NSG 3130 / NSG3130 Exam 1 (Latest )
Fundamental Concepts & Skills for Nursing Practice II | Galen College of Nursing
75 Questions | Verified Answers | Grade A
Section 1: Nursing Process and Critical Thinking (ADPIE, Clinical Judgment, &
Prioritization)
Q1: A nurse is caring for a patient admitted with dehydration. The nurse collects data including dry mucous
membranes, decreased skin turgor, and a heart rate of 110 bpm. Which step of the nursing process does this
represent?
A. Diagnosis
B. Assessment [CORRECT]
C. Planning
D. Evaluation
Correct Answer: B
Rationale: Collecting subjective and objective data such as physical findings (dry mucous membranes, decreased skin turgor) and
vital signs (tachycardia) is the Assessment phase of the nursing process (the 'A' in ADPIE). This phase involves gathering,
validating, and organizing patient data to identify actual and potential health problems. Diagnosis involves analyzing the data to
identify nursing diagnoses. Planning involves setting goals and selecting interventions. Evaluation involves reassessing and
determining whether outcomes were met.
Q2: A nurse analyzes a patient's data and identifies the following nursing diagnosis: 'Risk for impaired skin
integrity related to immobility as evidenced by bed rest for 3 days.' Which component is the etiology of this
nursing diagnosis?
A. Risk for impaired skin integrity
B. Immobility
C. Bed rest for 3 days
D. Both B and C [CORRECT]
Correct Answer: D
Rationale: A nursing diagnosis has three components: the problem (NANDA label), the etiology ('related to'), and the defining
characteristics ('as evidenced by'). The problem is 'Risk for impaired skin integrity.' The etiology (cause or contributing factor) is
'immobility.' 'Bed rest for 3 days' provides additional context supporting the etiology. For risk diagnoses, there are no actual
signs/symptoms since the problem has not yet occurred; instead, risk factors serve as the basis. Understanding these components is
essential for developing an accurate and individualized care plan.
Q3: A nurse is developing a care plan for a patient with a nursing diagnosis of 'Ineffective airway clearance
related to excessive mucus production.' Which intervention should the nurse include in the planning phase?
A. Auscultate lung sounds every 4 hours
B. The patient will maintain a patent airway with clear lung sounds within 48 hours [CORRECT]
C. Administer prescribed bronchodilator medications
D. Document the patient's response to treatments
Correct Answer: B
,Rationale: The Planning phase of the nursing process involves setting goals and outcomes and identifying interventions. The
statement 'The patient will maintain a patent airway with clear lung sounds within 48 hours' is a measurable, patient-centered
outcome/goal. Auscultating lung sounds is an assessment (data collection) activity. Administering medications is an implementation
activity. Documenting responses is an evaluation activity. Goals should be specific, measurable, achievable, relevant, and
time-bound (SMART) to guide the care plan effectively.
Q4: A nurse administers a prescribed diuretic to a patient with fluid overload and then reassesses the
patient's lung sounds and daily weight. Which steps of the nursing process did the nurse perform in this
sequence?
A. Assessment and Diagnosis
B. Implementation and Evaluation [CORRECT]
C. Planning and Implementation
D. Diagnosis and Planning
Correct Answer: B
Rationale: Administering the diuretic is an Implementation activity (carrying out the planned nursing intervention). Reassessing lung
sounds and daily weight afterward is an Evaluation activity (measuring the patient's response to determine if the intervention was
effective and if goals were met). The nursing process is cyclical and often overlaps, but administering medication directly
implements the care plan, and subsequent reassessment evaluates the outcome of that intervention.
Q5: Using Tanner's Clinical Judgment Model, a nurse observes a patient's incision site has increased
redness, warmth, and a small amount of purulent drainage. Which phase of Tanner's model is the nurse
demonstrating?
