NU 136 Exam 5
Questions with Answers | Pass Guaranteed| Updated-Galen
1. Which step of the nursing process comes first and forms the foundation for all
subsequent steps?
A. Diagnosis
B. Assessment
C. Planning
D. Implementation
Answer: B. Assessment
Rationale: Assessment is the first step of the nursing process (ADPIE) and
involves systematic collection of subjective and objective data; all other steps
depend on accurate assessment data.
2. A nurse writes the nursing diagnosis 'Impaired Gas Exchange related to fluid
accumulation in alveoli as evidenced by oxygen saturation of 88% and crackles
bilaterally.' Which part of the PES format does 'oxygen saturation of 88% and
crackles bilaterally' represent?
A. Problem
B. Etiology
C. Signs and symptoms (evidence/defining characteristics)
D. Goal
Answer: C. Signs and symptoms (evidence/defining characteristics)
Rationale: The PES format consists of Problem, Etiology (related to), and
Signs/Symptoms (as evidenced by). The measurable, observable data
supporting the diagnosis is the 'evidenced by' portion.
3. Which nursing diagnosis is written correctly as a 'risk for' diagnosis?
A. Risk for Impaired Skin Integrity related to immobility as evidenced by
redness over the sacrum
B. Risk for Impaired Skin Integrity related to immobility
, C. Impaired Skin Integrity related to immobility as evidenced by a stage 2
pressure injury
D. Risk for Infection as evidenced by elevated white blood cell count
Answer: B. Risk for Impaired Skin Integrity related to immobility
Rationale: A 'risk for' nursing diagnosis identifies a potential problem before it
occurs and therefore has no 'as evidenced by' (defining characteristics)
component, since the problem has not yet manifested; it only includes the
problem and related risk factors.
4. During the planning phase of the nursing process, the nurse establishes a goal
that states, 'The client will ambulate 50 feet with a walker by discharge.' This
goal is best described as which type?
A. Vague and non-measurable
B. A SMART, client-centered, measurable goal
C. A nursing diagnosis
D. An assessment finding
Answer: B. A SMART, client-centered, measurable goal
Rationale: This goal is Specific, Measurable, Attainable, Realistic, and Time-
bound (SMART) and is client-centered, describing an expected client outcome
rather than a nursing task.
5. A nurse administers a prescribed analgesic and repositions a client in pain.
Which step of the nursing process does this represent?
A. Assessment
B. Diagnosis
C. Implementation
D. Evaluation
Answer: C. Implementation
Rationale: Implementation is the step in which the nurse carries out planned
interventions, such as administering medications and performing comfort
measures, to achieve the established goals.
,6. After administering pain medication, the nurse returns in 30 minutes and asks
the client to rate their pain again. Which step of the nursing process is the nurse
performing?
A. Assessment only, unrelated to the nursing process
B. Evaluation, to determine whether the goal was met
C. Diagnosis
D. Planning
Answer: B. Evaluation, to determine whether the goal was met
Rationale: Evaluation involves reassessing the client to determine whether the
identified goals were achieved and whether the plan of care needs to be
revised.
7. A client states, 'I feel like I can't catch my breath.' The nurse recognizes this
statement as which type of data?
A. Objective data
B. Subjective data
C. Diagnostic data
D. Historical data only
Answer: B. Subjective data
Rationale: Subjective data consists of information reported by the client that
cannot be directly observed or measured by the nurse, such as feelings,
perceptions, and symptoms.
8. A nurse observes that a client's respiratory rate is 28 breaths/min with use of
accessory muscles. This is an example of which type of data?
A. Subjective data
B. Objective data
C. Secondary data only
D. Irrelevant data
Answer: B. Objective data
, Rationale: Objective data is information the nurse can directly observe,
measure, or verify, such as respiratory rate, use of accessory muscles, vital
signs, and laboratory results.
9. According to Maslow's hierarchy of needs, which client need should the nurse
address first?
A. A client's request for spiritual counseling
B. A client's need for oxygen due to labored breathing
C. A client's desire for more privacy during visits
D. A client's request to call a family member
Answer: B. A client's need for oxygen due to labored breathing
Rationale: Maslow's hierarchy places physiological needs, including
oxygenation, at the base of the pyramid; these must be met before addressing
safety, love/belonging, esteem, or self-actualization needs.
10. Using the ABC (Airway, Breathing, Circulation) framework, which client
should the nurse assess first?
A. A client reporting a headache rated 4/10
B. A client with stridor and difficulty speaking
C. A client requesting a warm blanket
D. A client asking about discharge instructions
Answer: B. A client with stridor and difficulty speaking
Rationale: Airway takes the highest priority in the ABC framework; stridor and
difficulty speaking indicate a potential airway obstruction, which is
immediately life-threatening and must be addressed first.
11. The nurse is caring for two clients: one reporting incisional pain rated 6/10
and one with a new onset of shortness of breath and oxygen saturation of 89%.
Which client should the nurse assess first?
A. The client with incisional pain, because pain control is a priority
B. The client with shortness of breath and low oxygen saturation, because
breathing takes priority over pain
C. Both clients should be assessed at exactly the same time
Questions with Answers | Pass Guaranteed| Updated-Galen
1. Which step of the nursing process comes first and forms the foundation for all
subsequent steps?
