NU 136 EXAM 3 FUNDAMENTALS OF NURSING 2026
QUESTION 1
A nurse is collecting data on a newly admitted patient. Which action demonstrates the
assessment phase of the nursing process?
A) Administering prescribed medications
B) Documenting the patient's vital signs
C) Setting goals for patient recovery
D) Evaluating the effectiveness of pain medication
CORRECT ANSWER: B) Documenting the patient's vital signs
RATIONALE: Assessment is the first phase of the nursing process and involves systematic
data collection, including both objective data (vital signs, physical examination findings)
and subjective data (patient reports). Administering medications is implementation, setting
goals is planning, and evaluating effectiveness is evaluation. Assessment provides the
foundation for identifying patient problems and developing an individualized care plan.
QUESTION 2
What are the five components of the nursing process in their correct sequence?
A) Planning, Assessment, Diagnosis, Implementation, Evaluation
B) Assessment, Diagnosis, Planning, Implementation, Evaluation
,C) Diagnosis, Assessment, Planning, Evaluation, Implementation
D) Assessment, Planning, Diagnosis, Implementation, Evaluation
CORRECT ANSWER: B) Assessment, Diagnosis, Planning, Implementation,
Evaluation
RATIONALE: The nursing process is a cyclical, systematic framework that guides nursing
practice. Assessment involves collecting comprehensive data about the patient. Nursing
diagnosis is analyzing the data to identify actual or potential health problems. Planning
involves establishing measurable goals and interventions. Implementation is carrying out
the planned interventions. Evaluation determines whether the goals were achieved. This
sequence ensures logical, patient-centered care delivery.
QUESTION 3
A nurse identifies the patient problem "Risk for falls related to unsteady gait." This
statement represents which part of the nursing process?
A) Assessment
B) Nursing diagnosis
C) Planning
D) Evaluation
CORRECT ANSWER: B) Nursing diagnosis
RATIONALE: A nursing diagnosis is a clinical judgment about a patient's response to
actual or potential health problems. "Risk for falls related to unsteady gait" identifies a
potential problem based on assessment data. Assessment involves collecting data,
planning sets goals and interventions, and evaluation judges outcomes. Nursing diagnoses
guide the selection of appropriate nursing interventions.
,QUESTION 4
Which patient goal is correctly written and measurable?
A) "Patient will understand how to use a walker."
B) "Patient will ambulate 50 feet with a walker by end of shift."
C) "The nurse will teach the patient to use a walker."
D) "Patient should be able to walk with a walker."
CORRECT ANSWER: B) "Patient will ambulate 50 feet with a walker by end of
shift."
RATIONALE: A correctly written outcome must be SMART: Specific, Measurable,
Achievable, Realistic, and Time-bound. Option B includes a specific action (ambulate),
measurable distance (50 feet), and time frame (by end of shift). "Understand" is not
measurable (Option A). Goals should focus on patient behavior, not nurse actions (Option
C). Option D lacks measurability and timeframe.
QUESTION 5
The nurse is preparing a patient's care plan. How often should the nursing care plan be
updated?
A) Only when the patient is discharged
B) Every 24 hours
C) Weekly
D) Only when the physician orders changes
CORRECT ANSWER: B) Every 24 hours
RATIONALE: Nursing care plans must be reviewed and updated at least every 24 hours to
reflect the patient's changing condition and response to interventions. Continuous
, evaluation ensures the plan remains relevant and effective. Waiting until discharge or
relying solely on physician orders would not provide timely, patient-centered care.
QUESTION 6
A nurse is caring for a patient who is post-operative following a hip replacement. Which
of the following is a correctly written expected outcome?
A) "The client will walk 50 feet by discharge"
B) "The client will ambulate independently"
C) "The client will be pain-free"
D) "The nurse will assist the client with walking"
CORRECT ANSWER: A) "The client will walk 50 feet by discharge"
RATIONALE: A correctly written outcome must be specific, measurable, achievable,
realistic, and time-bound (SMART). Option A includes a specific distance and timeframe.
Option B lacks measurability and a timeframe. Option C is unrealistic (pain-free is rarely
achievable). Option D describes a nursing intervention, not a patient outcome.
QUESTION 7
What is the primary source of information during a nursing assessment?
