NURSING PROCESS & CLINICAL JUDGMENT
QUESTIONS AND ANSWERS | LATEST 2026/2027
1. A nurse assesses a patient with pneumonia and notes crackles in the right
lower lobe, temperature 39.2°C (102.6°F), and oxygen saturation 89% on room
air. Which step of the nursing process is the nurse demonstrating?
A. Planning
B. Assessment
C. Implementation
D. Evaluation
Answer: B
Rationale: Collecting subjective and objective data (crackles, fever, SpO2) is the
assessment phase. Planning occurs after analysis, implementation is doing, and
evaluation measures response.
2. A patient with chronic heart failure has jugular vein distension and 3+ pedal
edema. The nurse identifies the nursing diagnosis of “Fluid Volume Excess.”
Which action is an appropriate nursing intervention?
A. Administer digoxin 0.125 mg PO daily
B. Restrict dietary sodium to 2 grams per day
C. Order a serum BNP level
D. Prescribe furosemide 40 mg IV
Answer: B
Rationale: Sodium restriction is an independent nursing intervention (within
scope). Administering digoxin and furosemide require provider orders. Ordering
lab tests is not a nursing action unless delegated.
,3. A nurse is analyzing cues from a patient with abdominal pain. The patient has
rebound tenderness, fever, and elevated WBC. The nurse suspects appendicitis.
Which nursing diagnosis has the highest priority?
A. Acute Pain related to inflammation
B. Risk for Deficient Fluid Volume related to nausea
C. Risk for Infection related to possible perforation
D. Anxiety related to impending surgery
Answer: C
Rationale: Risk for Infection (peritonitis from perforation) is the greatest threat to
physiological integrity and has highest priority. Pain, fluid volume, and anxiety are
important but secondary to preventing life-threatening infection.
4. A patient post-operative day 2 from a colectomy has a fever of 38.5°C
(101.3°F) and purulent drainage from the incision. The nurse notifies the
provider and obtains an order for wound culture. This represents which step of
the nursing process?
A. Assessment
B. Diagnosis
C. Implementation
D. Evaluation
Answer: C
Rationale: Carrying out the ordered wound culture is implementation. The
assessment (fever, drainage) occurred first. Diagnosis (identifying problem) and
evaluation (checking effectiveness) are separate steps.
5. A nurse in the emergency department receives report on four patients. Which
patient should the nurse assess first?
A. 45-year-old with chest pain and ECG showing ST-segment elevation
B. 60-year-old with COPD and SpO2 91% on 2 L/min oxygen
, C. 30-year-old with ankle fracture and pain rated 7/10
D. 70-year-old with confusion and urinary tract infection
Answer: A
Rationale: ST-elevation myocardial infarction (STEMI) is time-sensitive and life-
threatening. The nurse uses prioritization (ABCs and threat to life). The COPD
patient is stable on oxygen, pain is not immediately life-threatening, and confusion
from UTI is serious but less urgent than STEMI.
6. A patient with diabetes mellitus has a blood glucose of 45 mg/dL and is
drowsy but arousable. Which action should the nurse take first?
A. Administer glucagon intramuscularly
B. Give 15 grams of oral fast-acting carbohydrate
C. Start an IV line for dextrose 50%
D. Recheck the blood glucose in 15 minutes
Answer: B
*Rationale: For an awake patient who can swallow, oral carbohydrate (4 oz juice,
glucose tablets) is first-line treatment for hypoglycemia. Glucagon and IV dextrose
are for unconscious or seizing patients. Rechecking without treatment delays
care.*
7. A nurse is evaluating outcomes for a patient with acute kidney injury. Which
finding indicates that the goal “Patient will maintain fluid and electrolyte
balance” has been met?
