,D439 Foundations of Nursing Exam
Prep — Comprehensive Review +
Practice MCQs — Western Governors
University 2025/2026
1. A nurse is collecting data on a newly admitted client. Which finding is considered subjective data?
A. Blood pressure 148/92 mmHg
B. Client reports feeling nauseated
C. Heart rate 112 beats/min
D. Skin is warm and moist to touch
Correct Answer: B. Client reports feeling nauseated
Rationale: Subjective data are what the client reports or experiences (symptoms). Objective data are
measurable, observable findings such as vital signs and skin assessment .
2. During which phase of the nursing process does the nurse establish measurable, patient-centered goals and
expected outcomes?
A. Assessment
B. Diagnosis
C. Planning
D. Evaluation
Correct Answer: C. Planning
,Rationale: Planning involves setting SMART goals and expected outcomes that are specific, measurable,
achievable, realistic, and time-bound. Assessment collects data; diagnosis identifies problems; evaluation
determines goal achievement .
3. A client with chest pain and dyspnea is admitted to the unit. Which action should the nurse take first?
A. Administer prescribed pain medication
B. Assess airway and breathing
C. Notify the healthcare provider
D. Obtain a 12-lead ECG
Correct Answer: B. Assess airway and breathing
Rationale: According to the ABC (Airway, Breathing, Circulation) prioritization framework, airway and breathing
always take priority. Assessment precedes intervention .
4. Which entry in the medical record is an example of objective documentation?
A. “Client seems anxious about surgery”
B. “Client’s heart rate is 110 beats/min”
C. “Client is difficult to work with”
D. “Client feels sad today”
Correct Answer: B. “Client’s heart rate is 110 beats/min”
, Rationale: Objective documentation records measurable, observable data. Subjective entries reflect opinions
or patient-reported feelings .
5. A nurse is delegating tasks to unlicensed assistive personnel (UAP). Which task is appropriate to delegate?
A. Assess lung sounds
B. Measure intake and output
C. Administer insulin
D. Change a sterile dressing
Correct Answer: B. Measure intake and output
Rationale: Measurement of intake and output is a basic task within UAP scope of practice. Assessment,
medication administration, and sterile procedures require a licensed nurse .
6. A client refuses a prescribed medication. What should the nurse do first?
A. Hide the medication in food
B. Explore the reason for refusal
C. Apply restraints and administer
D. Document the refusal and ignore
Correct Answer: B. Explore the reason for refusal
Rationale: Respecting patient autonomy requires assessing the reason for refusal before taking further action.
The nurse should notify the provider if the refusal is clinically significant .
Prep — Comprehensive Review +
Practice MCQs — Western Governors
University 2025/2026
1. A nurse is collecting data on a newly admitted client. Which finding is considered subjective data?
A. Blood pressure 148/92 mmHg
B. Client reports feeling nauseated
C. Heart rate 112 beats/min
D. Skin is warm and moist to touch
Correct Answer: B. Client reports feeling nauseated
Rationale: Subjective data are what the client reports or experiences (symptoms). Objective data are
measurable, observable findings such as vital signs and skin assessment .
2. During which phase of the nursing process does the nurse establish measurable, patient-centered goals and
expected outcomes?
A. Assessment
B. Diagnosis
C. Planning
D. Evaluation
Correct Answer: C. Planning
,Rationale: Planning involves setting SMART goals and expected outcomes that are specific, measurable,
achievable, realistic, and time-bound. Assessment collects data; diagnosis identifies problems; evaluation
determines goal achievement .
3. A client with chest pain and dyspnea is admitted to the unit. Which action should the nurse take first?
A. Administer prescribed pain medication
B. Assess airway and breathing
C. Notify the healthcare provider
D. Obtain a 12-lead ECG
Correct Answer: B. Assess airway and breathing
Rationale: According to the ABC (Airway, Breathing, Circulation) prioritization framework, airway and breathing
always take priority. Assessment precedes intervention .
4. Which entry in the medical record is an example of objective documentation?
A. “Client seems anxious about surgery”
B. “Client’s heart rate is 110 beats/min”
C. “Client is difficult to work with”
D. “Client feels sad today”
Correct Answer: B. “Client’s heart rate is 110 beats/min”
, Rationale: Objective documentation records measurable, observable data. Subjective entries reflect opinions
or patient-reported feelings .
5. A nurse is delegating tasks to unlicensed assistive personnel (UAP). Which task is appropriate to delegate?
A. Assess lung sounds
B. Measure intake and output
C. Administer insulin
D. Change a sterile dressing
Correct Answer: B. Measure intake and output
Rationale: Measurement of intake and output is a basic task within UAP scope of practice. Assessment,
medication administration, and sterile procedures require a licensed nurse .
6. A client refuses a prescribed medication. What should the nurse do first?
A. Hide the medication in food
B. Explore the reason for refusal
C. Apply restraints and administer
D. Document the refusal and ignore
Correct Answer: B. Explore the reason for refusal
Rationale: Respecting patient autonomy requires assessing the reason for refusal before taking further action.
The nurse should notify the provider if the refusal is clinically significant .
