,NU 136/NU136 Exam 3 – Fundamentals of
Nursing – Actual Q&A (GCN) (Updated PDF)
1. Which sequence reflects the correct order of the nursing process?
A) Assessment, Diagnosis, Planning, Implementation, Evaluation
B) Diagnosis, Assessment, Planning, Implementation, Evaluation
C) Assessment, Planning, Diagnosis, Evaluation, Implementation
D) Implementation, Assessment, Diagnosis, Planning, Evaluation
Correct Answer: A) Assessment, Diagnosis, Planning, Implementation,
Evaluation
Rationale: The nursing process follows the ADPIE sequence: Assessment,
Diagnosis, Planning, Implementation, and Evaluation. Assessment must occur
first to gather data, and evaluation is the final step to determine goal
achievement.
2. A client is receiving furosemide daily. Which electrolyte imbalance should the
nurse monitor for most closely?
A) Hypercalcemia
B) Hypokalemia
C) Hypermagnesemia
D) Hypernatremia
Correct Answer: B) Hypokalemia
,Rationale: Furosemide is a loop diuretic that causes potassium loss in the urine,
placing the client at risk for hypokalemia. Older adults are especially vulnerable.
Potassium levels should be monitored.
3. The nurse is documenting care for a client who has stable vital signs and no
abnormal findings. Which charting method assumes standards of care are met
unless an exception occurs?
A) Narrative charting
B) PIE charting
C) Charting by exception
D) Focused charting
Correct Answer: C) Charting by exception
Rationale: Charting by exception documents only deviations from established
standards or expected findings. It assumes routine care was provided. Narrative,
PIE, and focused charting have different formats.
4. A client's nursing care plan should be reviewed and updated at which
interval?
A) Every 12 hours
B) Every 48 hours
C) Weekly
D) Every 24 hours
Correct Answer: D) Every 24 hours
, Rationale: The nursing care plan should be updated every 24 hours to reflect the
client's current condition, response to interventions, and changing needs. This
supports continuity of care.
5. A nurse is measuring a client's daily weight. Which action is most important
for accuracy?
A) Weigh at the same time each day with the same scale and same clothing
B) Weigh after meals
C) Use a different scale each day
D) Weigh before voiding
Correct Answer: A) Weigh at the same time each day with the same scale and
same clothing
Rationale: Daily weights should be obtained at the same time, on the same
scale, with the same clothing, after voiding, and before eating. This allows
accurate comparison and detection of fluid changes.
6. Which client action would be a HIPAA violation if performed by a nurse?
A) Discussing care with the healthcare team in a private area
B) Leaving a patient's chart open at the nurses' station
C) Documenting in the electronic health record
D) Providing discharge teaching privately
Correct Answer: B) Leaving a patient's chart open at the nurses' station
Nursing – Actual Q&A (GCN) (Updated PDF)
1. Which sequence reflects the correct order of the nursing process?
A) Assessment, Diagnosis, Planning, Implementation, Evaluation
B) Diagnosis, Assessment, Planning, Implementation, Evaluation
C) Assessment, Planning, Diagnosis, Evaluation, Implementation
D) Implementation, Assessment, Diagnosis, Planning, Evaluation
Correct Answer: A) Assessment, Diagnosis, Planning, Implementation,
Evaluation
Rationale: The nursing process follows the ADPIE sequence: Assessment,
Diagnosis, Planning, Implementation, and Evaluation. Assessment must occur
first to gather data, and evaluation is the final step to determine goal
achievement.
2. A client is receiving furosemide daily. Which electrolyte imbalance should the
nurse monitor for most closely?
A) Hypercalcemia
B) Hypokalemia
C) Hypermagnesemia
D) Hypernatremia
Correct Answer: B) Hypokalemia
,Rationale: Furosemide is a loop diuretic that causes potassium loss in the urine,
placing the client at risk for hypokalemia. Older adults are especially vulnerable.
Potassium levels should be monitored.
3. The nurse is documenting care for a client who has stable vital signs and no
abnormal findings. Which charting method assumes standards of care are met
unless an exception occurs?
A) Narrative charting
B) PIE charting
C) Charting by exception
D) Focused charting
Correct Answer: C) Charting by exception
Rationale: Charting by exception documents only deviations from established
standards or expected findings. It assumes routine care was provided. Narrative,
PIE, and focused charting have different formats.
4. A client's nursing care plan should be reviewed and updated at which
interval?
A) Every 12 hours
B) Every 48 hours
C) Weekly
D) Every 24 hours
Correct Answer: D) Every 24 hours
, Rationale: The nursing care plan should be updated every 24 hours to reflect the
client's current condition, response to interventions, and changing needs. This
supports continuity of care.
5. A nurse is measuring a client's daily weight. Which action is most important
for accuracy?
A) Weigh at the same time each day with the same scale and same clothing
B) Weigh after meals
C) Use a different scale each day
D) Weigh before voiding
Correct Answer: A) Weigh at the same time each day with the same scale and
same clothing
Rationale: Daily weights should be obtained at the same time, on the same
scale, with the same clothing, after voiding, and before eating. This allows
accurate comparison and detection of fluid changes.
6. Which client action would be a HIPAA violation if performed by a nurse?
A) Discussing care with the healthcare team in a private area
B) Leaving a patient's chart open at the nurses' station
C) Documenting in the electronic health record
D) Providing discharge teaching privately
Correct Answer: B) Leaving a patient's chart open at the nurses' station