A. Noticing [CORRECT]
B. Interpreting
C. Responding
D. Reflecting
Correct Answer: A
Rationale: Tanner's Clinical Judgment Model has four phases. Noticing is the first phase, where the nurse observes and recognizes
cues or patterns that may indicate a change in the patient's condition. Observing redness, warmth, and purulent drainage at the
incision site is the nurse 'noticing' salient cues. Interpreting involves making sense of the data (analyzing what the findings mean).
Responding involves taking nursing actions. Reflecting involves evaluating the effectiveness of the response and learning from the
experience.
Q6: A nurse is caring for four patients. Which patient should the nurse assess first based on the ABC
(Airway, Breathing, Circulation) prioritization framework?
A. A patient with a scheduled dressing change
B. A patient who is choking and unable to speak or cough [CORRECT]
C. A patient requesting pain medication for a headache rated 4/10
D. A patient who needs assistance with ordering a meal
Correct Answer: B
Rationale: The ABC prioritization framework directs the nurse to address life-threatening problems first: Airway before Breathing
before Circulation. A patient who is choking and unable to speak or cough has a compromised airway and requires immediate
intervention (abdominal thrusts/Heimlich maneuver). This is the highest priority because without a patent airway, the patient will
rapidly develop hypoxia and die. Dressing changes, pain medication for mild pain, and meal assistance are important but are not
life-threatening.
, Q7: A nurse is prioritizing patient care using Maslow's Hierarchy of Needs. Which patient need represents
the highest priority according to this framework?
A. A patient expressing feelings of low self-worth after a diagnosis
B. A patient who is unable to void following surgery [CORRECT]
C. A patient requesting a visit from the chaplain
D. A patient wanting to learn about their new diagnosis
Correct Answer: B
Rationale: Maslow's Hierarchy of Needs prioritizes physiological needs (Level 1) first, followed by safety (Level 2), love/belonging
(Level 3), esteem (Level 4), and self-actualization (Level 5). The inability to void (urinary elimination) is a physiological need and
takes the highest priority. Low self-worth relates to esteem needs. A chaplain visit relates to love/belonging and spiritual needs.
Learning about a diagnosis relates to self-actualization. Physiological needs always take precedence over psychosocial needs.
Q8: A nurse is delegating tasks to an unlicensed assistive personnel (UAP). Which task is most appropriate
to delegate to the UAP?
A. Performing an initial admission assessment on a new patient
B. Measuring and recording a stable patient's intake and output [CORRECT]
C. Administering a prescribed oral medication
D. Evaluating a patient's response to a blood transfusion
Correct Answer: B
Rationale: Measuring and recording intake and output for a stable patient is a routine, standardized task that falls within the UAP's
scope of practice and is appropriate for delegation. The Five Rights of Delegation must be followed: right task, right circumstance,
right person, right direction/communication, and right supervision. Assessment, medication administration, and evaluation require
nursing judgment and licensure and cannot be delegated to UAPs. The nurse remains responsible for supervising and validating the
UAP's work.
Q9: A nurse notes that a patient's blood pressure is 88/56 mmHg, pulse is 120 bpm, and the patient reports
feeling dizzy when standing. The nurse interprets these findings as potential hypovolemia and increases the
IV fluid rate per the provider's order. Which critical thinking skill is the nurse demonstrating?
A. Analysis
B. Self-regulation
C. Explanation
D. Inference [CORRECT]
Correct Answer: D
Rationale: Inference is the critical thinking skill of drawing conclusions from available data and evidence. The nurse observes
objective data (low BP, tachycardia) and subjective data (dizziness on standing) and draws the conclusion (inference) that the
patient is likely experiencing hypovolemia, then takes action based on that inference. Analysis involves breaking down complex
information into components. Self-regulation involves reflecting on one's own thinking process. Explanation involves providing
rationale and justifications for conclusions.
Q10: A nurse is caring for a patient with a nursing diagnosis of 'Acute pain related to surgical incision as
evidenced by patient report of 7/10 and facial grimacing.' After administering the prescribed analgesic, the
nurse reassesses the patient's pain level 30 minutes later and finds it is now 3/10. Which step of the nursing
process is the nurse performing?
