BSN Nursing Care Planning Examination
Practice Questions & [Verified Answers],
Plus Explained Rationales|2026 Latest
Update| Instant Download PDF
1. A nurse is developing a nursing care plan for a client admitted
with pneumonia. Which assessment finding should the nurse
prioritize when establishing the initial plan of care?
A. Decreased appetite for 2 days
B. Productive cough with yellow sputum
C. Respiratory rate of 32/min with oxygen saturation of 86%
D. Fatigue when performing activities of daily living
Answer: C. Respiratory rate of 32/min with oxygen saturation of 86%
Rationale: Impaired oxygenation is the priority because it represents
an immediate threat to physiologic stability. Using the ABC
framework, breathing and oxygenation take precedence over
nutrition, activity tolerance, and other concerns.
2. Which statement best describes the purpose of a nursing care
plan?
A. To replace the client's medical treatment plan
B. To provide a standardized list of physician prescriptions
C. To organize individualized nursing interventions and expected
outcomes
D. To document only the client's admission assessment
Answer: C. To organize individualized nursing interventions and
expected outcomes
1|Page
,Rationale: A nursing care plan translates assessment findings and
nursing diagnoses into individualized goals, interventions, and
evaluation criteria. It promotes continuity, communication, and
systematic nursing care.
3. A client with heart failure has bilateral crackles, dyspnea, and
peripheral edema. Which nursing diagnosis is most appropriate?
A. Activity Intolerance related to generalized weakness
B. Excess Fluid Volume related to compromised regulatory mechanisms
C. Deficient Knowledge related to unfamiliarity with medications
D. Imbalanced Nutrition: Less Than Body Requirements related to
anorexia
Answer: B. Excess Fluid Volume related to compromised regulatory
mechanisms
Rationale: Crackles, edema, and dyspnea are classic manifestations of
fluid accumulation associated with heart failure. The diagnosis should
be supported by the client's current assessment findings rather than
anticipated complications.
4. Which component of a nursing diagnosis identifies the underlying
cause or contributing factor?
A. Diagnostic label
B. Defining characteristic
C. Related factor
D. Medical diagnosis
Answer: C. Related factor
Rationale: The related factor describes the etiology or contributing
condition associated with the nursing diagnosis. Defining
characteristics are assessment findings that support the diagnosis.
2|Page
, 5. A nurse writes the following outcome: “The client will have
improved mobility.” Which revision would make the outcome
most measurable?
A. The client will understand mobility techniques.
B. The client will demonstrate improved movement eventually.
C. The client will ambulate 50 meters with a walker by the end of the
shift.
D. The client will try to walk more frequently.
Answer: C. The client will ambulate 50 meters with a walker by the
end of the shift.
Rationale: A measurable outcome specifies the behavior, amount,
assistive device, and time frame. This allows the nurse to objectively
determine whether the goal was achieved.
6. A client is diagnosed with acute pain after abdominal surgery.
Which outcome is most appropriate?
A. The client will have no postoperative complications.
B. The client will verbalize a pain level of 3/10 or less within 1 hour of
intervention.
C. The client will receive analgesics as prescribed.
D. The nurse will monitor the client's pain every 4 hours.
Answer: B. The client will verbalize a pain level of 3/10 or less within 1
hour of intervention.
Rationale: A patient-centered outcome describes the desired change
in the client's condition. Medication administration and monitoring
are nursing interventions, not patient outcomes.
7. A nurse is prioritizing diagnoses for a client with chronic
obstructive pulmonary disease who has ineffective airway
3|Page
, clearance, insomnia, and deficient knowledge. Which diagnosis
should receive the highest priority?
A. Insomnia
B. Deficient Knowledge
C. Ineffective Airway Clearance
D. Disturbed Sleep Pattern
Answer: C. Ineffective Airway Clearance
Rationale: Airway clearance directly affects ventilation and
oxygenation and therefore takes priority over sleep and educational
needs. Physiologic threats are generally addressed before lower-
priority psychosocial or educational problems.
8. Which nursing intervention is most appropriate for a client with
impaired skin integrity related to immobility?
A. Encourage prolonged bed rest
B. Reposition the client at regular intervals
C. Restrict protein intake
D. Massage reddened areas vigorously
Answer: B. Reposition the client at regular intervals
Rationale: Regular repositioning reduces prolonged pressure and
promotes tissue perfusion. Vigorous massage over reddened tissue
can cause additional tissue injury, while adequate nutrition rather
than protein restriction generally supports healing.
9. Which intervention demonstrates the principle of individualized
nursing care?
A. Applying the same turning schedule to every hospitalized client
B. Using the hospital's standard education script without modification
C. Adapting medication education to the client's literacy and language
4|Page
Practice Questions & [Verified Answers],
Plus Explained Rationales|2026 Latest
Update| Instant Download PDF
1. A nurse is developing a nursing care plan for a client admitted
with pneumonia. Which assessment finding should the nurse
prioritize when establishing the initial plan of care?
A. Decreased appetite for 2 days
B. Productive cough with yellow sputum
C. Respiratory rate of 32/min with oxygen saturation of 86%
D. Fatigue when performing activities of daily living
Answer: C. Respiratory rate of 32/min with oxygen saturation of 86%
Rationale: Impaired oxygenation is the priority because it represents
an immediate threat to physiologic stability. Using the ABC
framework, breathing and oxygenation take precedence over
nutrition, activity tolerance, and other concerns.
2. Which statement best describes the purpose of a nursing care
plan?
A. To replace the client's medical treatment plan
B. To provide a standardized list of physician prescriptions
C. To organize individualized nursing interventions and expected
outcomes
D. To document only the client's admission assessment
Answer: C. To organize individualized nursing interventions and
expected outcomes
1|Page
,Rationale: A nursing care plan translates assessment findings and
nursing diagnoses into individualized goals, interventions, and
evaluation criteria. It promotes continuity, communication, and
systematic nursing care.
3. A client with heart failure has bilateral crackles, dyspnea, and
peripheral edema. Which nursing diagnosis is most appropriate?
A. Activity Intolerance related to generalized weakness
B. Excess Fluid Volume related to compromised regulatory mechanisms
C. Deficient Knowledge related to unfamiliarity with medications
D. Imbalanced Nutrition: Less Than Body Requirements related to
anorexia
Answer: B. Excess Fluid Volume related to compromised regulatory
mechanisms
Rationale: Crackles, edema, and dyspnea are classic manifestations of
fluid accumulation associated with heart failure. The diagnosis should
be supported by the client's current assessment findings rather than
anticipated complications.
4. Which component of a nursing diagnosis identifies the underlying
cause or contributing factor?
A. Diagnostic label
B. Defining characteristic
C. Related factor
D. Medical diagnosis
Answer: C. Related factor
Rationale: The related factor describes the etiology or contributing
condition associated with the nursing diagnosis. Defining
characteristics are assessment findings that support the diagnosis.
2|Page
, 5. A nurse writes the following outcome: “The client will have
improved mobility.” Which revision would make the outcome
most measurable?
A. The client will understand mobility techniques.
B. The client will demonstrate improved movement eventually.
C. The client will ambulate 50 meters with a walker by the end of the
shift.
D. The client will try to walk more frequently.
Answer: C. The client will ambulate 50 meters with a walker by the
end of the shift.
Rationale: A measurable outcome specifies the behavior, amount,
assistive device, and time frame. This allows the nurse to objectively
determine whether the goal was achieved.
6. A client is diagnosed with acute pain after abdominal surgery.
Which outcome is most appropriate?
A. The client will have no postoperative complications.
B. The client will verbalize a pain level of 3/10 or less within 1 hour of
intervention.
C. The client will receive analgesics as prescribed.
D. The nurse will monitor the client's pain every 4 hours.
Answer: B. The client will verbalize a pain level of 3/10 or less within 1
hour of intervention.
Rationale: A patient-centered outcome describes the desired change
in the client's condition. Medication administration and monitoring
are nursing interventions, not patient outcomes.
7. A nurse is prioritizing diagnoses for a client with chronic
obstructive pulmonary disease who has ineffective airway
3|Page
, clearance, insomnia, and deficient knowledge. Which diagnosis
should receive the highest priority?
A. Insomnia
B. Deficient Knowledge
C. Ineffective Airway Clearance
D. Disturbed Sleep Pattern
Answer: C. Ineffective Airway Clearance
Rationale: Airway clearance directly affects ventilation and
oxygenation and therefore takes priority over sleep and educational
needs. Physiologic threats are generally addressed before lower-
priority psychosocial or educational problems.
8. Which nursing intervention is most appropriate for a client with
impaired skin integrity related to immobility?
A. Encourage prolonged bed rest
B. Reposition the client at regular intervals
C. Restrict protein intake
D. Massage reddened areas vigorously
Answer: B. Reposition the client at regular intervals
Rationale: Regular repositioning reduces prolonged pressure and
promotes tissue perfusion. Vigorous massage over reddened tissue
can cause additional tissue injury, while adequate nutrition rather
than protein restriction generally supports healing.
9. Which intervention demonstrates the principle of individualized
nursing care?
A. Applying the same turning schedule to every hospitalized client
B. Using the hospital's standard education script without modification
C. Adapting medication education to the client's literacy and language
4|Page
