I gain 5 kg in a week.' Which part of his statement shows a need for further teaching?

A patient who has just been told she has had a miscarriage sits quietly in tears. The most therapeutic nursing approach is to:

A newly admitted patient speaks only Bengali. For the admission assessment, the nurse should use:

A nurse uses the PIE format to write a progress note. In this format, 'E' stands for:

A patient's goal was 'walks 30 metres with a frame by day 3'. On day 3 he walks only 10 metres before stopping, short of breath. The nurse should next:

In an SBAR report, the patient's admission diagnosis, relevant history and allergies belong in:

A newly diagnosed patient with heart failure has limited reading skills. The best discharge teaching strategy is to:

The daughter of a patient shouts at the nurse that her mother's call bell was ignored for 20 minutes. Which response is best?

A nurse forgot to document a dressing change done at 10:00 and remembers at 15:00. The correct entry is to:

A main advantage of bedside handover at shift change compared with handover at the nurses' station is that:

After handover, a nurse has four patients. Which should she assess first? (A) Day 2 after cholecystectomy, pain 4/10. (B) Diabetic, glucose 11 mmol/L (198 mg/dL) before breakfast. (C) Pneumonia patient, RR 30/min, SpO2 88% on 2 L/min. (D) Patient due for discharge, awaiting teaching.

Which statement is a nursing diagnosis rather than a medical diagnosis?

On day 2 after a myocardial infarction, a patient reports chest pain 6/10 and says he is too worried about his job to concentrate. HR 104/min, BP 150/92 mmHg. The plan is to teach him a low-salt diet today. What should the nurse do first?

On the way to theatre, a patient who signed consent yesterday says, 'I've changed my mind, I don't want this operation.' The nurse should first:

A nurse finds that an hour ago she entered blood glucose and vital signs into the electronic record of the wrong patient. Both patients are stable. What is the correct action?

Which finding recorded on admission is subjective data?

A nurse photographs a patient's unusual wound on her personal phone to show colleagues at a teaching session. This action:

On the evening before surgery a patient says, 'I keep thinking something will go wrong tomorrow.' Which response is most therapeutic?

Which question is an open-ended question?

Day 1 after a laparotomy, a 58-year-old man has these findings: pain 6/10, SpO2 89% on room air with coarse crackles and a weak cough, temperature 37.6 °C, and he is asking anxiously when he can eat. Which finding needs the nurse's action first?

A nurse calls the doctor about a patient on day 2 after hip replacement: HR 124/min, BP 86/50 mmHg, RR 26/min, temperature 38.9 °C, new confusion; history of diabetes; on IV cefazolin prophylaxis that ended yesterday. Which is the best opening Situation statement?

A patient with type 2 diabetes on insulin plans to fast during Ramadan. Which advice is correct?

The son of an elderly Arab patient asks the nurse not to tell his father that his biopsy shows cancer. The best initial action is to:

A male nurse is admitting a conservative Muslim woman. When greeting her, it is most respectful to: