Fundamentals of Nursing Practice –
Comprehensive Exam 1 (Detailed Answers)
Complete Practice Examination – 150 Questions
SECTION 1: NURSING PROCESS & CRITICAL THINKING (Questions 1-30)
Question 1:
The nurse is caring for a patient with pneumonia. Which action demonstrates the assessment phase of
the nursing process?
A) Administering prescribed antibiotics
B) Auscultating lung sounds
C) Evaluating the effectiveness of oxygen therapy
D) Documenting the patient's response to treatment
Answer: B) Auscultating lung sounds
Rationale: Assessment is the first step of the nursing process, involving data collection. Auscultating lung
sounds is a physical assessment technique used to gather objective data. Administration of antibiotics is
implementation. Evaluation involves determining the effectiveness of interventions. Documentation
occurs throughout the process.
Question 2:
The nurse is developing a care plan for a patient with impaired mobility. Which nursing diagnosis is
written correctly?
A) Risk for falls
B) Risk for falls related to impaired mobility
C) Risk for falls R/T impaired mobility
D) Risk for falls as evidenced by unsteady gait
Answer: C) Risk for falls R/T impaired mobility
Rationale: A properly written nursing diagnosis includes the problem statement and the etiology (related
factors) connected by "related to" (R/T). "Risk for falls R/T impaired mobility" is correctly formatted. The
phrase "as evidenced by" (AEB) is used for actual diagnoses, not risk diagnoses.
Question 3:
The nurse is caring for a patient who is anxious about an upcoming procedure. Which intervention
demonstrates therapeutic communication?
,A) "Don't worry, everything will be fine"
B) "You seem anxious. Tell me more about your concerns."
C) "I had that procedure and it wasn't bad at all."
D) "You should try to relax and not think about it."
Answer: B) "You seem anxious. Tell me more about your concerns."
Rationale: Therapeutic communication involves acknowledging the patient's feelings and encouraging
expression of concerns. This response validates the patient's anxiety and opens the door for discussion.
False reassurance, changing the subject, and giving personal opinions are not therapeutic.
Question 4:
The nurse is evaluating the effectiveness of pain management for a postoperative patient. Which action
is MOST appropriate?
A) Ask the patient to rate pain on a scale of 0-10
B) Observe the patient's facial expression
C) Assess vital signs
D) All of the above
Answer: D) All of the above
Rationale: Evaluation involves multiple assessment methods. Pain is subjective; the patient's self-report
is the gold standard. Observation of facial expressions and vital signs can provide additional objective
data. All of these methods contribute to a comprehensive evaluation of pain management effectiveness.
Question 5:
The nurse is prioritizing patient care. Which patient should be seen FIRST?
A) A patient with a fever of 101°F (38.3°C)
B) A patient with chest pain and diaphoresis
C) A patient requesting pain medication
D) A patient who needs assistance with ambulation
Answer: B) A patient with chest pain and diaphoresis
Rationale: Chest pain with diaphoresis may indicate a myocardial infarction, a life-threatening
emergency requiring immediate attention. This patient should be seen first. Maslow's hierarchy of needs
and the ABCs (Airway, Breathing, Circulation) guide prioritization. Physiological needs take priority over
comfort and mobility needs.
Question 6:
The nurse is documenting patient care. Which documentation is MOST appropriate?
A) "Patient is in a good mood today"
B) "Patient reports pain 7/10 in right knee"
,C) "Patient seems to be improving"
D) "Patient is difficult and uncooperative"
Answer: B) "Patient reports pain 7/10 in right knee"
Rationale: Documentation should be objective, factual, and based on assessment data. "Patient reports
pain 7/10" is objective and measurable. Subjective statements ("good mood," "seems improving") and
judgmental statements ("difficult," "uncooperative") are not appropriate in professional documentation.
Question 7:
The nurse is using the SBAR communication tool. What does SBAR stand for?
A) Situation, Background, Assessment, Recommendation
B) Symptoms, Background, Assessment, Referral
C) Situation, Background, Action, Referral
D) Symptoms, Background, Action, Recommendation
Answer: A) Situation, Background, Assessment, Recommendation
Rationale: SBAR is a standardized communication tool used to improve patient safety and
communication between healthcare providers. It stands for Situation (current problem), Background
(pertinent history), Assessment (nurse's assessment), and Recommendation (what is needed). It provides
a structured, concise format for communication.
Question 8:
The nurse is caring for a patient with a new diagnosis of diabetes. Which action is an example of the
implementation phase?
A) Assessing the patient's blood glucose level
B) Teaching the patient how to administer insulin
C) Evaluating the patient's understanding of the teaching
D) Identifying the nursing diagnosis
Answer: B) Teaching the patient how to administer insulin
Rationale: Implementation is the phase of the nursing process where the nurse carries out the planned
interventions. Teaching a patient is a nursing intervention. Assessing blood glucose is assessment.
Evaluating understanding is evaluation. Identifying the nursing diagnosis is planning.
Question 9:
The nurse is caring for a patient who is confused. Which intervention is MOST appropriate for patient
safety?
A) Place the bed in the lowest position and use bed alarms
B) Keep the lights dim to prevent agitation
C) Use physical restraints to prevent falls
D) Assign the patient to a room farthest from the nurses' station
, Answer: A) Place the bed in the lowest position and use bed alarms
Rationale: Falls are a significant risk for confused patients. Keeping the bed low and using bed alarms are
appropriate safety measures. Physical restraints should be avoided unless absolutely necessary and used
only with a provider's order. The patient should be placed near the nurses' station for frequent
observation.
Question 10:
The nurse is planning care for a patient. Which is the FIRST step in the planning phase?
A) Develop nursing diagnoses
B) Prioritize nursing diagnoses
C) Set goals and outcomes
D) Implement interventions
Answer: B) Prioritize nursing diagnoses
Rationale: After nursing diagnoses are identified, they must be prioritized based on Maslow's hierarchy
of needs and urgency. Life-threatening problems (ABCs) take priority. After prioritization, goals,
outcomes, and interventions are developed. Implementation comes after planning.
Question 11:
The nurse is assessing a patient's vital signs. Which finding should be reported to the healthcare
provider?
A) Temperature 98.6°F (37°C)
B) Heart rate 88 bpm
C) Respiratory rate 28 breaths/min
D) Blood pressure 120/80 mmHg
Answer: C) Respiratory rate 28 breaths/min
Rationale: A respiratory rate of 28 breaths/min is tachypnea and should be reported. Normal respiratory
rate is 12-20 breaths/min. Temperature 98.6°F, heart rate 88 bpm, and blood pressure 120/80 mmHg
are within normal limits.
Question 12:
The nurse is evaluating a patient's response to treatment. Which finding indicates the treatment is
effective?
A) Patient's pain decreases from 8/10 to 3/10
B) Patient's temperature increases from 100°F to 101°F
C) Patient's oxygen saturation decreases from 95% to 90%
D) Patient's blood pressure increases from 130/80 to 160/90
Comprehensive Exam 1 (Detailed Answers)
Complete Practice Examination – 150 Questions
SECTION 1: NURSING PROCESS & CRITICAL THINKING (Questions 1-30)
Question 1:
The nurse is caring for a patient with pneumonia. Which action demonstrates the assessment phase of
the nursing process?
A) Administering prescribed antibiotics
B) Auscultating lung sounds
C) Evaluating the effectiveness of oxygen therapy
D) Documenting the patient's response to treatment
Answer: B) Auscultating lung sounds
Rationale: Assessment is the first step of the nursing process, involving data collection. Auscultating lung
sounds is a physical assessment technique used to gather objective data. Administration of antibiotics is
implementation. Evaluation involves determining the effectiveness of interventions. Documentation
occurs throughout the process.
Question 2:
The nurse is developing a care plan for a patient with impaired mobility. Which nursing diagnosis is
written correctly?
A) Risk for falls
B) Risk for falls related to impaired mobility
C) Risk for falls R/T impaired mobility
D) Risk for falls as evidenced by unsteady gait
Answer: C) Risk for falls R/T impaired mobility
Rationale: A properly written nursing diagnosis includes the problem statement and the etiology (related
factors) connected by "related to" (R/T). "Risk for falls R/T impaired mobility" is correctly formatted. The
phrase "as evidenced by" (AEB) is used for actual diagnoses, not risk diagnoses.
Question 3:
The nurse is caring for a patient who is anxious about an upcoming procedure. Which intervention
demonstrates therapeutic communication?
,A) "Don't worry, everything will be fine"
B) "You seem anxious. Tell me more about your concerns."
C) "I had that procedure and it wasn't bad at all."
D) "You should try to relax and not think about it."
Answer: B) "You seem anxious. Tell me more about your concerns."
Rationale: Therapeutic communication involves acknowledging the patient's feelings and encouraging
expression of concerns. This response validates the patient's anxiety and opens the door for discussion.
False reassurance, changing the subject, and giving personal opinions are not therapeutic.
Question 4:
The nurse is evaluating the effectiveness of pain management for a postoperative patient. Which action
is MOST appropriate?
