NUR 155 Foundations of Nursing Exams 2, 3 & 4
Complete Review | Questions, Answers & Rationales |
2026/2027 Exam Prep | 100% Correct - Galen College
1: The Nursing Process and Critical Thinking
1. The nurse is using the nursing process to plan care for a client. Which step
involves analyzing data to identify client problems?
1. Assessment
2. Diagnosis
3. Planning
4. Evaluation
Answer: 2. Diagnosis
Rationale:
Diagnosis is the second step of the nursing process and involves analyzing the data
collected during assessment to identify client problems (nursing diagnoses). Assessment
involves collecting data. Planning involves developing goals and interventions.
Evaluation involves determining if the goals were met. The nursing diagnosis provides
the foundation for the care plan and guides the selection of interventions.
• Client Needs: Safe and Effective Care Environment
• Clinical Judgment/Cognitive Skill(s): Analyze Cues
• Cognitive Ability: Understanding
• Content Area: Nursing Process
• Integrated Process: Nursing Process/Analysis
• Priority Concepts: Clinical Judgment, Nursing Process
• Strategies: Subject
Test-Taking Strategy:
Focus on the phrase "analyzing data to identify client problems." Assessment is data
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,collection, planning is goal setting, and evaluation is outcome measurement. Diagnosis
is the only step that involves analyzing data to identify problems.
2. The nurse is caring for a client with impaired physical mobility. Which statement
is an appropriately written outcome for this client?
1. The client will be able to walk without assistance by discharge.
2. The client will ambulate 50 feet with a walker by the end of the shift.
3. The client will try to walk more often.
4. The client will feel better about their mobility.
Answer: 2. The client will ambulate 50 feet with a walker by the end of the shift.
Rationale:
Outcomes must be SMART: Specific, Measurable, Attainable, Realistic, and Time-bound.
"The client will ambulate 50 feet with a walker by the end of the shift" is specific
(ambulate 50 feet), measurable (50 feet), attainable, realistic, and time-bound (by the
end of the shift). Options 1, 3, and 4 are vague, not measurable, or not time-bound.
• Client Needs: Safe and Effective Care Environment
• Clinical Judgment/Cognitive Skill(s): Generate Solutions
• Cognitive Ability: Applying
• Content Area: Nursing Process
• Integrated Process: Nursing Process/Planning
• Priority Concepts: Clinical Judgment, Goal Setting
• Strategies: Subject
Test-Taking Strategy:
Focus on the SMART criteria for outcome writing. Eliminate options that lack specificity,
measurability, or a time frame.
3. A nurse is using the SBAR communication tool. Which information should the
nurse include in the 'B' (Background) section?
1. The patient's current vital signs
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, 2. The nurse's recommendation for a change in treatment
3. The reason for the current call or encounter
4. A brief summary of the patient's medical history
Answer: 4. A brief summary of the patient's medical history
Rationale:
Background (B) includes the patient's admitting diagnosis, medical history, and relevant
clinical information that sets the context for the current situation. Current vital signs
belong in Assessment (A). The reason for the call is Situation (S). The nurse's
recommendation is Recommendation (R).
• Client Needs: Safe and Effective Care Environment
• Clinical Judgment/Cognitive Skill(s): Take Action
• Cognitive Ability: Applying
• Content Area: Foundations of Care: Communication
• Integrated Process: Nursing Process/Implementation
• Priority Concepts: Communication, Safety
• Strategies: Subject
Test-Taking Strategy:
Recall the SBAR acronym: Situation, Background, Assessment, Recommendation.
Background includes the patient's history and context.
4. The nurse is admitting a client who speaks a different language. Which action is
most appropriate for effective communication?
1. Speak loudly and slowly to the client
2. Use a certified medical interpreter
3. Ask a family member to interpret
4. Use hand gestures to communicate
Answer: 2. Use a certified medical interpreter
Rationale:
Using a certified medical interpreter is the most appropriate action for effective
communication with a client who speaks a different language. Speaking loudly, using
family members, or relying on hand gestures can lead to miscommunication and
potential safety risks.
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, • Client Needs: Psychosocial Integrity
• Clinical Judgment/Cognitive Skill(s): Take Action
• Cognitive Ability: Applying
• Content Area: Foundations of Care: Communication
• Integrated Process: Nursing Process/Implementation
• Priority Concepts: Culture, Communication
• Strategies: Strategic Words
Test-Taking Strategy:
Note the strategic word "most appropriate." A certified medical interpreter is the gold
standard for communication with clients who have limited English proficiency.
5. The nurse is performing a morning assessment and notes the client to be
experiencing dyspnea. Which client assessment findings would most indicate this
respiratory condition? (Select all that apply.)
1. Occasional productive cough
2. Temperature 100.1 °F
3. Pulse oximetry 89%
4. Respirations 26 & shallow
5. Patient in orthopneic position
Answer: 3, 4, 5
Rationale:
Dyspnea is characterized by subjective difficulty breathing. Objective signs include
tachypnea (rapid respirations), shallow breathing, hypoxia (SpO2 < 92%), and orthopnea
(difficulty breathing when lying flat). Fever and a productive cough may be present but
are not specific indicators of dyspnea.
• Client Needs: Physiological Integrity
• Clinical Judgment/Cognitive Skill(s): Recognize Cues
• Cognitive Ability: Analyzing
• Content Area: Health Assessment
• Integrated Process: Nursing Process/Assessment
• Priority Concepts: Oxygenation, Assessment
• Strategies: Comparable or Alike Options
Page 4 of 137
Complete Review | Questions, Answers & Rationales |
2026/2027 Exam Prep | 100% Correct - Galen College
1: The Nursing Process and Critical Thinking
1. The nurse is using the nursing process to plan care for a client. Which step
involves analyzing data to identify client problems?
