1
Fundamentals of Nursing Final Exam | 200
Advanced Practice Questions with Verified
Answers & Detailed Rationales | Complete
Review for Nursing Students | NCLEX-Aligned |
Graded A+
SECTION 1: THE NURSING PROCESS (Questions 1–30)
1. A nurse is caring for a client with a localized infection. Which of the following
assessment findings is the most specific indicator of a systemic infection?
A. Edema at the site of injury
B. Purulent drainage from a wound
C. Increase in immature white blood cells (shift to the left)
D. Pain and tenderness on palpation
Correct answer: C
Rationale: A "shift to the left" indicates an increase in immature neutrophils
(bands), which is a classic sign that the body is responding to a systemic bacterial
infection. Localized signs like edema, purulent drainage, and pain indicate local
infection, not systemic involvement . This finding is the most specific laboratory
indicator of systemic infection.
2. The nurse is monitoring a patient who is 24 hours post-operation from
surgery. Which finding requires immediate intervention?
A. Blood pressure 100/80 mmHg
B. 24-hour urine output of 300 mL
1
, 2
C. Pain rating of 4 on 1-10 scale
D. Temperature of 37.1°C (98.8°F)
Correct answer: B
Rationale: A 24-hour urine output of 300 mL is significantly below the minimum
acceptable output of 30 mL/hour (720 mL/24 hours) or 400 mL/24 hours for
adults . This indicates oliguria and possible renal impairment or hypovolemia
requiring immediate intervention. A BP of 100/80 is acceptable post-op, pain of
4/10 requires intervention but is not as urgent, and a temperature of 37.1°C is
within normal range.
3. The interpretation of the data collected about the patient represents which
step of the nursing process?
A. Assessment of the patient
B. Health problems of the patient
C. Proposed plan of care for the patient
D. Nursing interventions done for the patient
Correct answer: A
Rationale: Assessment is the systematic collection, organization, and
interpretation of patient data. The interpretation of collected data is a crucial
component of the assessment phase of the nursing process. It includes both
subjective and objective data gathering and analysis to identify patient needs .
4. Which of the following is the most appropriate goal for a nursing diagnosis of
diarrhea?
A. The patient will experience decreased frequency of bowel elimination
B. The patient will take anti-diarrhea medication
C. The patient will give stool specimen for laboratory investigation
D. The patient will save stool for inspection by the nurse
2
, 3
Correct answer: A
Rationale: Patient goals should be measurable outcomes related to the nursing
diagnosis. "The patient will experience decreased frequency of bowel elimination"
is an appropriate, measurable goal. Taking medication (B) is an intervention, not
an outcome. Giving a specimen (C) is a diagnostic test, not a goal. Saving stool for
inspection (D) is not a meaningful patient outcome .
5. In the SBAR communication tool, the 'B' stands for:
A. Behavior
B. Background
C. Beliefs
D. Baseline
Correct answer: B
Rationale: SBAR is a standardized communication framework that stands
for Situation, Background, Assessment, and Recommendation. 'Background'
provides relevant clinical context, including the patient's diagnosis, medical
history, and current status, which is essential for effective handoff communication
and patient safety .
6. A nurse is developing a care plan for a patient. Which of the following is the
outcome of the planning phase of the nursing process?
A. Nursing care notes
B. Nursing care objectives
C. Nursing care plan
D. Nursing history
Correct answer: C
Rationale: The planning phase results in the development of a written nursing
care plan, which includes nursing diagnoses, goals/outcomes, and nursing
3
, 4
interventions. Nursing care notes (A) are documentation of implementation.
Nursing care objectives (B) are part of the plan but not the complete outcome.
Nursing history (D) is collected during the assessment phase .
7. A nurse is assessing a patient who complains of a sharp, localized pain in the
right lower quadrant of the abdomen. This is an example of:
A. Objective data
B. Subjective data
C. Secondary data
D. Inference
Correct answer: B
Rationale: Subjective data are the client's perceptions, feelings, or descriptions of
health problems, such as pain reported by the patient. These are symptoms that
cannot be measured by others and are only known to the person experiencing
them. Objective data are observable and measurable signs .
8. Which of the following is an example of objective data?
A. Patient states, "I am in severe pain"
B. Patient's heart rate is 88 bpm
C. Patient rates pain 4 out of 10
D. Patient says they are worried about surgery
Correct answer: B
Rationale: Objective data are observable and measurable signs that can be seen,
heard, felt, or measured by the nurse. Heart rate is a measurable vital sign and is
therefore objective data. The other options are subjective data, which are the
client's perceptions, feelings, or descriptions of their health problems .
