2026/2027 | Updated Edition with 100% Correct Solutions |
Nursing Fundamentals Exam Prep | Pass Guaranteed - A+
Graded
Topic 1: Nursing Process (12 Questions)
Q1
Scenario: A nurse admits a 72-year-old client with heart failure who reports increasing
shortness of breath, weight gain of 5 pounds in 3 days, and ankle swelling. The nurse
notes the client is taking furosemide 40mg daily at home but admits to occasionally
skipping doses when feeling better.
Question: Which nursing diagnosis should be the nurse's priority based on this
assessment data?
A. Nonadherence to medication regimen related to lack of knowledge
B. Excess fluid volume related to compromised regulatory mechanism
C. Activity intolerance related to imbalance between oxygen supply and demand
D. Knowledge deficit related to disease management [CORRECT: B]
,Correct Answer: B
Rationale: Using the nursing process and Maslow's hierarchy of needs, physiological
needs take priority. "Excess fluid volume" represents an immediate life-threatening
physiological problem (potential for pulmonary edema, cardiac decompensation) that
requires immediate intervention. The 5-pound weight gain in 3 days, ankle edema, and
SOB are classic signs of fluid overload in heart failure. While nonadherence (A) caused
the problem, it is not the immediate priority. Activity intolerance (C) is a symptom of the
fluid overload. Knowledge deficit (D) is important for discharge planning but not the
acute priority.
Distractor Analysis: Option A addresses the cause but not the immediate physiological
crisis. Option C is a secondary diagnosis resulting from the primary fluid volume
excess. Option D is appropriate for teaching but not priority in acute exacerbation.
Q2
Scenario: A nurse is developing a care plan for a client post-appendectomy. The client
has a nursing diagnosis of "Acute pain related to surgical incision." The nurse identifies
outcomes: (1) Client will verbalize pain level ≤3/10 by discharge, (2) Client will
demonstrate nonpharmacological pain relief techniques, (3) Client will be pain-free
within 24 hours.
Question: Which outcome is inappropriately stated for this nursing diagnosis?
A. Client will verbalize pain level ≤3/10 by discharge
,B. Client will demonstrate nonpharmacological pain relief techniques
C. Client will be pain-free within 24 hours [CORRECT: C]
D. All outcomes are appropriately stated
Correct Answer: C
Rationale: Outcomes must be realistic, measurable, and achievable. "Pain-free within 24
hours" post-appendectomy is unrealistic and potentially unsafe—some pain is expected
and completely eliminating it may require excessive sedation or indicate complications.
This sets up the client and nurse for failure. Outcomes A and B are SMART (Specific,
Measurable, Achievable, Relevant, Time-bound). Option A acknowledges that some pain
is acceptable post-surgery. Option B focuses on client empowerment and realistic
self-management. Updated 2026 pain management standards emphasize functional
pain control rather than zero pain scores.
Distractor Analysis: Options A and B represent appropriate, achievable outcomes.
Option D is incorrect because outcome C violates outcome-writing principles.
Q3
Scenario: During morning assessment, a nurse collects the following data on a
postoperative client: Temperature 38.2°C (100.8°F), pulse 92, respirations 18, blood
pressure 128/76, incision site warm and erythematous with purulent drainage, client
reports pain 6/10 at incision site.
, Question: Which action represents the evaluation phase of the nursing process?
A. Documenting the wound appearance and vital signs
B. Notifying the surgeon of potential wound infection
C. Comparing current wound status to expected healing outcomes [CORRECT: C]
D. Administering prescribed antibiotic therapy
Correct Answer: C
Rationale: The five phases of the nursing process are: Assessment (gathering data),
Diagnosis (analyzing data), Planning (setting goals/outcomes), Implementation
(performing interventions), and Evaluation (determining if outcomes were met).
Comparing current status to expected outcomes (Option C) is the definition of
evaluation—judging whether progress toward goals is occurring. Option A is
assessment. Option B and D are implementation activities. The 2026 NCLEX test plan
emphasizes that evaluation involves comparing actual outcomes to expected outcomes
and revising the plan as needed.
Distractor Analysis: Option A is assessment (data collection). Options B and D are
implementation (taking action based on the care plan).
Q4