1. Assessment
2. Diagnosis
3. Planning
4. Evaluation
Answer: 2. Diagnosis
Rationale:
Diagnosis is the second step of the nursing process and involves analyzing the data
collected during assessment to identify client problems (nursing diagnoses). Assessment
involves collecting data. Planning involves developing goals and interventions.
Evaluation involves determining if the goals were met. The nursing diagnosis provides
the foundation for the care plan and guides the selection of interventions.
• Client Needs: Safe and Effective Care Environment
• Clinical Judgment/Cognitive Skill(s): Analyze Cues
• Cognitive Ability: Understanding
• Content Area: Nursing Process
• Integrated Process: Nursing Process/Analysis
• Priority Concepts: Clinical Judgment, Nursing Process
• Strategies: Subject
Test-Taking Strategy:
Focus on the phrase "analyzing data to identify client problems." Assessment is data
Page 1 of 137
,collection, planning is goal setting, and evaluation is outcome measurement. Diagnosis
is the only step that involves analyzing data to identify problems.
2. The nurse is caring for a client with impaired physical mobility. Which statement
is an appropriately written outcome for this client?
1. The client will be able to walk without assistance by discharge.
2. The client will ambulate 50 feet with a walker by the end of the shift.
3. The client will try to walk more often.
4. The client will feel better about their mobility.
Answer: 2. The client will ambulate 50 feet with a walker by the end of the shift.
Rationale:
Outcomes must be SMART: Specific, Measurable, Attainable, Realistic, and Time-bound.
"The client will ambulate 50 feet with a walker by the end of the shift" is specific
(ambulate 50 feet), measurable (50 feet), attainable, realistic, and time-bound (by the
end of the shift). Options 1, 3, and 4 are vague, not measurable, or not time-bound.
• Client Needs: Safe and Effective Care Environment
• Clinical Judgment/Cognitive Skill(s): Generate Solutions
• Cognitive Ability: Applying
• Content Area: Nursing Process
• Integrated Process: Nursing Process/Planning
• Priority Concepts: Clinical Judgment, Goal Setting
• Strategies: Subject
Test-Taking Strategy:
Focus on the SMART criteria for outcome writing. Eliminate options that lack specificity,
measurability, or a time frame.
3. A nurse is using the SBAR communication tool. Which information should the
nurse include in the 'B' (Background) section?
1. The patient's current vital signs
Page 2 of 137
, 2. The nurse's recommendation for a change in treatment
3. The reason for the current call or encounter
4. A brief summary of the patient's medical history
Answer: 4. A brief summary of the patient's medical history
Rationale:
Background (B) includes the patient's admitting diagnosis, medical history, and relevant
clinical information that sets the context for the current situation. Current vital signs
belong in Assessment (A). The reason for the call is Situation (S). The nurse's
recommendation is Recommendation (R).
• Client Needs: Safe and Effective Care Environment
• Clinical Judgment/Cognitive Skill(s): Take Action
• Cognitive Ability: Applying
• Content Area: Foundations of Care: Communication
• Integrated Process: Nursing Process/Implementation
• Priority Concepts: Communication, Safety
• Strategies: Subject
Test-Taking Strategy:
Recall the SBAR acronym: Situation, Background, Assessment, Recommendation.
Background includes the patient's history and context.
4. The nurse is admitting a client who speaks a different language. Which action is
most appropriate for effective communication?
1. Speak loudly and slowly to the client
2. Use a certified medical interpreter
3. Ask a family member to interpret
4. Use hand gestures to communicate
Answer: 2. Use a certified medical interpreter
Rationale:
Using a certified medical interpreter is the most appropriate action for effective
communication with a client who speaks a different language. Speaking loudly, using
family members, or relying on hand gestures can lead to miscommunication and
potential safety risks.
Page 3 of 137
, • Client Needs: Psychosocial Integrity
• Clinical Judgment/Cognitive Skill(s): Take Action
• Cognitive Ability: Applying
• Content Area: Foundations of Care: Communication
• Integrated Process: Nursing Process/Implementation
• Priority Concepts: Culture, Communication
• Strategies: Strategic Words
Test-Taking Strategy:
Note the strategic word "most appropriate." A certified medical interpreter is the gold
standard for communication with clients who have limited English proficiency.
5. The nurse is performing a morning assessment and notes the client to be
experiencing dyspnea. Which client assessment findings would most indicate this
respiratory condition? (Select all that apply.)
1. Occasional productive cough
2. Temperature 100.1 °F
3. Pulse oximetry 89%
4. Respirations 26 & shallow
5. Patient in orthopneic position
Answer: 3, 4, 5
Rationale:
Dyspnea is characterized by subjective difficulty breathing. Objective signs include
tachypnea (rapid respirations), shallow breathing, hypoxia (SpO2 < 92%), and orthopnea
(difficulty breathing when lying flat). Fever and a productive cough may be present but
are not specific indicators of dyspnea.
• Client Needs: Physiological Integrity
• Clinical Judgment/Cognitive Skill(s): Recognize Cues
• Cognitive Ability: Analyzing
• Content Area: Health Assessment
• Integrated Process: Nursing Process/Assessment
• Priority Concepts: Oxygenation, Assessment
• Strategies: Comparable or Alike Options
Page 4 of 137
