, NU 136 Fundamentals of Nursing Exam 3 Actual 2026/2027 –
100% Verified | Detailed Rationales – Pass Guaranteed – A+
Graded
SECTION 1: THE NURSING PROCESS & DOCUMENTATION
Question 1
Which phase of the nursing process involves collecting subjective and objective
data?
A) Diagnosis
B) Assessment
C) Planning
D) Implementation
Correct Answer: B) Assessment
Rationale: Assessment is the first step of the nursing process, during which the
nurse gathers both subjective data (what the patient says) and objective data
(measurable findings). Diagnosis follows analysis of data, planning sets goals, and
implementation carries out the planned interventions.
Question 2
A patient's potassium level is 3.0 mEq/L. The nurse identifies this as a problem.
This step is:
A) Assessment
B) Diagnosis
C) Planning
D) Evaluation
Correct Answer: B) Diagnosis
Rationale: The diagnosis phase involves analyzing assessment data to identify
actual or potential health problems. The nurse uses clinical judgment to formulate
nursing diagnoses based on the data collected.
,Question 3
A patient's outcome statement includes "by discharge." Which component of a
goal does this represent?
A) Subject
B) Behavior
C) Condition
D) Time frame
Correct Answer: D) Time frame
Rationale: A well-written goal includes four components: subject (who), behavior
(what), condition (under what circumstances), and time frame (when). "By
discharge" specifies when the goal should be met.
Question 4
Which documentation method records only significant findings or deviations from
normal?
A) Narrative charting
B) Focus charting
C) Charting by exception
D) POMR
Correct Answer: C) Charting by exception
Rationale: Charting by exception (CBE) assumes all standards were met unless
documented otherwise. Only abnormal findings or deviations from expected
norms are recorded, making documentation more efficient.
Question 5
A nurse is documenting a patient's pain reassessment. Which entry is most
appropriate?
A) "Patient seems comfortable."
B) "Patient resting quietly."
, C) "Pain is better."
D) "Patient reports pain 1/10 on 0-10 scale."
Correct Answer: D) "Patient reports pain 1/10 on 0-10 scale."
Rationale: Documentation must be objective, measurable, and specific. Vague
terms like "seems comfortable" or "better" are subjective and inadequate for
legal and professional standards.
Question 6
The primary purpose of the medical record is to:
A) Provide a legal defense for the hospital
B) Serve as a written record of patient care
C) Track employee performance
D) Determine the patient's insurance coverage
Correct Answer: B) Serve as a written record of patient care
Rationale: The medical record is a comprehensive documentation of the patient's
care, providing continuity and communication among healthcare providers. While
it may serve legal and billing purposes, its primary function is to document patient
care.
Question 7
A nurse accidentally documents vital signs in the wrong patient's chart. The nurse
should:
A) Erase the entry completely
B) Draw a single line through the entry, write "error," and initial
C) Use correction fluid
D) Leave it and document in the correct chart
Correct Answer: B) Draw a single line through the entry, write "error," and
initial
100% Verified | Detailed Rationales – Pass Guaranteed – A+
Graded
SECTION 1: THE NURSING PROCESS & DOCUMENTATION
Question 1
Which phase of the nursing process involves collecting subjective and objective
data?
A) Diagnosis
B) Assessment
C) Planning
D) Implementation
Correct Answer: B) Assessment
Rationale: Assessment is the first step of the nursing process, during which the
nurse gathers both subjective data (what the patient says) and objective data
(measurable findings). Diagnosis follows analysis of data, planning sets goals, and
implementation carries out the planned interventions.
Question 2
A patient's potassium level is 3.0 mEq/L. The nurse identifies this as a problem.
This step is:
A) Assessment
B) Diagnosis
C) Planning
D) Evaluation
Correct Answer: B) Diagnosis
Rationale: The diagnosis phase involves analyzing assessment data to identify
actual or potential health problems. The nurse uses clinical judgment to formulate
nursing diagnoses based on the data collected.
,Question 3
A patient's outcome statement includes "by discharge." Which component of a
goal does this represent?
A) Subject
B) Behavior
C) Condition
D) Time frame
Correct Answer: D) Time frame
Rationale: A well-written goal includes four components: subject (who), behavior
(what), condition (under what circumstances), and time frame (when). "By
discharge" specifies when the goal should be met.
Question 4
Which documentation method records only significant findings or deviations from
normal?
A) Narrative charting
B) Focus charting
C) Charting by exception
D) POMR
Correct Answer: C) Charting by exception
Rationale: Charting by exception (CBE) assumes all standards were met unless
documented otherwise. Only abnormal findings or deviations from expected
norms are recorded, making documentation more efficient.
Question 5
A nurse is documenting a patient's pain reassessment. Which entry is most
appropriate?
A) "Patient seems comfortable."
B) "Patient resting quietly."
, C) "Pain is better."
D) "Patient reports pain 1/10 on 0-10 scale."
Correct Answer: D) "Patient reports pain 1/10 on 0-10 scale."
Rationale: Documentation must be objective, measurable, and specific. Vague
terms like "seems comfortable" or "better" are subjective and inadequate for
legal and professional standards.
Question 6
The primary purpose of the medical record is to:
A) Provide a legal defense for the hospital
B) Serve as a written record of patient care
C) Track employee performance
D) Determine the patient's insurance coverage
Correct Answer: B) Serve as a written record of patient care
Rationale: The medical record is a comprehensive documentation of the patient's
care, providing continuity and communication among healthcare providers. While
it may serve legal and billing purposes, its primary function is to document patient
care.
Question 7
A nurse accidentally documents vital signs in the wrong patient's chart. The nurse
should:
A) Erase the entry completely
B) Draw a single line through the entry, write "error," and initial
C) Use correction fluid
D) Leave it and document in the correct chart
Correct Answer: B) Draw a single line through the entry, write "error," and
initial