A) The patient's family
B) The patient's medical records
C) The patient
D) The healthcare provider
QUESTION 1
A nurse is collecting data on a newly admitted patient. Which action demonstrates the
assessment phase of the nursing process?
A) Administering prescribed medications
B) Documenting the patient's vital signs
C) Setting goals for patient recovery
D) Evaluating the effectiveness of pain medication
CORRECT ANSWER: B) Documenting the patient's vital signs
RATIONALE: Assessment is the first phase of the nursing process and involves systematic
data collection, including both objective data (vital signs, physical examination findings)
and subjective data (patient reports). Administering medications is implementation, setting
goals is planning, and evaluating effectiveness is evaluation. Assessment provides the
foundation for identifying patient problems and developing an individualized care plan.
QUESTION 2
What are the five components of the nursing process in their correct sequence?
A) Planning, Assessment, Diagnosis, Implementation, Evaluation
B) Assessment, Diagnosis, Planning, Implementation, Evaluation
,C) Diagnosis, Assessment, Planning, Evaluation, Implementation
D) Assessment, Planning, Diagnosis, Implementation, Evaluation
CORRECT ANSWER: B) Assessment, Diagnosis, Planning, Implementation,
Evaluation
RATIONALE: The nursing process is a cyclical, systematic framework that guides nursing
practice. Assessment involves collecting comprehensive data about the patient. Nursing
diagnosis is analyzing the data to identify actual or potential health problems. Planning
involves establishing measurable goals and interventions. Implementation is carrying out
the planned interventions. Evaluation determines whether the goals were achieved. This
sequence ensures logical, patient-centered care delivery.
QUESTION 3
A nurse identifies the patient problem "Risk for falls related to unsteady gait." This
statement represents which part of the nursing process?
A) Assessment
B) Nursing diagnosis
C) Planning
D) Evaluation
CORRECT ANSWER: B) Nursing diagnosis
RATIONALE: A nursing diagnosis is a clinical judgment about a patient's response to
actual or potential health problems. "Risk for falls related to unsteady gait" identifies a
potential problem based on assessment data. Assessment involves collecting data,
planning sets goals and interventions, and evaluation judges outcomes. Nursing diagnoses
guide the selection of appropriate nursing interventions.
,QUESTION 4
Which patient goal is correctly written and measurable?
A) "Patient will understand how to use a walker."
B) "Patient will ambulate 50 feet with a walker by end of shift."
C) "The nurse will teach the patient to use a walker."
D) "Patient should be able to walk with a walker."
CORRECT ANSWER: B) "Patient will ambulate 50 feet with a walker by end of
shift."
RATIONALE: A correctly written outcome must be SMART: Specific, Measurable,
Achievable, Realistic, and Time-bound. Option B includes a specific action (ambulate),
measurable distance (50 feet), and time frame (by end of shift). "Understand" is not
measurable (Option A). Goals should focus on patient behavior, not nurse actions (Option
C). Option D lacks measurability and timeframe.
QUESTION 5
The nurse is preparing a patient's care plan. How often should the nursing care plan be
updated?
A) Only when the patient is discharged
B) Every 24 hours
C) Weekly
D) Only when the physician orders changes
CORRECT ANSWER: B) Every 24 hours
RATIONALE: Nursing care plans must be reviewed and updated at least every 24 hours to
reflect the patient's changing condition and response to interventions. Continuous
, evaluation ensures the plan remains relevant and effective. Waiting until discharge or
relying solely on physician orders would not provide timely, patient-centered care.
QUESTION 6
A nurse is caring for a patient who is post-operative following a hip replacement. Which
of the following is a correctly written expected outcome?
A) "The client will walk 50 feet by discharge"
B) "The client will ambulate independently"
C) "The client will be pain-free"
D) "The nurse will assist the client with walking"
CORRECT ANSWER: A) "The client will walk 50 feet by discharge"
RATIONALE: A correctly written outcome must be specific, measurable, achievable,
realistic, and time-bound (SMART). Option A includes a specific distance and timeframe.
Option B lacks measurability and a timeframe. Option C is unrealistic (pain-free is rarely
achievable). Option D describes a nursing intervention, not a patient outcome.
QUESTION 7
What is the primary source of information during a nursing assessment?
A) The patient's family
B) The patient's medical records
C) The patient
D) The healthcare provider
