BSN 206 – Foundations Of Nursing
Fundamentals Exam Questions with Answers|
Nightingale College
,1. A nurse collects data indicating a client has a temperature of 102.2°F, dry
mucous membranes, and reports feeling thirsty. Which step of the nursing
process is the nurse performing?
A. Diagnosis
B. Assessment
C. Planning
D. Evaluation
Answer: B
Rationale: Assessment is the systematic collection of subjective and objective
data about a client's health status. Gathering vital signs, physical findings, and
client reports of symptoms is the data-collection phase, which precedes
forming a nursing diagnosis.
2. The nurse writes the following statement in a client's plan of care: 'Impaired
skin integrity related to immobility as evidenced by a stage II pressure injury on
the sacrum.' This is an example of what?
A. A medical diagnosis
B. A nursing diagnosis
C. An expected outcome
D. A nursing intervention
Answer: B
Rationale: A nursing diagnosis follows the PES format (Problem, Etiology,
Signs/Symptoms). This statement identifies a client problem (impaired skin
integrity), its cause (immobility), and supporting evidence (stage II pressure
injury), which is characteristic of a nursing diagnosis rather than a medical
diagnosis or intervention.
3. During the planning phase of the nursing process, the nurse's priority action is
to:
A. Implement prescribed treatments
B. Establish measurable, client-centered goals
C. Document the client's response to care
D. Perform a head-to-toe assessment
Answer: B
, Rationale: Planning involves setting realistic, measurable goals and outcomes
based on identified nursing diagnoses. Implementation of treatments and
documentation of responses occur later in the process; assessment precedes
planning.
4. Which outcome statement is written correctly using SMART criteria?
A. Client will feel better about mobility
B. Client will ambulate 50 feet with a walker by discharge
C. Nurse will encourage client to walk more
D. Client understands the importance of exercise
Answer: B
Rationale: SMART outcomes are Specific, Measurable, Attainable, Realistic,
and Time-limited. 'Ambulate 50 feet with a walker by discharge' specifies a
measurable distance, the method, and a timeframe, unlike vague statements
about feelings or understanding.
5. A nurse determines that a client did not meet the expected outcome of pain
relief after administering an analgesic. What should the nurse do next?
A. Discontinue the plan of care
B. Reassess the client and revise the plan
C. Document that the plan failed and take no further action
D. Wait until the next shift to reassess
Answer: B
Rationale: Evaluation is an ongoing process. When an outcome is not met, the
nurse must reassess the client's status, determine why the goal wasn't
achieved, and revise the nursing diagnosis, goals, or interventions as needed.
6. Which of the following is considered objective data?
A. Client states, 'I have a headache.'
B. Client rates pain as 7 out of 10
C. Blood pressure of 148/92 mmHg
D. Client reports feeling anxious
Answer: C
Rationale: Objective data are measurable and observable findings obtained
through physical examination or diagnostic testing, such as a blood pressure
, reading. Statements about pain, headache, or anxiety are subjective data
reported by the client.
7. A nurse is using Maslow's hierarchy of needs to prioritize care for four clients.
Which client should be assessed first?
A. A client requesting information about a support group
B. A client with a respiratory rate of 32 and audible wheezing
C. A client asking for reassurance about surgery
D. A client who wants to discuss discharge planning
Answer: B
Rationale: Maslow's hierarchy places physiological needs, including
oxygenation, as the highest priority. A respiratory rate of 32 with wheezing
signals actual or potential airway/breathing compromise and takes priority
over psychosocial or informational needs.
8. Which action best reflects the implementation phase of the nursing process?
A. Identifying that a client has a risk for falls
B. Setting a goal for the client to remain injury-free
C. Placing the bed in the lowest position and applying a fall-risk armband
D. Comparing the client's outcomes to the goals set
Answer: C
Rationale: Implementation is the phase in which the nurse carries out planned
interventions, such as fall-prevention measures. Identifying risk is diagnosis,
setting a goal is planning, and comparing outcomes is evaluation.
9. Critical thinking in nursing practice is best described as:
A. Following physician orders exactly as written
B. A purposeful, reflective reasoning process used to make clinical judgments
C. Relying solely on textbook knowledge
D. Completing tasks as quickly as possible
Answer: B
Rationale: Critical thinking involves purposeful, disciplined reasoning that
integrates knowledge, experience, and clinical data to make sound judgments
and decisions, rather than simply following orders or completing tasks quickly.