A. Assessment
B. Planning
Fundamental Concepts & Skills for Nursing Practice II | Galen College of Nursing
75 Questions | Verified Answers | Grade A
Section 1: Nursing Process and Critical Thinking (ADPIE, Clinical Judgment, &
Prioritization)
Q1: A nurse is caring for a patient admitted with dehydration. The nurse collects data including dry mucous
membranes, decreased skin turgor, and a heart rate of 110 bpm. Which step of the nursing process does this
represent?
A. Diagnosis
B. Assessment [CORRECT]
C. Planning
D. Evaluation
Correct Answer: B
Rationale: Collecting subjective and objective data such as physical findings (dry mucous membranes, decreased skin turgor) and
vital signs (tachycardia) is the Assessment phase of the nursing process (the 'A' in ADPIE). This phase involves gathering,
validating, and organizing patient data to identify actual and potential health problems. Diagnosis involves analyzing the data to
identify nursing diagnoses. Planning involves setting goals and selecting interventions. Evaluation involves reassessing and
determining whether outcomes were met.
Q2: A nurse analyzes a patient's data and identifies the following nursing diagnosis: 'Risk for impaired skin
integrity related to immobility as evidenced by bed rest for 3 days.' Which component is the etiology of this
nursing diagnosis?
A. Risk for impaired skin integrity
B. Immobility
C. Bed rest for 3 days
D. Both B and C [CORRECT]
Correct Answer: D
Rationale: A nursing diagnosis has three components: the problem (NANDA label), the etiology ('related to'), and the defining
characteristics ('as evidenced by'). The problem is 'Risk for impaired skin integrity.' The etiology (cause or contributing factor) is
'immobility.' 'Bed rest for 3 days' provides additional context supporting the etiology. For risk diagnoses, there are no actual
signs/symptoms since the problem has not yet occurred; instead, risk factors serve as the basis. Understanding these components is
essential for developing an accurate and individualized care plan.
Q3: A nurse is developing a care plan for a patient with a nursing diagnosis of 'Ineffective airway clearance
related to excessive mucus production.' Which intervention should the nurse include in the planning phase?
A. Auscultate lung sounds every 4 hours
B. The patient will maintain a patent airway with clear lung sounds within 48 hours [CORRECT]
C. Administer prescribed bronchodilator medications
D. Document the patient's response to treatments
Correct Answer: B
,Rationale: The Planning phase of the nursing process involves setting goals and outcomes and identifying interventions. The
statement 'The patient will maintain a patent airway with clear lung sounds within 48 hours' is a measurable, patient-centered
outcome/goal. Auscultating lung sounds is an assessment (data collection) activity. Administering medications is an implementation
activity. Documenting responses is an evaluation activity. Goals should be specific, measurable, achievable, relevant, and
time-bound (SMART) to guide the care plan effectively.
Q4: A nurse administers a prescribed diuretic to a patient with fluid overload and then reassesses the
patient's lung sounds and daily weight. Which steps of the nursing process did the nurse perform in this
sequence?
A. Assessment and Diagnosis
B. Implementation and Evaluation [CORRECT]
C. Planning and Implementation
D. Diagnosis and Planning
Correct Answer: B
Rationale: Administering the diuretic is an Implementation activity (carrying out the planned nursing intervention). Reassessing lung
sounds and daily weight afterward is an Evaluation activity (measuring the patient's response to determine if the intervention was
effective and if goals were met). The nursing process is cyclical and often overlaps, but administering medication directly
implements the care plan, and subsequent reassessment evaluates the outcome of that intervention.
Q5: Using Tanner's Clinical Judgment Model, a nurse observes a patient's incision site has increased
redness, warmth, and a small amount of purulent drainage. Which phase of Tanner's model is the nurse
demonstrating?
