MODULE 7: NURSING FUNDAMENTALS COMPREHENSIVE EXAMINATION
SECTION A: THE NURSING PROCESS AND CRITICAL THINKING
1. A nurse is caring for a patient with a new diagnosis of diabetes. The nurse identifies
that the patient is anxious about self-administering insulin. This identification is part
of which step of the nursing process?
A. Assessment
B. Diagnosis
C. Planning
D. Evaluation
B. Diagnosis. The nursing diagnosis identifies the patient's actual or potential
health problem (anxiety) based on the assessment data collected. It is a clinical
judgment, not a medical diagnosis.
2. During the evaluation phase of the nursing process, the nurse determines that a
patient's goal of "ambulating to the bathroom without assistance" was not met.
What is the nurse's priority action?
A. Document the failure in the patient's chart.
B. Reassess the patient and modify the care plan.
C. Inform the physician that the patient is non-compliant.
D. Ask another nurse to attempt to ambulate the patient.
B. Reassess the patient and modify the care plan. Evaluation is not the end of
the process. If a goal is not met, the nurse must reassess the patient's condition
and revise the plan of care to better meet the patient's needs.
3. A nurse is using a critical thinking model to make clinical decisions. Which of the
following is the most important component of critical thinking in nursing?
A. The ability to perform technical skills quickly.
B. A strict adherence to hospital policy.
C. A questioning, reflective, and analytical approach.
, D. Memorizing a wide range of medical facts.
C. A questioning, reflective, and analytical approach. Critical thinking involves
purposeful, goal-directed thinking based on evidence and standards, not just
rote memorization or technical proficiency. It requires the nurse to question,
analyze, and reflect on the situation.
4. A nurse is developing a care plan for a patient. Which of the following is a correctly
written, patient-centered goal?
A. Nurse will turn patient every 2 hours.
B. Patient will be free from falls.
C. Patient will ambulate 50 feet in the hallway by day 3.
D. Patient will understand discharge instructions.
C. Patient will ambulate 50 feet in the hallway by day 3. This goal is specific,
measurable, achievable, relevant, and time-bound (SMART). It focuses on the
patient's action and includes a specific, measurable outcome and a timeframe.
5. The nurse is performing an initial assessment on a newly admitted patient. Which
type of data is the nurse primarily collecting?
A. Subjective data only.
B. Objective data only.
C. Both subjective and objective data.
D. Evaluative data.
C. Both subjective and objective data. An initial assessment is comprehensive
and includes subjective data (what the patient says, e.g., "I feel dizzy") and
objective data (what the nurse observes and measures, e.g., blood pressure is
90/50 mmHg).
6. A patient states, "I have a terrible headache." The nurse records this information.
This is an example of:
A. An objective finding.
B. A subjective finding.
C. A nursing diagnosis.
D. A medical diagnosis.
B. A subjective finding. Subjective data are the patient's perceptions, feelings,
and experiences, often reported as symptoms. Only the patient can validate
this information.
7. Which phase of the nursing process involves prioritizing patient problems and
identifying expected outcomes?
A. Assessment
, B. Diagnosis
C. Planning
D. Implementation
C. Planning. The planning phase involves prioritizing the identified nursing
diagnoses, establishing patient-centered goals and expected outcomes, and
selecting appropriate nursing interventions.
8. A nurse is implementing a nursing intervention that was prescribed by a physician,
such as administering a medication. This is an example of:
A. A nurse-initiated intervention.
B. A physician-initiated intervention.
C. A collaborative intervention.
D. A dependent nursing intervention.
B. A physician-initiated intervention. Also known as a dependent intervention,
this action requires a physician's order. The nurse is responsible for safely and
correctly implementing the order.
9. A nurse notices a patient is developing a pressure ulcer and initiates a turning
schedule and applies a specialized dressing. This is an example of:
A. A nurse-initiated intervention.
B. A physician-initiated intervention.
C. A dependent nursing intervention.
D. A collaborative intervention.
A. A nurse-initiated intervention. Also known as an independent intervention,
this is an action that a nurse can perform autonomously based on their
knowledge and skills, without a physician's order. Preventing pressure ulcers is
a core nursing responsibility.
10. A nurse and a physical therapist work together to help a patient improve their
mobility after a stroke. This is an example of:
A. A nurse-initiated intervention.
B. A physician-initiated intervention.
C. A dependent nursing intervention.
D. A collaborative intervention.
D. A collaborative intervention. This involves multiple healthcare professionals
(e.g., nurse, PT, OT) working together toward a common patient goal. The nurse
coordinates care with other disciplines.
