NR-224 – Fundamentals of Nursing Complete
Study Guide & Practice Questions Patient Care
Principles, Nursing Process, Clinical Skills,
Safety Standards, and Exam Review
Question 1
A nurse is caring for a client who reports acute pain. After administering a
prescribed analgesic, which step of the nursing process should the nurse perform
next?
A) Assessment
B) Diagnosis
C) Planning
D) Evaluation
Answer: D) Evaluation
Rationale: The nursing process follows a systematic sequence: Assessment,
Diagnosis, Planning, Implementation, and Evaluation. After implementing an
intervention (administering the analgesic), the nurse must evaluate its
effectiveness. This is the final step before reassessing and potentially modifying
the plan of care.
Question 2
During the assessment phase of the nursing process, which type of data would be
considered subjective?
A) Blood pressure reading of 140/90 mmHg
B) Client's statement of "I feel dizzy"
C) Oxygen saturation of 94%
D) Presence of pedal edema
Answer: B) Client's statement of "I feel dizzy"
Rationale: Subjective data are information provided by the client, including
feelings, perceptions, and concerns. Objective data are measurable, observable, and
,verifiable (vital signs, physical assessment findings). The client's statement about
feeling dizzy is subjective; vital signs and physical findings are objective.
Question 3
A nurse is developing a care plan for a client with impaired mobility. Which of the
following is an appropriate nursing diagnosis statement?
A) "Impaired physical mobility related to pain as evidenced by limited range of
motion"
B) "Client will ambulate with assistance within 24 hours"
C) "Assist client with range-of-motion exercises"
D) "Musculoskeletal impairment secondary to fracture"
Answer: A) "Impaired physical mobility related to pain as evidenced by
limited range of motion"
Rationale: A nursing diagnosis follows the PES format: Problem (Impaired
physical mobility), Etiology (related to pain), and Signs/Symptoms (as evidenced
by limited range of motion). Option B is a goal statement, C is an intervention, and
D is a medical diagnosis.
Question 4
The nurse is using critical thinking to prioritize client care. Which of the following
clients should the nurse assess first?
A) A client requesting pain medication for a headache
B) A client with a new onset of chest pain and diaphoresis
C) A client needing assistance with ambulation to the bathroom
D) A client with a scheduled wound dressing change
Answer: B) A client with a new onset of chest pain and diaphoresis
Rationale: Using Maslow's hierarchy and ABCs (Airway, Breathing, Circulation),
the client with chest pain and diaphoresis indicates a potential life-threatening
cardiac event and should be assessed first. Pain management, ambulation
assistance, and wound care are important but lower priority.
,Question 5
Which of the following demonstrates appropriate documentation using the SOAP
format?
A) S: "Client reports headache", O: Vital signs WNL, A: Pain related to tension, P:
Administer ibuprofen
B) O: Vital signs WNL, S: "Client reports headache", A: Pain related to tension, P:
Administer ibuprofen
C) S: "Client reports headache", O: Vital signs WNL, P: Administer ibuprofen, A:
Pain related to tension
D) A: Pain related to tension, S: "Client reports headache", O: Vital signs WNL, P:
Administer ibuprofen
Answer: A) S: "Client reports headache", O: Vital signs WNL, A: Pain
related to tension, P: Administer ibuprofen
Rationale: SOAP documentation follows: Subjective data (client's report),
Objective data (observable findings), Assessment (nursing diagnosis/analysis), and
Plan (interventions). Correct sequencing is essential for accurate, organized
documentation.
Question 6
A nurse is developing expected outcomes for a client with hypertension. Which of
the following is a properly written outcome?
A) "Client will understand the importance of medication compliance"
B) "Client will have blood pressure within normal limits by discharge"
C) "Client will take prescribed medication as ordered"
D) "Blood pressure will be 120/80 mmHg"
Answer: B) "Client will have blood pressure within normal limits by
discharge"
Rationale: A well-written outcome is specific, measurable, attainable, realistic,
and time-bound (SMART). Option B specifies the client, the criterion (blood
pressure within normal limits), and a time frame (by discharge). "Understand" is
not measurable, and Option C is an intervention, not an outcome.
, Question 7
The nurse is performing a focused assessment on a client with shortness of breath.
Which of the following should be included?
A) Lung sounds, respiratory rate, oxygen saturation, and level of consciousness
B) Bowel sounds, appetite, and dietary intake
C) Gait, balance, and mobility status
D) Skin integrity, wound appearance, and drainage
Answer: A) Lung sounds, respiratory rate, oxygen saturation, and level of
consciousness
Rationale: A focused assessment targets the specific body system affected by the
client's chief complaint. For shortness of breath, the nurse should assess the
respiratory system and related indicators of oxygenation and perfusion. The other
options are appropriate for different focused assessments.
Question 8
Which of the following is an example of a nursing intervention that is
independent?
A) Administering a prescribed medication
B) Assisting a client with deep breathing exercises
C) Inserting an indwelling urinary catheter per provider order
D) Applying a prescribed wound dressing
Answer: B) Assisting a client with deep breathing exercises
Rationale: Independent nursing interventions are those that a nurse can perform
without a provider's order. These include client education, comfort measures,
positioning, and promoting mobility. Dependent interventions require a provider's
order (medications, catheter insertion). Interdependent interventions involve
collaboration with other healthcare team members.
Question 9
The nurse is using the nursing process to address a client's fall risk. During the
implementation phase, which action should the nurse take?
Study Guide & Practice Questions Patient Care
Principles, Nursing Process, Clinical Skills,
Safety Standards, and Exam Review
Question 1
A nurse is caring for a client who reports acute pain. After administering a
prescribed analgesic, which step of the nursing process should the nurse perform
next?
A) Assessment
B) Diagnosis
C) Planning
D) Evaluation
Answer: D) Evaluation
Rationale: The nursing process follows a systematic sequence: Assessment,
Diagnosis, Planning, Implementation, and Evaluation. After implementing an
intervention (administering the analgesic), the nurse must evaluate its
effectiveness. This is the final step before reassessing and potentially modifying
the plan of care.
Question 2
During the assessment phase of the nursing process, which type of data would be
considered subjective?
A) Blood pressure reading of 140/90 mmHg
B) Client's statement of "I feel dizzy"
C) Oxygen saturation of 94%
D) Presence of pedal edema
Answer: B) Client's statement of "I feel dizzy"
Rationale: Subjective data are information provided by the client, including
feelings, perceptions, and concerns. Objective data are measurable, observable, and
,verifiable (vital signs, physical assessment findings). The client's statement about
feeling dizzy is subjective; vital signs and physical findings are objective.
Question 3
A nurse is developing a care plan for a client with impaired mobility. Which of the
following is an appropriate nursing diagnosis statement?
A) "Impaired physical mobility related to pain as evidenced by limited range of
motion"
B) "Client will ambulate with assistance within 24 hours"
C) "Assist client with range-of-motion exercises"
D) "Musculoskeletal impairment secondary to fracture"
Answer: A) "Impaired physical mobility related to pain as evidenced by
limited range of motion"
Rationale: A nursing diagnosis follows the PES format: Problem (Impaired
physical mobility), Etiology (related to pain), and Signs/Symptoms (as evidenced
by limited range of motion). Option B is a goal statement, C is an intervention, and
D is a medical diagnosis.
Question 4
The nurse is using critical thinking to prioritize client care. Which of the following
clients should the nurse assess first?
A) A client requesting pain medication for a headache
B) A client with a new onset of chest pain and diaphoresis
C) A client needing assistance with ambulation to the bathroom
D) A client with a scheduled wound dressing change
Answer: B) A client with a new onset of chest pain and diaphoresis
Rationale: Using Maslow's hierarchy and ABCs (Airway, Breathing, Circulation),
the client with chest pain and diaphoresis indicates a potential life-threatening
cardiac event and should be assessed first. Pain management, ambulation
assistance, and wound care are important but lower priority.
,Question 5
Which of the following demonstrates appropriate documentation using the SOAP
format?
A) S: "Client reports headache", O: Vital signs WNL, A: Pain related to tension, P:
Administer ibuprofen
B) O: Vital signs WNL, S: "Client reports headache", A: Pain related to tension, P:
Administer ibuprofen
C) S: "Client reports headache", O: Vital signs WNL, P: Administer ibuprofen, A:
Pain related to tension
D) A: Pain related to tension, S: "Client reports headache", O: Vital signs WNL, P:
Administer ibuprofen
Answer: A) S: "Client reports headache", O: Vital signs WNL, A: Pain
related to tension, P: Administer ibuprofen
Rationale: SOAP documentation follows: Subjective data (client's report),
Objective data (observable findings), Assessment (nursing diagnosis/analysis), and
Plan (interventions). Correct sequencing is essential for accurate, organized
documentation.
Question 6
A nurse is developing expected outcomes for a client with hypertension. Which of
the following is a properly written outcome?
A) "Client will understand the importance of medication compliance"
B) "Client will have blood pressure within normal limits by discharge"
C) "Client will take prescribed medication as ordered"
D) "Blood pressure will be 120/80 mmHg"
Answer: B) "Client will have blood pressure within normal limits by
discharge"
Rationale: A well-written outcome is specific, measurable, attainable, realistic,
and time-bound (SMART). Option B specifies the client, the criterion (blood
pressure within normal limits), and a time frame (by discharge). "Understand" is
not measurable, and Option C is an intervention, not an outcome.
, Question 7
The nurse is performing a focused assessment on a client with shortness of breath.
Which of the following should be included?
A) Lung sounds, respiratory rate, oxygen saturation, and level of consciousness
B) Bowel sounds, appetite, and dietary intake
C) Gait, balance, and mobility status
D) Skin integrity, wound appearance, and drainage
Answer: A) Lung sounds, respiratory rate, oxygen saturation, and level of
consciousness
Rationale: A focused assessment targets the specific body system affected by the
client's chief complaint. For shortness of breath, the nurse should assess the
respiratory system and related indicators of oxygenation and perfusion. The other
options are appropriate for different focused assessments.
Question 8
Which of the following is an example of a nursing intervention that is
independent?
A) Administering a prescribed medication
B) Assisting a client with deep breathing exercises
C) Inserting an indwelling urinary catheter per provider order
D) Applying a prescribed wound dressing
Answer: B) Assisting a client with deep breathing exercises
Rationale: Independent nursing interventions are those that a nurse can perform
without a provider's order. These include client education, comfort measures,
positioning, and promoting mobility. Dependent interventions require a provider's
order (medications, catheter insertion). Interdependent interventions involve
collaboration with other healthcare team members.
Question 9
The nurse is using the nursing process to address a client's fall risk. During the
implementation phase, which action should the nurse take?