A. Weight gain of 1.5 kg in 24 hours
B. Serum potassium 5.8 mEq/L
C. Urine output 50 mL/hour
D. Blood pressure 150/90 mm Hg
Answer: C
*Rationale: Urine output ≥0.5 mL/kg/hour (approx 30–50 mL/hour) indicates
QUESTIONS AND ANSWERS | LATEST 2026/2027
1. A nurse assesses a patient with pneumonia and notes crackles in the right
lower lobe, temperature 39.2°C (102.6°F), and oxygen saturation 89% on room
air. Which step of the nursing process is the nurse demonstrating?
A. Planning
B. Assessment
C. Implementation
D. Evaluation
Answer: B
Rationale: Collecting subjective and objective data (crackles, fever, SpO2) is the
assessment phase. Planning occurs after analysis, implementation is doing, and
evaluation measures response.
2. A patient with chronic heart failure has jugular vein distension and 3+ pedal
edema. The nurse identifies the nursing diagnosis of “Fluid Volume Excess.”
Which action is an appropriate nursing intervention?
A. Administer digoxin 0.125 mg PO daily
B. Restrict dietary sodium to 2 grams per day
C. Order a serum BNP level
D. Prescribe furosemide 40 mg IV
Answer: B
Rationale: Sodium restriction is an independent nursing intervention (within
scope). Administering digoxin and furosemide require provider orders. Ordering
lab tests is not a nursing action unless delegated.
,3. A nurse is analyzing cues from a patient with abdominal pain. The patient has
rebound tenderness, fever, and elevated WBC. The nurse suspects appendicitis.
Which nursing diagnosis has the highest priority?
A. Acute Pain related to inflammation
B. Risk for Deficient Fluid Volume related to nausea
C. Risk for Infection related to possible perforation
D. Anxiety related to impending surgery
Answer: C
Rationale: Risk for Infection (peritonitis from perforation) is the greatest threat to
physiological integrity and has highest priority. Pain, fluid volume, and anxiety are
important but secondary to preventing life-threatening infection.
4. A patient post-operative day 2 from a colectomy has a fever of 38.5°C
(101.3°F) and purulent drainage from the incision. The nurse notifies the
provider and obtains an order for wound culture. This represents which step of
the nursing process?
A. Assessment
B. Diagnosis
C. Implementation
D. Evaluation
Answer: C
Rationale: Carrying out the ordered wound culture is implementation. The
assessment (fever, drainage) occurred first. Diagnosis (identifying problem) and
evaluation (checking effectiveness) are separate steps.
5. A nurse in the emergency department receives report on four patients. Which
patient should the nurse assess first?
A. 45-year-old with chest pain and ECG showing ST-segment elevation
B. 60-year-old with COPD and SpO2 91% on 2 L/min oxygen
, C. 30-year-old with ankle fracture and pain rated 7/10
D. 70-year-old with confusion and urinary tract infection
Answer: A
Rationale: ST-elevation myocardial infarction (STEMI) is time-sensitive and life-
threatening. The nurse uses prioritization (ABCs and threat to life). The COPD
patient is stable on oxygen, pain is not immediately life-threatening, and confusion
from UTI is serious but less urgent than STEMI.
6. A patient with diabetes mellitus has a blood glucose of 45 mg/dL and is
drowsy but arousable. Which action should the nurse take first?
A. Administer glucagon intramuscularly
B. Give 15 grams of oral fast-acting carbohydrate
C. Start an IV line for dextrose 50%
D. Recheck the blood glucose in 15 minutes
Answer: B
*Rationale: For an awake patient who can swallow, oral carbohydrate (4 oz juice,
glucose tablets) is first-line treatment for hypoglycemia. Glucagon and IV dextrose
are for unconscious or seizing patients. Rechecking without treatment delays
care.*
7. A nurse is evaluating outcomes for a patient with acute kidney injury. Which
finding indicates that the goal “Patient will maintain fluid and electrolyte
balance” has been met?
A. Weight gain of 1.5 kg in 24 hours
B. Serum potassium 5.8 mEq/L
C. Urine output 50 mL/hour
D. Blood pressure 150/90 mm Hg
Answer: C
*Rationale: Urine output ≥0.5 mL/kg/hour (approx 30–50 mL/hour) indicates
