NACE Foundations of Nursing 2026 |
Questions, Answers & Detailed Rationales
Chapter 1: Nursing Process & Clinical Judgment
1. A nurse is caring for a patient admitted with dehydration. Which action best
demonstrates the Assessment phase of the nursing process?
A) Administering IV fluids as prescribed
B) Asking the patient about fluid intake over the past 24 hours
C) Setting a goal for the patient to drink 2,000 mL daily
D) Documenting that the patient received 500 mL of IV fluid
Correct Answer: B) Asking the patient about fluid intake over the past 24
hours
Rationale: The Assessment phase involves collecting subjective and
objective data to establish a patient database. Asking about fluid intake directly
gathers patient-reported data. Administering fluids is Implementation; setting
goals is Planning; and charting administered fluid is Evaluation/Documentation.
2. A patient states, "I feel like something terrible is going to happen." Which
nursing diagnosis is most appropriate?
A) Acute Pain
B) Anxiety
C) Risk for Falls
D) Deficient Knowledge
Correct Answer: B) Anxiety
Rationale: The patient's expression of apprehension and dread aligns with
the defining characteristics of Anxiety (NANDA-I). Acute Pain requires reports of
physical discomfort; Risk for Falls pertains to mobility/vulnerability factors;
Deficient Knowledge relates to a cognitive deficit, not an emotional one.
3. Which statement reflects the Evaluation phase of the nursing process?
A) The patient will ambulate 50 feet by end of shift
B) The nurse measures the patient's oxygen saturation after repositioning
,C) The nurse repositions the patient to improve oxygenation
D) The nurse identifies that the patient has impaired gas exchange
Correct Answer: B) The nurse measures the patient's oxygen saturation
after repositioning
Rationale: Evaluation involves determining whether goals were met by
reassessing the patient after interventions. Measuring oxygen saturation after
repositioning assesses the effectiveness of the intervention. Option A is a goal
(Planning); Option C is Implementation; Option D is Diagnosis.
4. A nursing student is learning about the NCSBN Clinical Judgment Measurement
Model (CJMM). Which cognitive process occurs IMMEDIATELY after the nurse
analyzes cues?
A) Recognize Cues
B) Generate Solutions
C) Prioritize Hypotheses
D) Evaluate Outcomes
Correct Answer: C) Prioritize Hypotheses
Rationale: The NCSBN CJMM layers in order are: Recognize Cues →
Analyze Cues → Prioritize Hypotheses → Generate Solutions → Take Action →
Evaluate Outcomes. After analyzing cues, the nurse must prioritize hypotheses to
determine which potential problems are most urgent.
5. A nurse is formulating a nursing diagnosis for a patient who is post-operative
and refuses to cough and deep breathe due to incisional pain. Which NANDA
diagnosis is MOST appropriate?
A) Ineffective Airway Clearance related to incisional pain
B) Impaired Gas Exchange related to shallow breathing
C) Ineffective Coping related to surgical recovery
D) Acute Pain related to surgical incision as evidenced by guarding and refusal to
cough
Correct Answer: D) Acute Pain related to surgical incision as evidenced by
guarding and refusal to cough
Rationale: NANDA diagnoses follow the format: Problem + related to + as
,evidenced by. The patient's primary problem driving the behavior is acute pain,
which causes the refusal to cough. While Ineffective Airway Clearance and
Impaired Gas Exchange are potential complications, they are not yet the primary
diagnosis.
6. A nurse is prioritizing client care using Maslow's Hierarchy of Needs. Which
need is the highest priority?
A) Love and belonging
B) Self-esteem
C) Safety and security
D) Physiological needs
Correct Answer: D) Physiological needs
Rationale: According to Maslow's Hierarchy, physiological needs (e.g., air,
water, food, shelter, sleep) are the most basic and must be met before addressing
higher-level needs. In nursing, this translates to prioritizing oxygenation,
hydration, nutrition, and elimination. Safety comes next, followed by
love/belonging, esteem, and self-actualization.
7. A nurse is caring for a patient admitted with dehydration. In which order of the
nursing process (ADPIE) should the nurse perform the following actions? 1)
Develop a plan to increase oral fluid intake, 2) Measure intake and output, 3) Ask
the patient about usual daily fluid consumption, 4) Administer prescribed IV
fluids, 5) Compare intake and output values to assess progress.
A) 3, 2, 1, 4, 5
B) 3, 1, 4, 2, 5
C) 1, 3, 2, 4, 5
D) 2, 3, 1, 4, 5
Correct Answer: A) 3, 2, 1, 4, 5
Rationale: The ADPIE sequence is: Assessment (ask about fluid habits —
step 3), Diagnosis (identify dehydration from data), Planning (develop fluid
increase plan — step 1), Implementation (measure I&O — step 2, then administer
IV fluids — step 4), Evaluation (compare I&O — step 5). Option A correctly follows
the ADPIE framework.
, 8. A nurse is assessing a patient who reports a sudden onset of severe chest pain
radiating to the left arm. Which action should the nurse take FIRST?
A) Administer prescribed nitroglycerin
B) Obtain a full set of vital signs
C) Notify the healthcare provider immediately
D) Perform a comprehensive pain assessment
Correct Answer: B) Obtain a full set of vital signs
Rationale: When a patient presents with signs suggestive of acute
coronary syndrome, the nurse should first obtain a full set of vital signs to
establish a baseline and identify instability. This is part of the Assessment phase.
While notifying the provider is essential, assessment (vital signs) should precede
intervention and notification to provide accurate clinical data.
9. A nurse is evaluating a patient's response to pain medication administered 30
minutes ago. Which finding best indicates the medication was effective?
A) The patient is sleeping
B) The patient reports pain decreased from 8/10 to 3/10
C) The patient's heart rate increased from 88 to 102 bpm
D) The patient requests a different medication
Correct Answer: B) The patient reports pain decreased from 8/10 to 3/10
Rationale: Evaluation of pain intervention effectiveness is best
determined by the patient's self-report of pain intensity. A decrease from 8/10 to
3/10 indicates significant improvement. Sleeping may indicate relief but is not as
reliable as a verbal pain rating. An increased heart rate suggests worsening pain
or anxiety.
10. A nurse identifies that a patient has a nursing diagnosis of Risk for Falls. Which
action is the PRIORITY intervention?
A) Document the risk in the chart
B) Place the call light within reach and instruct the patient to call for assistance
C) Restrain the patient to prevent falls
D) Complete a fall risk assessment
Questions, Answers & Detailed Rationales
Chapter 1: Nursing Process & Clinical Judgment
1. A nurse is caring for a patient admitted with dehydration. Which action best
demonstrates the Assessment phase of the nursing process?
A) Administering IV fluids as prescribed
B) Asking the patient about fluid intake over the past 24 hours
C) Setting a goal for the patient to drink 2,000 mL daily
D) Documenting that the patient received 500 mL of IV fluid
Correct Answer: B) Asking the patient about fluid intake over the past 24
hours
Rationale: The Assessment phase involves collecting subjective and
objective data to establish a patient database. Asking about fluid intake directly
gathers patient-reported data. Administering fluids is Implementation; setting
goals is Planning; and charting administered fluid is Evaluation/Documentation.
2. A patient states, "I feel like something terrible is going to happen." Which
nursing diagnosis is most appropriate?
A) Acute Pain
B) Anxiety
C) Risk for Falls
D) Deficient Knowledge
Correct Answer: B) Anxiety
Rationale: The patient's expression of apprehension and dread aligns with
the defining characteristics of Anxiety (NANDA-I). Acute Pain requires reports of
physical discomfort; Risk for Falls pertains to mobility/vulnerability factors;
Deficient Knowledge relates to a cognitive deficit, not an emotional one.
3. Which statement reflects the Evaluation phase of the nursing process?
A) The patient will ambulate 50 feet by end of shift
B) The nurse measures the patient's oxygen saturation after repositioning
,C) The nurse repositions the patient to improve oxygenation
D) The nurse identifies that the patient has impaired gas exchange
Correct Answer: B) The nurse measures the patient's oxygen saturation
after repositioning
Rationale: Evaluation involves determining whether goals were met by
reassessing the patient after interventions. Measuring oxygen saturation after
repositioning assesses the effectiveness of the intervention. Option A is a goal
(Planning); Option C is Implementation; Option D is Diagnosis.
4. A nursing student is learning about the NCSBN Clinical Judgment Measurement
Model (CJMM). Which cognitive process occurs IMMEDIATELY after the nurse
analyzes cues?
A) Recognize Cues
B) Generate Solutions
C) Prioritize Hypotheses
D) Evaluate Outcomes
Correct Answer: C) Prioritize Hypotheses
Rationale: The NCSBN CJMM layers in order are: Recognize Cues →
Analyze Cues → Prioritize Hypotheses → Generate Solutions → Take Action →
Evaluate Outcomes. After analyzing cues, the nurse must prioritize hypotheses to
determine which potential problems are most urgent.
5. A nurse is formulating a nursing diagnosis for a patient who is post-operative
and refuses to cough and deep breathe due to incisional pain. Which NANDA
diagnosis is MOST appropriate?
A) Ineffective Airway Clearance related to incisional pain
B) Impaired Gas Exchange related to shallow breathing
C) Ineffective Coping related to surgical recovery
D) Acute Pain related to surgical incision as evidenced by guarding and refusal to
cough
Correct Answer: D) Acute Pain related to surgical incision as evidenced by
guarding and refusal to cough
Rationale: NANDA diagnoses follow the format: Problem + related to + as
,evidenced by. The patient's primary problem driving the behavior is acute pain,
which causes the refusal to cough. While Ineffective Airway Clearance and
Impaired Gas Exchange are potential complications, they are not yet the primary
diagnosis.
6. A nurse is prioritizing client care using Maslow's Hierarchy of Needs. Which
need is the highest priority?
A) Love and belonging
B) Self-esteem
C) Safety and security
D) Physiological needs
Correct Answer: D) Physiological needs
Rationale: According to Maslow's Hierarchy, physiological needs (e.g., air,
water, food, shelter, sleep) are the most basic and must be met before addressing
higher-level needs. In nursing, this translates to prioritizing oxygenation,
hydration, nutrition, and elimination. Safety comes next, followed by
love/belonging, esteem, and self-actualization.
7. A nurse is caring for a patient admitted with dehydration. In which order of the
nursing process (ADPIE) should the nurse perform the following actions? 1)
Develop a plan to increase oral fluid intake, 2) Measure intake and output, 3) Ask
the patient about usual daily fluid consumption, 4) Administer prescribed IV
fluids, 5) Compare intake and output values to assess progress.
A) 3, 2, 1, 4, 5
B) 3, 1, 4, 2, 5
C) 1, 3, 2, 4, 5
D) 2, 3, 1, 4, 5
Correct Answer: A) 3, 2, 1, 4, 5
Rationale: The ADPIE sequence is: Assessment (ask about fluid habits —
step 3), Diagnosis (identify dehydration from data), Planning (develop fluid
increase plan — step 1), Implementation (measure I&O — step 2, then administer
IV fluids — step 4), Evaluation (compare I&O — step 5). Option A correctly follows
the ADPIE framework.
, 8. A nurse is assessing a patient who reports a sudden onset of severe chest pain
radiating to the left arm. Which action should the nurse take FIRST?
A) Administer prescribed nitroglycerin
B) Obtain a full set of vital signs
C) Notify the healthcare provider immediately
D) Perform a comprehensive pain assessment
Correct Answer: B) Obtain a full set of vital signs
Rationale: When a patient presents with signs suggestive of acute
coronary syndrome, the nurse should first obtain a full set of vital signs to
establish a baseline and identify instability. This is part of the Assessment phase.
While notifying the provider is essential, assessment (vital signs) should precede
intervention and notification to provide accurate clinical data.
9. A nurse is evaluating a patient's response to pain medication administered 30
minutes ago. Which finding best indicates the medication was effective?
A) The patient is sleeping
B) The patient reports pain decreased from 8/10 to 3/10
C) The patient's heart rate increased from 88 to 102 bpm
D) The patient requests a different medication
Correct Answer: B) The patient reports pain decreased from 8/10 to 3/10
Rationale: Evaluation of pain intervention effectiveness is best
determined by the patient's self-report of pain intensity. A decrease from 8/10 to
3/10 indicates significant improvement. Sleeping may indicate relief but is not as
reliable as a verbal pain rating. An increased heart rate suggests worsening pain
or anxiety.
10. A nurse identifies that a patient has a nursing diagnosis of Risk for Falls. Which
action is the PRIORITY intervention?
A) Document the risk in the chart
B) Place the call light within reach and instruct the patient to call for assistance
C) Restrain the patient to prevent falls
D) Complete a fall risk assessment