A. Noticing [CORRECT]
B. Interpreting
C. Responding
D. Reflecting
Correct Answer: A
Rationale: Tanner's Clinical Judgment Model has four phases. Noticing is the first phase, where the nurse observes and recognizes
cues or patterns that may indicate a change in the patient's condition. Observing redness, warmth, and purulent drainage at the
incision site is the nurse 'noticing' salient cues. Interpreting involves making sense of the data (analyzing what the findings mean).
Responding involves taking nursing actions. Reflecting involves evaluating the effectiveness of the response and learning from the
experience.
Q6: A nurse is caring for four patients. Which patient should the nurse assess first based on the ABC
(Airway, Breathing, Circulation) prioritization framework?
A. A patient with a scheduled dressing change
B. A patient who is choking and unable to speak or cough [CORRECT]
C. A patient requesting pain medication for a headache rated 4/10
D. A patient who needs assistance with ordering a meal
Correct Answer: B
Rationale: The ABC prioritization framework directs the nurse to address life-threatening problems first: Airway before Breathing
before Circulation. A patient who is choking and unable to speak or cough has a compromised airway and requires immediate
intervention (abdominal thrusts/Heimlich maneuver). This is the highest priority because without a patent airway, the patient will
rapidly develop hypoxia and die. Dressing changes, pain medication for mild pain, and meal assistance are important but are not
life-threatening.
, Q7: A nurse is prioritizing patient care using Maslow's Hierarchy of Needs. Which patient need represents
the highest priority according to this framework?
A. A patient expressing feelings of low self-worth after a diagnosis
B. A patient who is unable to void following surgery [CORRECT]
C. A patient requesting a visit from the chaplain
D. A patient wanting to learn about their new diagnosis
Correct Answer: B
Rationale: Maslow's Hierarchy of Needs prioritizes physiological needs (Level 1) first, followed by safety (Level 2), love/belonging
(Level 3), esteem (Level 4), and self-actualization (Level 5). The inability to void (urinary elimination) is a physiological need and
takes the highest priority. Low self-worth relates to esteem needs. A chaplain visit relates to love/belonging and spiritual needs.
Learning about a diagnosis relates to self-actualization. Physiological needs always take precedence over psychosocial needs.
Q8: A nurse is delegating tasks to an unlicensed assistive personnel (UAP). Which task is most appropriate
to delegate to the UAP?
A. Performing an initial admission assessment on a new patient
B. Measuring and recording a stable patient's intake and output [CORRECT]
C. Administering a prescribed oral medication
D. Evaluating a patient's response to a blood transfusion
Correct Answer: B
Rationale: Measuring and recording intake and output for a stable patient is a routine, standardized task that falls within the UAP's
scope of practice and is appropriate for delegation. The Five Rights of Delegation must be followed: right task, right circumstance,
right person, right direction/communication, and right supervision. Assessment, medication administration, and evaluation require
nursing judgment and licensure and cannot be delegated to UAPs. The nurse remains responsible for supervising and validating the
UAP's work.
Q9: A nurse notes that a patient's blood pressure is 88/56 mmHg, pulse is 120 bpm, and the patient reports
feeling dizzy when standing. The nurse interprets these findings as potential hypovolemia and increases the
IV fluid rate per the provider's order. Which critical thinking skill is the nurse demonstrating?
A. Analysis
B. Self-regulation
C. Explanation
D. Inference [CORRECT]
Correct Answer: D
Rationale: Inference is the critical thinking skill of drawing conclusions from available data and evidence. The nurse observes
objective data (low BP, tachycardia) and subjective data (dizziness on standing) and draws the conclusion (inference) that the
patient is likely experiencing hypovolemia, then takes action based on that inference. Analysis involves breaking down complex
information into components. Self-regulation involves reflecting on one's own thinking process. Explanation involves providing
rationale and justifications for conclusions.
Q10: A nurse is caring for a patient with a nursing diagnosis of 'Acute pain related to surgical incision as
evidenced by patient report of 7/10 and facial grimacing.' After administering the prescribed analgesic, the
nurse reassesses the patient's pain level 30 minutes later and finds it is now 3/10. Which step of the nursing
process is the nurse performing?
A. Assessment
B. Planning