Fundamentals Exam Questions with Answers|
Nightingale College
,1. A nurse collects data indicating a client has a temperature of 102.2°F, dry
mucous membranes, and reports feeling thirsty. Which step of the nursing
process is the nurse performing?
A. Diagnosis
B. Assessment
C. Planning
D. Evaluation
Answer: B
Rationale: Assessment is the systematic collection of subjective and objective
data about a client's health status. Gathering vital signs, physical findings, and
client reports of symptoms is the data-collection phase, which precedes
forming a nursing diagnosis.
2. The nurse writes the following statement in a client's plan of care: 'Impaired
skin integrity related to immobility as evidenced by a stage II pressure injury on
the sacrum.' This is an example of what?
A. A medical diagnosis
B. A nursing diagnosis
C. An expected outcome
D. A nursing intervention
Answer: B
Rationale: A nursing diagnosis follows the PES format (Problem, Etiology,
Signs/Symptoms). This statement identifies a client problem (impaired skin
integrity), its cause (immobility), and supporting evidence (stage II pressure
injury), which is characteristic of a nursing diagnosis rather than a medical
diagnosis or intervention.
3. During the planning phase of the nursing process, the nurse's priority action is
to:
A. Implement prescribed treatments
B. Establish measurable, client-centered goals
C. Document the client's response to care
D. Perform a head-to-toe assessment
Answer: B
, Rationale: Planning involves setting realistic, measurable goals and outcomes
based on identified nursing diagnoses. Implementation of treatments and
documentation of responses occur later in the process; assessment precedes
planning.
4. Which outcome statement is written correctly using SMART criteria?
A. Client will feel better about mobility
B. Client will ambulate 50 feet with a walker by discharge
C. Nurse will encourage client to walk more
D. Client understands the importance of exercise
Answer: B
Rationale: SMART outcomes are Specific, Measurable, Attainable, Realistic,
and Time-limited. 'Ambulate 50 feet with a walker by discharge' specifies a
measurable distance, the method, and a timeframe, unlike vague statements
about feelings or understanding.
5. A nurse determines that a client did not meet the expected outcome of pain
relief after administering an analgesic. What should the nurse do next?
A. Discontinue the plan of care
B. Reassess the client and revise the plan
C. Document that the plan failed and take no further action
D. Wait until the next shift to reassess
Answer: B
Rationale: Evaluation is an ongoing process. When an outcome is not met, the
nurse must reassess the client's status, determine why the goal wasn't
achieved, and revise the nursing diagnosis, goals, or interventions as needed.
6. Which of the following is considered objective data?
A. Client states, 'I have a headache.'
B. Client rates pain as 7 out of 10
C. Blood pressure of 148/92 mmHg
D. Client reports feeling anxious
Answer: C
Rationale: Objective data are measurable and observable findings obtained
through physical examination or diagnostic testing, such as a blood pressure
, reading. Statements about pain, headache, or anxiety are subjective data
reported by the client.
7. A nurse is using Maslow's hierarchy of needs to prioritize care for four clients.
Which client should be assessed first?
A. A client requesting information about a support group
B. A client with a respiratory rate of 32 and audible wheezing
C. A client asking for reassurance about surgery
D. A client who wants to discuss discharge planning
Answer: B
Rationale: Maslow's hierarchy places physiological needs, including
oxygenation, as the highest priority. A respiratory rate of 32 with wheezing
signals actual or potential airway/breathing compromise and takes priority
over psychosocial or informational needs.
8. Which action best reflects the implementation phase of the nursing process?
A. Identifying that a client has a risk for falls
B. Setting a goal for the client to remain injury-free
C. Placing the bed in the lowest position and applying a fall-risk armband
D. Comparing the client's outcomes to the goals set
Answer: C
Rationale: Implementation is the phase in which the nurse carries out planned
interventions, such as fall-prevention measures. Identifying risk is diagnosis,
setting a goal is planning, and comparing outcomes is evaluation.
9. Critical thinking in nursing practice is best described as:
A. Following physician orders exactly as written
B. A purposeful, reflective reasoning process used to make clinical judgments
C. Relying solely on textbook knowledge
D. Completing tasks as quickly as possible
Answer: B
Rationale: Critical thinking involves purposeful, disciplined reasoning that
integrates knowledge, experience, and clinical data to make sound judgments
and decisions, rather than simply following orders or completing tasks quickly.