A) Ask the patient to rate pain on a scale of 0-10
B) Observe the patient's facial expression
C) Assess vital signs
D) All of the above
Answer: D) All of the above
Rationale: Evaluation involves multiple assessment methods. Pain is subjective; the patient's self-report
is the gold standard. Observation of facial expressions and vital signs can provide additional objective
data. All of these methods contribute to a comprehensive evaluation of pain management effectiveness.
Question 5:
The nurse is prioritizing patient care. Which patient should be seen FIRST?
A) A patient with a fever of 101°F (38.3°C)
B) A patient with chest pain and diaphoresis
C) A patient requesting pain medication
D) A patient who needs assistance with ambulation
Answer: B) A patient with chest pain and diaphoresis
Rationale: Chest pain with diaphoresis may indicate a myocardial infarction, a life-threatening
emergency requiring immediate attention. This patient should be seen first. Maslow's hierarchy of needs
and the ABCs (Airway, Breathing, Circulation) guide prioritization. Physiological needs take priority over
comfort and mobility needs.
Question 6:
The nurse is documenting patient care. Which documentation is MOST appropriate?
A) "Patient is in a good mood today"
B) "Patient reports pain 7/10 in right knee"
,C) "Patient seems to be improving"
D) "Patient is difficult and uncooperative"
Answer: B) "Patient reports pain 7/10 in right knee"
Rationale: Documentation should be objective, factual, and based on assessment data. "Patient reports
pain 7/10" is objective and measurable. Subjective statements ("good mood," "seems improving") and
judgmental statements ("difficult," "uncooperative") are not appropriate in professional documentation.
Question 7:
The nurse is using the SBAR communication tool. What does SBAR stand for?
A) Situation, Background, Assessment, Recommendation
B) Symptoms, Background, Assessment, Referral
C) Situation, Background, Action, Referral
D) Symptoms, Background, Action, Recommendation
Answer: A) Situation, Background, Assessment, Recommendation
Rationale: SBAR is a standardized communication tool used to improve patient safety and
communication between healthcare providers. It stands for Situation (current problem), Background
(pertinent history), Assessment (nurse's assessment), and Recommendation (what is needed). It provides
a structured, concise format for communication.
Question 8:
The nurse is caring for a patient with a new diagnosis of diabetes. Which action is an example of the
implementation phase?
A) Assessing the patient's blood glucose level
B) Teaching the patient how to administer insulin
C) Evaluating the patient's understanding of the teaching
D) Identifying the nursing diagnosis
Answer: B) Teaching the patient how to administer insulin
Rationale: Implementation is the phase of the nursing process where the nurse carries out the planned
interventions. Teaching a patient is a nursing intervention. Assessing blood glucose is assessment.
Evaluating understanding is evaluation. Identifying the nursing diagnosis is planning.
Question 9:
The nurse is caring for a patient who is confused. Which intervention is MOST appropriate for patient
safety?
A) Place the bed in the lowest position and use bed alarms
B) Keep the lights dim to prevent agitation
C) Use physical restraints to prevent falls
D) Assign the patient to a room farthest from the nurses' station
, Answer: A) Place the bed in the lowest position and use bed alarms
Rationale: Falls are a significant risk for confused patients. Keeping the bed low and using bed alarms are
appropriate safety measures. Physical restraints should be avoided unless absolutely necessary and used
only with a provider's order. The patient should be placed near the nurses' station for frequent
observation.
Question 10:
The nurse is planning care for a patient. Which is the FIRST step in the planning phase?
A) Develop nursing diagnoses
B) Prioritize nursing diagnoses
C) Set goals and outcomes
D) Implement interventions
Answer: B) Prioritize nursing diagnoses
Rationale: After nursing diagnoses are identified, they must be prioritized based on Maslow's hierarchy
of needs and urgency. Life-threatening problems (ABCs) take priority. After prioritization, goals,
outcomes, and interventions are developed. Implementation comes after planning.
Question 11:
The nurse is assessing a patient's vital signs. Which finding should be reported to the healthcare
provider?
A) Temperature 98.6°F (37°C)
B) Heart rate 88 bpm
C) Respiratory rate 28 breaths/min
D) Blood pressure 120/80 mmHg
Answer: C) Respiratory rate 28 breaths/min
Rationale: A respiratory rate of 28 breaths/min is tachypnea and should be reported. Normal respiratory
rate is 12-20 breaths/min. Temperature 98.6°F, heart rate 88 bpm, and blood pressure 120/80 mmHg
are within normal limits.
Question 12:
The nurse is evaluating a patient's response to treatment. Which finding indicates the treatment is
effective?
A) Patient's pain decreases from 8/10 to 3/10
B) Patient's temperature increases from 100°F to 101°F
C) Patient's oxygen saturation decreases from 95% to 90%
D) Patient's blood pressure increases from 130/80 to 160/90