11. The final step of the nursing process, where the nurse determines if the patient's
goals have been met, is:
SECTION A: THE NURSING PROCESS AND CRITICAL THINKING
1. A nurse is caring for a patient with a new diagnosis of diabetes. The nurse identifies
that the patient is anxious about self-administering insulin. This identification is part
of which step of the nursing process?
A. Assessment
B. Diagnosis
C. Planning
D. Evaluation
B. Diagnosis. The nursing diagnosis identifies the patient's actual or potential
health problem (anxiety) based on the assessment data collected. It is a clinical
judgment, not a medical diagnosis.
2. During the evaluation phase of the nursing process, the nurse determines that a
patient's goal of "ambulating to the bathroom without assistance" was not met.
What is the nurse's priority action?
A. Document the failure in the patient's chart.
B. Reassess the patient and modify the care plan.
C. Inform the physician that the patient is non-compliant.
D. Ask another nurse to attempt to ambulate the patient.
B. Reassess the patient and modify the care plan. Evaluation is not the end of
the process. If a goal is not met, the nurse must reassess the patient's condition
and revise the plan of care to better meet the patient's needs.
3. A nurse is using a critical thinking model to make clinical decisions. Which of the
following is the most important component of critical thinking in nursing?
A. The ability to perform technical skills quickly.
B. A strict adherence to hospital policy.
C. A questioning, reflective, and analytical approach.
, D. Memorizing a wide range of medical facts.
C. A questioning, reflective, and analytical approach. Critical thinking involves
purposeful, goal-directed thinking based on evidence and standards, not just
rote memorization or technical proficiency. It requires the nurse to question,
analyze, and reflect on the situation.
4. A nurse is developing a care plan for a patient. Which of the following is a correctly
written, patient-centered goal?
A. Nurse will turn patient every 2 hours.
B. Patient will be free from falls.
C. Patient will ambulate 50 feet in the hallway by day 3.
D. Patient will understand discharge instructions.
C. Patient will ambulate 50 feet in the hallway by day 3. This goal is specific,
measurable, achievable, relevant, and time-bound (SMART). It focuses on the
patient's action and includes a specific, measurable outcome and a timeframe.
5. The nurse is performing an initial assessment on a newly admitted patient. Which
type of data is the nurse primarily collecting?
A. Subjective data only.
B. Objective data only.
C. Both subjective and objective data.
D. Evaluative data.
C. Both subjective and objective data. An initial assessment is comprehensive
and includes subjective data (what the patient says, e.g., "I feel dizzy") and
objective data (what the nurse observes and measures, e.g., blood pressure is
90/50 mmHg).
6. A patient states, "I have a terrible headache." The nurse records this information.
This is an example of:
A. An objective finding.
B. A subjective finding.
C. A nursing diagnosis.
D. A medical diagnosis.
B. A subjective finding. Subjective data are the patient's perceptions, feelings,
and experiences, often reported as symptoms. Only the patient can validate
this information.
7. Which phase of the nursing process involves prioritizing patient problems and
identifying expected outcomes?
A. Assessment
, B. Diagnosis
C. Planning
D. Implementation
C. Planning. The planning phase involves prioritizing the identified nursing
diagnoses, establishing patient-centered goals and expected outcomes, and
selecting appropriate nursing interventions.
8. A nurse is implementing a nursing intervention that was prescribed by a physician,
such as administering a medication. This is an example of:
A. A nurse-initiated intervention.
B. A physician-initiated intervention.
C. A collaborative intervention.
D. A dependent nursing intervention.
B. A physician-initiated intervention. Also known as a dependent intervention,
this action requires a physician's order. The nurse is responsible for safely and
correctly implementing the order.
9. A nurse notices a patient is developing a pressure ulcer and initiates a turning
schedule and applies a specialized dressing. This is an example of:
A. A nurse-initiated intervention.
B. A physician-initiated intervention.
C. A dependent nursing intervention.
D. A collaborative intervention.
A. A nurse-initiated intervention. Also known as an independent intervention,
this is an action that a nurse can perform autonomously based on their
knowledge and skills, without a physician's order. Preventing pressure ulcers is
a core nursing responsibility.
10. A nurse and a physical therapist work together to help a patient improve their
mobility after a stroke. This is an example of:
A. A nurse-initiated intervention.
B. A physician-initiated intervention.
C. A dependent nursing intervention.
D. A collaborative intervention.
D. A collaborative intervention. This involves multiple healthcare professionals
(e.g., nurse, PT, OT) working together toward a common patient goal. The nurse
coordinates care with other disciplines.
11. The final step of the nursing process, where the nurse determines if the patient's
goals have been met, is:
