NURSING FUNDAMENTALS - EXAM 2
QUESTIONS AND ANSWERS GRADED A+
2025/2026
A client comes to the walk-in clinic with reports of abdominal pain and diarrhea. While taking
the client's vital signs, the nurse is implementing which phase of the nursing process?
A. Assessment
B. Diagnosis
C. Planning
D. Implementation - ANS A. Assessment
Rationale: The first step in the nursing process is assessment, the process of collecting data. All
subsequent phases of the nursing process (options 2, 3, and 4) rely on accurate and complete
data.
The nurse is measuring the client's urine output and straining the urine to assess for stones.
Which of the following should the nurse record as objective data?
A. The client reports abdominal pain
B. The client's urine output was 450 mL
C. The client states, "I didn't see any stones in my urine."
D. The client states, "I feel like I have passed a stone." - ANS B. The client's urine output was
450 mL.
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,Rationale: Objective data is measurable data that can be seen, heard, or verified by the nurse.
The objective data is the measurement of the urine output. A client's statements and reports of
symptoms are documented as subjective data, such as the data found in options 1, 3, and 4.
When evaluating an elderly client's blood pressure (BP) of 146/78 mmHg, the nurse does which
of the following before determining whether the BP is normal or represents hypertension?
A. Compare this reading against defined standards
B. Compare the reading with one taken in the opposite arm
C. Determine gaps in the vital signs in the client record
D. Compare the current measurement with previous ones - ANS A. Compare this reading
against defined
Rationale: Analysis of the client's BP requires knowledge of the normal BP range for an older
adult. The nurse compares the client's data against identified standards to determine whether
this reading is normal or abnormal. Measuring the BP in the other arm (option 2) and
comparing the reading to previous ones (option 4) will give additional client data, but the
comparison alone will not determine whether the BP is normal. Gaps in the record (option 3)
will not aid in interpreting the current measurement.
Which of the following behaviors by the nurse demonstrates that the nurse is participating in
critical thinking? Select all that apply.
A. Admitting not knowing how to do a procedure and requesting help
B. Using clever and persuasive remarks to support an opinion or position
C. Accepting without question the values acquired in nursing school
D. Finding a quick and logical answer, even to complex questions
E. Gathering three assistants to transfer the client to a stretcher after noting the client weighs
300 lbs. - ANS A. Admitting not knowing how to do a procedure and requesting help
E. Gathering three assistants to transfer the client to a stretcher after noting the client weighs
300 lbs.
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,Rationale: Critical thinking in nursing is self-directed, supporting what nurses know and making
clear what they do not know. It is important for nurses to recognize when they lack the
knowledge they need to provide safe care for a client (option 1). Nurses must also utilize their
resources to acquire the support they need to care for a client safely (option 5). Options 2, 3,
and 4 do not demonstrate critical thinking.
The nurse has documented the following outcome goal in the care plan: "The client will transfer
from bed to chair with two-person assist." The charge nurse tells the nurse to add which of the
following to complete the goal?
A. Client behavior
B. Conditions or modifiers
C. Performance criteria
D. Target time - ANS D. Target time
Rationale: The outcome goal does not state the target timeframe for when the nurse should
expect to see the client behavior ("transfer"). The condition or modifier is present ("with two
assists"). The performance criterion is "from bed to chair."
The nurse who documents on the client's care plan the outcome goal "Anxiety will be relieved
within 20 to 40 minutes following administration of lorazepam (Ativan)" is engaged in which
step of the nursing process?
A. Assessment
B. Planning
C. Implementation
D. Evaluation - ANS B. Planning
Rationale: The planning step of the nursing process involves formulating client goals and
designing the nursing interventions required to prevent, reduce, or eliminate the client's health
problems. Outcome goals are documented on the client's care plan. Assessment data (option 1)
is used to help identify a client's human response, and once a plan is established, the
interventions are implemented (option 3) and evaluated (option 4).
3 @COPYRIGHT 2025/2026 ALLRIGHTS RESERVED.
, When the client resists taking a liquid medication that is essential to treatment, the nurse
demonstrates critical thinking by doing which of the following first?
A. Omitting this dose of medication and waiting until the client is more cooperative
B. Suggesting the medication can be diluted in a beverage
C. Asking the nurse manager about how to approach the situation
D. Notifying the physician inability to give the client this medication - ANS B. Suggesting the
medication can be diluted in a beverage
Rationale: Diluting the medication in a beverage may make the medication more palatable.
Using critical thinking skills, the nurse should try to problem-solve in a situation such as this
before asking for the assistance of the nurse manager. Suggesting an alternative method of
taking the medication (provided that there are no contraindications to diluting the medication)
should improve the likelihood of the client taking the medication.
Which professionally appropriate response should the nurse make when a more stringent policy
for the use of restraints is introduced on a surgical unit?
A. Use the previous, less restrictive policy conscientiously
B. Express immediate disagreement with the new policy
C. Ask for the rationale behind the new policy
D. Obey the policy but continue to voice disapproval of it to co-workers - ANS C. Ask for the
rationale behind the new policy
Rationale: Understanding the rationale behind a decision helps the nurse analyze the proposed
change and understand its purpose. Options 1, 2, and 4 represent unprofessional behavior.
Option 1 also places a client's safety at risk.
The nurse assigned to care for a postoperative client has asked an unlicensed assistive person
(UAP) to help the client ambulate in the hall. Before delegating this task, the nurse must do
which of the following?
4 @COPYRIGHT 2025/2026 ALLRIGHTS RESERVED.
QUESTIONS AND ANSWERS GRADED A+
2025/2026
A client comes to the walk-in clinic with reports of abdominal pain and diarrhea. While taking
the client's vital signs, the nurse is implementing which phase of the nursing process?
A. Assessment
B. Diagnosis
C. Planning
D. Implementation - ANS A. Assessment
Rationale: The first step in the nursing process is assessment, the process of collecting data. All
subsequent phases of the nursing process (options 2, 3, and 4) rely on accurate and complete
data.
The nurse is measuring the client's urine output and straining the urine to assess for stones.
Which of the following should the nurse record as objective data?
A. The client reports abdominal pain
B. The client's urine output was 450 mL
C. The client states, "I didn't see any stones in my urine."
D. The client states, "I feel like I have passed a stone." - ANS B. The client's urine output was
450 mL.
1 @COPYRIGHT 2025/2026 ALLRIGHTS RESERVED.
,Rationale: Objective data is measurable data that can be seen, heard, or verified by the nurse.
The objective data is the measurement of the urine output. A client's statements and reports of
symptoms are documented as subjective data, such as the data found in options 1, 3, and 4.
When evaluating an elderly client's blood pressure (BP) of 146/78 mmHg, the nurse does which
of the following before determining whether the BP is normal or represents hypertension?
A. Compare this reading against defined standards
B. Compare the reading with one taken in the opposite arm
C. Determine gaps in the vital signs in the client record
D. Compare the current measurement with previous ones - ANS A. Compare this reading
against defined
Rationale: Analysis of the client's BP requires knowledge of the normal BP range for an older
adult. The nurse compares the client's data against identified standards to determine whether
this reading is normal or abnormal. Measuring the BP in the other arm (option 2) and
comparing the reading to previous ones (option 4) will give additional client data, but the
comparison alone will not determine whether the BP is normal. Gaps in the record (option 3)
will not aid in interpreting the current measurement.
Which of the following behaviors by the nurse demonstrates that the nurse is participating in
critical thinking? Select all that apply.
A. Admitting not knowing how to do a procedure and requesting help
B. Using clever and persuasive remarks to support an opinion or position
C. Accepting without question the values acquired in nursing school
D. Finding a quick and logical answer, even to complex questions
E. Gathering three assistants to transfer the client to a stretcher after noting the client weighs
300 lbs. - ANS A. Admitting not knowing how to do a procedure and requesting help
E. Gathering three assistants to transfer the client to a stretcher after noting the client weighs
300 lbs.
2 @COPYRIGHT 2025/2026 ALLRIGHTS RESERVED.
,Rationale: Critical thinking in nursing is self-directed, supporting what nurses know and making
clear what they do not know. It is important for nurses to recognize when they lack the
knowledge they need to provide safe care for a client (option 1). Nurses must also utilize their
resources to acquire the support they need to care for a client safely (option 5). Options 2, 3,
and 4 do not demonstrate critical thinking.
The nurse has documented the following outcome goal in the care plan: "The client will transfer
from bed to chair with two-person assist." The charge nurse tells the nurse to add which of the
following to complete the goal?
A. Client behavior
B. Conditions or modifiers
C. Performance criteria
D. Target time - ANS D. Target time
Rationale: The outcome goal does not state the target timeframe for when the nurse should
expect to see the client behavior ("transfer"). The condition or modifier is present ("with two
assists"). The performance criterion is "from bed to chair."
The nurse who documents on the client's care plan the outcome goal "Anxiety will be relieved
within 20 to 40 minutes following administration of lorazepam (Ativan)" is engaged in which
step of the nursing process?
A. Assessment
B. Planning
C. Implementation
D. Evaluation - ANS B. Planning
Rationale: The planning step of the nursing process involves formulating client goals and
designing the nursing interventions required to prevent, reduce, or eliminate the client's health
problems. Outcome goals are documented on the client's care plan. Assessment data (option 1)
is used to help identify a client's human response, and once a plan is established, the
interventions are implemented (option 3) and evaluated (option 4).
3 @COPYRIGHT 2025/2026 ALLRIGHTS RESERVED.
, When the client resists taking a liquid medication that is essential to treatment, the nurse
demonstrates critical thinking by doing which of the following first?
A. Omitting this dose of medication and waiting until the client is more cooperative
B. Suggesting the medication can be diluted in a beverage
C. Asking the nurse manager about how to approach the situation
D. Notifying the physician inability to give the client this medication - ANS B. Suggesting the
medication can be diluted in a beverage
Rationale: Diluting the medication in a beverage may make the medication more palatable.
Using critical thinking skills, the nurse should try to problem-solve in a situation such as this
before asking for the assistance of the nurse manager. Suggesting an alternative method of
taking the medication (provided that there are no contraindications to diluting the medication)
should improve the likelihood of the client taking the medication.
Which professionally appropriate response should the nurse make when a more stringent policy
for the use of restraints is introduced on a surgical unit?
A. Use the previous, less restrictive policy conscientiously
B. Express immediate disagreement with the new policy
C. Ask for the rationale behind the new policy
D. Obey the policy but continue to voice disapproval of it to co-workers - ANS C. Ask for the
rationale behind the new policy
Rationale: Understanding the rationale behind a decision helps the nurse analyze the proposed
change and understand its purpose. Options 1, 2, and 4 represent unprofessional behavior.
Option 1 also places a client's safety at risk.
The nurse assigned to care for a postoperative client has asked an unlicensed assistive person
(UAP) to help the client ambulate in the hall. Before delegating this task, the nurse must do
which of the following?
4 @COPYRIGHT 2025/2026 ALLRIGHTS RESERVED.
