,NU 136 Exam 3 | Fundamentals of Nursing | Galen
College | Q & A | 2026 Edition (PDF)
1. Which of the following best describes the primary purpose of documentation in nursing?
A) To satisfy hospital administrative requirements only
B) To communicate patient information and ensure continuity of care
C) To protect the nurse from all legal liability
D) To provide data exclusively for research studies
Correct Answer: To communicate patient information and ensure continuity of care
Expert Rationale: Documentation serves multiple purposes, but its primary purpose is to communicate
patient information and ensure continuity of care among healthcare providers. Legal protection,
administrative requirements, and research are secondary purposes. Accurate documentation is essential
for patient safety and quality improvement.
2. What is the correct sequence of the five steps of the nursing process?
A) Assessment, Planning, Diagnosis, Implementation, Evaluation
B) Assessment, Diagnosis, Planning, Implementation, Evaluation
C) Diagnosis, Assessment, Planning, Implementation, Evaluation
D) Planning, Assessment, Diagnosis, Implementation, Evaluation
Correct Answer: Assessment, Diagnosis, Planning, Implementation, Evaluation
Expert Rationale: The five steps of the nursing process in order are Assessment, Diagnosis, Planning,
Implementation, and Evaluation (ADPIE). This systematic approach guides nursing care and clinical
decision-making. Assessment involves data collection, diagnosis involves analyzing data, planning
involves setting goals, implementation involves carrying out interventions, and evaluation measures
outcomes.
3. A nurse collects vital signs, auscultates lung sounds, and asks the patient about pain. These actions
represent which step of the nursing process?
,A) Planning
B) Assessment
C) Implementation
D) Evaluation
Correct Answer: Assessment
Expert Rationale: Assessment is the systematic collection of subjective and objective data to form a
database. Vital signs, lung sounds, and patient interview are all assessment activities. Planning involves
setting goals, implementation carries out interventions, and evaluation measures outcome achievement.
4. After analyzing assessment data, the nurse identifies that the patient is at risk for falls. This action falls
under which phase of the nursing process?
A) Assessment
B) Diagnosis
C) Planning
D) Implementation
Correct Answer: Diagnosis
Expert Rationale: Diagnosis involves analyzing collected data to identify actual or potential health
problems. Identifying a risk for falls is a nursing diagnosis. Assessment gathers data, planning sets goals,
and implementation provides interventions. Nursing diagnosis is the second step of the five-step nursing
process.
5. A nurse writes, "Patient will ambulate 50 feet with a walker by the end of the shift." This is an
example of which component of the nursing process?
A) Assessment
B) Nursing diagnosis
C) Planning
D) Implementation
, Correct Answer: Planning
Expert Rationale: Planning involves setting measurable, realistic goals and expected outcomes. The
statement includes a specific, measurable goal (50 feet) with a time frame (by end of shift). Assessment
collects data, diagnosis identifies problems, and implementation carries out interventions.
6. A nurse is evaluating a patient's response to pain medication. This action is part of which phase of the
nursing process?
A) Assessment
B) Planning
C) Implementation
D) Evaluation
Correct Answer: Evaluation
Expert Rationale: Evaluation is the phase of the nursing process where the nurse determines whether
the patient's goals have been met and evaluates the effectiveness of interventions. Assessment collects
data, planning sets goals, and implementation carries out interventions. Evaluation is the fifth and final
step.
7. Which of the following is an example of a nursing diagnosis?
A) Pneumonia
B) Risk for falls
C) Hypertension
D) Diabetes mellitus
Correct Answer: Risk for falls
Expert Rationale: Risk for falls is a nursing diagnosis that identifies a potential health problem that
nurses can address independently. Pneumonia, hypertension, and diabetes mellitus are medical
College | Q & A | 2026 Edition (PDF)
1. Which of the following best describes the primary purpose of documentation in nursing?
A) To satisfy hospital administrative requirements only
B) To communicate patient information and ensure continuity of care
C) To protect the nurse from all legal liability
D) To provide data exclusively for research studies
Correct Answer: To communicate patient information and ensure continuity of care
Expert Rationale: Documentation serves multiple purposes, but its primary purpose is to communicate
patient information and ensure continuity of care among healthcare providers. Legal protection,
administrative requirements, and research are secondary purposes. Accurate documentation is essential
for patient safety and quality improvement.
2. What is the correct sequence of the five steps of the nursing process?
A) Assessment, Planning, Diagnosis, Implementation, Evaluation
B) Assessment, Diagnosis, Planning, Implementation, Evaluation
C) Diagnosis, Assessment, Planning, Implementation, Evaluation
D) Planning, Assessment, Diagnosis, Implementation, Evaluation
Correct Answer: Assessment, Diagnosis, Planning, Implementation, Evaluation
Expert Rationale: The five steps of the nursing process in order are Assessment, Diagnosis, Planning,
Implementation, and Evaluation (ADPIE). This systematic approach guides nursing care and clinical
decision-making. Assessment involves data collection, diagnosis involves analyzing data, planning
involves setting goals, implementation involves carrying out interventions, and evaluation measures
outcomes.
3. A nurse collects vital signs, auscultates lung sounds, and asks the patient about pain. These actions
represent which step of the nursing process?
,A) Planning
B) Assessment
C) Implementation
D) Evaluation
Correct Answer: Assessment
Expert Rationale: Assessment is the systematic collection of subjective and objective data to form a
database. Vital signs, lung sounds, and patient interview are all assessment activities. Planning involves
setting goals, implementation carries out interventions, and evaluation measures outcome achievement.
4. After analyzing assessment data, the nurse identifies that the patient is at risk for falls. This action falls
under which phase of the nursing process?
A) Assessment
B) Diagnosis
C) Planning
D) Implementation
Correct Answer: Diagnosis
Expert Rationale: Diagnosis involves analyzing collected data to identify actual or potential health
problems. Identifying a risk for falls is a nursing diagnosis. Assessment gathers data, planning sets goals,
and implementation provides interventions. Nursing diagnosis is the second step of the five-step nursing
process.
5. A nurse writes, "Patient will ambulate 50 feet with a walker by the end of the shift." This is an
example of which component of the nursing process?
A) Assessment
B) Nursing diagnosis
C) Planning
D) Implementation
, Correct Answer: Planning
Expert Rationale: Planning involves setting measurable, realistic goals and expected outcomes. The
statement includes a specific, measurable goal (50 feet) with a time frame (by end of shift). Assessment
collects data, diagnosis identifies problems, and implementation carries out interventions.
6. A nurse is evaluating a patient's response to pain medication. This action is part of which phase of the
nursing process?
A) Assessment
B) Planning
C) Implementation
D) Evaluation
Correct Answer: Evaluation
Expert Rationale: Evaluation is the phase of the nursing process where the nurse determines whether
the patient's goals have been met and evaluates the effectiveness of interventions. Assessment collects
data, planning sets goals, and implementation carries out interventions. Evaluation is the fifth and final
step.
7. Which of the following is an example of a nursing diagnosis?
A) Pneumonia
B) Risk for falls
C) Hypertension
D) Diabetes mellitus
Correct Answer: Risk for falls
Expert Rationale: Risk for falls is a nursing diagnosis that identifies a potential health problem that
nurses can address independently. Pneumonia, hypertension, and diabetes mellitus are medical