A. Diagnosis
B. Assessment
C. Planning
D. Implementation
Answer: B. Assessment
Rationale: Assessment is the first step of the nursing process (ADPIE) and
involves systematic collection of subjective and objective data; all other steps
depend on accurate assessment data.
2. A nurse writes the nursing diagnosis 'Impaired Gas Exchange related to fluid
accumulation in alveoli as evidenced by oxygen saturation of 88% and crackles
bilaterally.' Which part of the PES format does 'oxygen saturation of 88% and
crackles bilaterally' represent?
A. Problem
B. Etiology
C. Signs and symptoms (evidence/defining characteristics)
D. Goal
Answer: C. Signs and symptoms (evidence/defining characteristics)
Rationale: The PES format consists of Problem, Etiology (related to), and
Signs/Symptoms (as evidenced by). The measurable, observable data
supporting the diagnosis is the 'evidenced by' portion.
3. Which nursing diagnosis is written correctly as a 'risk for' diagnosis?
A. Risk for Impaired Skin Integrity related to immobility as evidenced by
redness over the sacrum
B. Risk for Impaired Skin Integrity related to immobility
, C. Impaired Skin Integrity related to immobility as evidenced by a stage 2
pressure injury
D. Risk for Infection as evidenced by elevated white blood cell count
Answer: B. Risk for Impaired Skin Integrity related to immobility
Rationale: A 'risk for' nursing diagnosis identifies a potential problem before it
occurs and therefore has no 'as evidenced by' (defining characteristics)
component, since the problem has not yet manifested; it only includes the
problem and related risk factors.
4. During the planning phase of the nursing process, the nurse establishes a goal
that states, 'The client will ambulate 50 feet with a walker by discharge.' This
goal is best described as which type?
A. Vague and non-measurable
B. A SMART, client-centered, measurable goal
C. A nursing diagnosis
D. An assessment finding
Answer: B. A SMART, client-centered, measurable goal
Rationale: This goal is Specific, Measurable, Attainable, Realistic, and Time-
bound (SMART) and is client-centered, describing an expected client outcome
rather than a nursing task.
5. A nurse administers a prescribed analgesic and repositions a client in pain.
Which step of the nursing process does this represent?
A. Assessment
B. Diagnosis
C. Implementation
D. Evaluation
Answer: C. Implementation
Rationale: Implementation is the step in which the nurse carries out planned
interventions, such as administering medications and performing comfort
measures, to achieve the established goals.
,6. After administering pain medication, the nurse returns in 30 minutes and asks
the client to rate their pain again. Which step of the nursing process is the nurse
performing?
A. Assessment only, unrelated to the nursing process
B. Evaluation, to determine whether the goal was met
C. Diagnosis
D. Planning
Answer: B. Evaluation, to determine whether the goal was met
Rationale: Evaluation involves reassessing the client to determine whether the
identified goals were achieved and whether the plan of care needs to be
revised.
7. A client states, 'I feel like I can't catch my breath.' The nurse recognizes this
statement as which type of data?
A. Objective data
B. Subjective data
C. Diagnostic data
D. Historical data only
Answer: B. Subjective data
Rationale: Subjective data consists of information reported by the client that
cannot be directly observed or measured by the nurse, such as feelings,
perceptions, and symptoms.
8. A nurse observes that a client's respiratory rate is 28 breaths/min with use of
accessory muscles. This is an example of which type of data?
A. Subjective data
B. Objective data
C. Secondary data only
D. Irrelevant data
Answer: B. Objective data
, Rationale: Objective data is information the nurse can directly observe,
measure, or verify, such as respiratory rate, use of accessory muscles, vital
signs, and laboratory results.
9. According to Maslow's hierarchy of needs, which client need should the nurse
address first?
A. A client's request for spiritual counseling
B. A client's need for oxygen due to labored breathing
C. A client's desire for more privacy during visits
D. A client's request to call a family member
Answer: B. A client's need for oxygen due to labored breathing
Rationale: Maslow's hierarchy places physiological needs, including
oxygenation, at the base of the pyramid; these must be met before addressing
safety, love/belonging, esteem, or self-actualization needs.
10. Using the ABC (Airway, Breathing, Circulation) framework, which client
should the nurse assess first?
A. A client reporting a headache rated 4/10
B. A client with stridor and difficulty speaking
C. A client requesting a warm blanket
D. A client asking about discharge instructions
Answer: B. A client with stridor and difficulty speaking
Rationale: Airway takes the highest priority in the ABC framework; stridor and
difficulty speaking indicate a potential airway obstruction, which is
immediately life-threatening and must be addressed first.
11. The nurse is caring for two clients: one reporting incisional pain rated 6/10
and one with a new onset of shortness of breath and oxygen saturation of 89%.
Which client should the nurse assess first?
A. The client with incisional pain, because pain control is a priority
B. The client with shortness of breath and low oxygen saturation, because
breathing takes priority over pain
C. Both clients should be assessed at exactly the same time
