NUR3632 FOUNDATIONS EXAM 2 QUESTIONS
COMPLETE WITH 100% VERIFIED ANSWERS AND
DETAILED RATIONALES
1. A nurse is prioritizing patient care according to Maslow's hierarchy
of needs. Which patient should the nurse assess first?
A. A patient who is upset about missing a family birthday party
B. A patient who reports severe pain (8/10) after surgery
C. A patient with a new colostomy who refuses to look at the stoma
D. A patient with audible wheezing and oxygen saturation of 89%
Correct Answer: D. According to Maslow's hierarchy, physiologic needs
(oxygenation, circulation, nutrition, elimination, temperature) are the
highest priority and must be met before higher-level needs. Airway and
breathing take precedence over pain, self-esteem, and belonging needs.
2. A nurse is writing a nursing diagnosis for a patient. Which part of
the diagnosis represents the etiology (related factor)?
A. Ineffective Airway Clearance
B. Thick secretions
C. Crackles in lung bases and oxygen saturation of 88%
D. As evidenced by
Correct Answer: B. The etiology is the related factor that contributes to
the problem. In the diagnosis "Ineffective Airway Clearance related to
thick secretions as evidenced by crackles," the etiology is "thick
secretions".
,3. What is the correct order of the nursing process (ADPIE)?
A. Assessment, Planning, Implementation, Diagnosis, Evaluation
B. Assessment, Diagnosis, Planning, Implementation, Evaluation
C. Assessment, Implementation, Diagnosis, Planning, Evaluation
D. Diagnosis, Assessment, Planning, Implementation, Evaluation
Correct Answer: B. The nursing process follows the sequence:
Assessment, Diagnosis, Planning, Implementation, and Evaluation
(ADPIE).
4. A nurse is using critical pathway methodology for planning care.
Which statement accurately describes this system?
A. The nurse uses a binary decision tree for stepwise assessment and
intervention
B. The nurse uses broad, research-based practice recommendations
that may not have been tested
C. The nurse uses a minimal practice standard and is able to alter care
to meet individual needs
D. The nurse uses preprinted provider orders to expedite the order
process
Correct Answer: C. A critical pathway is a sequential, interdisciplinary,
minimal practice standard for a specific patient population that provides
flexibility to alter care to meet individualized patient needs.
5. A nurse plans to place a patient on precautions for skin breakdown
after noticing reddened heels. This is an example of what type of
planning?
A. Initial planning
B. Standardized planning
,C. Ongoing planning
D. Discharge planning
Correct Answer: C. Ongoing planning is problem-oriented and keeps the
plan up to date as new actual or potential problems are identified.
6. A nurse is collecting more patient data to confirm a diagnosis of
emphysema. What type of diagnosis does this intervention seek to
confirm?
A. Actual
B. Possible
C. Risk
D. Collaborative
Correct Answer: B. An intervention for a possible diagnosis is to collect
more patient data to confirm or rule out the problem.
7. Which nursing action occurs during the outcome identification and
planning step of the nursing process?
A. The nurse formulates nursing diagnoses
B. The nurse identifies expected patient outcomes
C. The nurse assesses the patient's mental status
D. The nurse evaluates the patient's outcome achievement
Correct Answer: B. During the outcome identification and planning
step, the nurse identifies and writes expected patient outcomes, selects
evidence-based interventions, and communicates the plan of care.
8. According to Maslow's hierarchy, which need is the lowest priority?
A. Physiologic needs
B. Safety needs
, C. Self-esteem needs
D. Self-actualization needs
Correct Answer: D. Maslow's hierarchy prioritizes needs from lowest
(most basic) to highest: (1) physiologic, (2) safety, (3) love and
belonging, (4) self-esteem, and (5) self-actualization.
9. A nurse is using a binary decision tree that guides stepwise
assessment with intense specificity and no provider flexibility. What is
this called?
A. Critical pathway
B. Clinical guideline
C. Algorithm
D. Order set
Correct Answer: C. An algorithm is a binary decision tree that guides
stepwise assessment and intervention with intense specificity and no
provider flexibility.
10. When planning care for a patient with chronic lung disease
receiving oxygen through a nasal cannula, what does the nurse
expect?
A. The oxygen must be humidified
B. The rate will be no more than 2 to 3 L/min or less
C. Arterial blood gases will be drawn every 4 hours
D. The rate will be 6 L/min or more
Correct Answer: B. A rate higher than 3 L/min may destroy the hypoxic
drive that stimulates respirations in a patient with chronic lung disease.