4
Fundamentals of Nursing Final Exam | 200
Advanced Practice Questions with Verified
Answers & Detailed Rationales | Complete
Review for Nursing Students | NCLEX-Aligned |
Graded A+
SECTION 1: THE NURSING PROCESS (Questions 1–30)
1. A nurse is caring for a client with a localized infection. Which of the following
assessment findings is the most specific indicator of a systemic infection?
A. Edema at the site of injury
B. Purulent drainage from a wound
C. Increase in immature white blood cells (shift to the left)
D. Pain and tenderness on palpation
Correct answer: C
Rationale: A "shift to the left" indicates an increase in immature neutrophils
(bands), which is a classic sign that the body is responding to a systemic bacterial
infection. Localized signs like edema, purulent drainage, and pain indicate local
infection, not systemic involvement . This finding is the most specific laboratory
indicator of systemic infection.
2. The nurse is monitoring a patient who is 24 hours post-operation from
surgery. Which finding requires immediate intervention?
A. Blood pressure 100/80 mmHg
B. 24-hour urine output of 300 mL
1
, 2
C. Pain rating of 4 on 1-10 scale
D. Temperature of 37.1°C (98.8°F)
Correct answer: B
Rationale: A 24-hour urine output of 300 mL is significantly below the minimum
acceptable output of 30 mL/hour (720 mL/24 hours) or 400 mL/24 hours for
adults . This indicates oliguria and possible renal impairment or hypovolemia
requiring immediate intervention. A BP of 100/80 is acceptable post-op, pain of
4/10 requires intervention but is not as urgent, and a temperature of 37.1°C is
within normal range.
3. The interpretation of the data collected about the patient represents which
step of the nursing process?
A. Assessment of the patient
B. Health problems of the patient
C. Proposed plan of care for the patient
D. Nursing interventions done for the patient
Correct answer: A
Rationale: Assessment is the systematic collection, organization, and
interpretation of patient data. The interpretation of collected data is a crucial
component of the assessment phase of the nursing process. It includes both
subjective and objective data gathering and analysis to identify patient needs .
4. Which of the following is the most appropriate goal for a nursing diagnosis of
diarrhea?
A. The patient will experience decreased frequency of bowel elimination
B. The patient will take anti-diarrhea medication
C. The patient will give stool specimen for laboratory investigation
D. The patient will save stool for inspection by the nurse
2
, 3
Correct answer: A
Rationale: Patient goals should be measurable outcomes related to the nursing
diagnosis. "The patient will experience decreased frequency of bowel elimination"
is an appropriate, measurable goal. Taking medication (B) is an intervention, not
an outcome. Giving a specimen (C) is a diagnostic test, not a goal. Saving stool for
inspection (D) is not a meaningful patient outcome .
5. In the SBAR communication tool, the 'B' stands for:
A. Behavior
B. Background
C. Beliefs
D. Baseline
Correct answer: B
Rationale: SBAR is a standardized communication framework that stands
for Situation, Background, Assessment, and Recommendation. 'Background'
provides relevant clinical context, including the patient's diagnosis, medical
history, and current status, which is essential for effective handoff communication
and patient safety .
6. A nurse is developing a care plan for a patient. Which of the following is the
outcome of the planning phase of the nursing process?
A. Nursing care notes
B. Nursing care objectives
C. Nursing care plan
D. Nursing history
Correct answer: C
Rationale: The planning phase results in the development of a written nursing
care plan, which includes nursing diagnoses, goals/outcomes, and nursing
3
, 4
interventions. Nursing care notes (A) are documentation of implementation.
Nursing care objectives (B) are part of the plan but not the complete outcome.
Nursing history (D) is collected during the assessment phase .
7. A nurse is assessing a patient who complains of a sharp, localized pain in the
right lower quadrant of the abdomen. This is an example of:
A. Objective data
B. Subjective data
C. Secondary data
D. Inference
Correct answer: B
Rationale: Subjective data are the client's perceptions, feelings, or descriptions of
health problems, such as pain reported by the patient. These are symptoms that
cannot be measured by others and are only known to the person experiencing
them. Objective data are observable and measurable signs .
8. Which of the following is an example of objective data?
A. Patient states, "I am in severe pain"
B. Patient's heart rate is 88 bpm
C. Patient rates pain 4 out of 10
D. Patient says they are worried about surgery
Correct answer: B
Rationale: Objective data are observable and measurable signs that can be seen,
heard, felt, or measured by the nurse. Heart rate is a measurable vital sign and is
therefore objective data. The other options are subjective data, which are the
client's perceptions, feelings, or descriptions of their health problems .
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