11. What are the five classic elements of evaluation in correct
sequence?
COMPLETE WITH 100% VERIFIED ANSWERS AND
DETAILED RATIONALES
1. A nurse is prioritizing patient care according to Maslow's hierarchy
of needs. Which patient should the nurse assess first?
A. A patient who is upset about missing a family birthday party
B. A patient who reports severe pain (8/10) after surgery
C. A patient with a new colostomy who refuses to look at the stoma
D. A patient with audible wheezing and oxygen saturation of 89%
Correct Answer: D. According to Maslow's hierarchy, physiologic needs
(oxygenation, circulation, nutrition, elimination, temperature) are the
highest priority and must be met before higher-level needs. Airway and
breathing take precedence over pain, self-esteem, and belonging needs.
2. A nurse is writing a nursing diagnosis for a patient. Which part of
the diagnosis represents the etiology (related factor)?
A. Ineffective Airway Clearance
B. Thick secretions
C. Crackles in lung bases and oxygen saturation of 88%
D. As evidenced by
Correct Answer: B. The etiology is the related factor that contributes to
the problem. In the diagnosis "Ineffective Airway Clearance related to
thick secretions as evidenced by crackles," the etiology is "thick
secretions".
,3. What is the correct order of the nursing process (ADPIE)?
A. Assessment, Planning, Implementation, Diagnosis, Evaluation
B. Assessment, Diagnosis, Planning, Implementation, Evaluation
C. Assessment, Implementation, Diagnosis, Planning, Evaluation
D. Diagnosis, Assessment, Planning, Implementation, Evaluation
Correct Answer: B. The nursing process follows the sequence:
Assessment, Diagnosis, Planning, Implementation, and Evaluation
(ADPIE).
4. A nurse is using critical pathway methodology for planning care.
Which statement accurately describes this system?
A. The nurse uses a binary decision tree for stepwise assessment and
intervention
B. The nurse uses broad, research-based practice recommendations
that may not have been tested
C. The nurse uses a minimal practice standard and is able to alter care
to meet individual needs
D. The nurse uses preprinted provider orders to expedite the order
process
Correct Answer: C. A critical pathway is a sequential, interdisciplinary,
minimal practice standard for a specific patient population that provides
flexibility to alter care to meet individualized patient needs.
5. A nurse plans to place a patient on precautions for skin breakdown
after noticing reddened heels. This is an example of what type of
planning?
A. Initial planning
B. Standardized planning
,C. Ongoing planning
D. Discharge planning
Correct Answer: C. Ongoing planning is problem-oriented and keeps the
plan up to date as new actual or potential problems are identified.
6. A nurse is collecting more patient data to confirm a diagnosis of
emphysema. What type of diagnosis does this intervention seek to
confirm?
A. Actual
B. Possible
C. Risk
D. Collaborative
Correct Answer: B. An intervention for a possible diagnosis is to collect
more patient data to confirm or rule out the problem.
7. Which nursing action occurs during the outcome identification and
planning step of the nursing process?
A. The nurse formulates nursing diagnoses
B. The nurse identifies expected patient outcomes
C. The nurse assesses the patient's mental status
D. The nurse evaluates the patient's outcome achievement
Correct Answer: B. During the outcome identification and planning
step, the nurse identifies and writes expected patient outcomes, selects
evidence-based interventions, and communicates the plan of care.
8. According to Maslow's hierarchy, which need is the lowest priority?
A. Physiologic needs
B. Safety needs
, C. Self-esteem needs
D. Self-actualization needs
Correct Answer: D. Maslow's hierarchy prioritizes needs from lowest
(most basic) to highest: (1) physiologic, (2) safety, (3) love and
belonging, (4) self-esteem, and (5) self-actualization.
9. A nurse is using a binary decision tree that guides stepwise
assessment with intense specificity and no provider flexibility. What is
this called?
A. Critical pathway
B. Clinical guideline
C. Algorithm
D. Order set
Correct Answer: C. An algorithm is a binary decision tree that guides
stepwise assessment and intervention with intense specificity and no
provider flexibility.
10. When planning care for a patient with chronic lung disease
receiving oxygen through a nasal cannula, what does the nurse
expect?
A. The oxygen must be humidified
B. The rate will be no more than 2 to 3 L/min or less
C. Arterial blood gases will be drawn every 4 hours
D. The rate will be 6 L/min or more
Correct Answer: B. A rate higher than 3 L/min may destroy the hypoxic
drive that stimulates respirations in a patient with chronic lung disease.
11. What are the five classic elements of evaluation in correct
sequence?
