ORI GI NA L C ONTE NT
NU R S I NG ED U C AT I ON · STUDY QUESTION BANK
NU 136 Fundamentals of Nursing
Exam 3 Study Guide · Edition · Questions with Full Answer Rationales
50 Questions Full Rationales Answer Key Included
50 5 100%
Q UES T IO NS S ECT IO NS R AT I O N A L E S
W H AT T H I S C OV E R S
01 Nursing Process, Documentation & Critical Thinking Questions 1 - 10
02 Safety, Infection Prevention & Asepsis Questions 11 - 20
03 Vital Signs, Health Assessment & Pain Management Questions 21 - 30
04 Mobility, Skin Integrity & Wound Care Questions 31 - 40
05 Nutrition, Elimination & Fluid Balance Questions 41 - 50
A B O U T T H I S S T U DY G U I D E
This study guide contains 50 original multiple-choice questions written to support independent review of the core concepts
covered in this course. Every item was authored specifically for this guide, mapped to high-yield course topics, and paired
with a detailed answer rationale that explains both the correct response and the strongest distractor. This publication is an
independent study aid: it is not the actual examination of any institution, and it is not affiliated with or endorsed by any school
or program. Use it alongside your course materials to test application-level understanding and master the reasoning behind
every answer.
M A S T E R Y TA R G E T LE VE L F O R M AT
80% (40 of 50) Undergraduate PDF · 50 Questions
S T U D Y Q U ES T IO N B A N K Pag e 1
, NU 136 Fundamentals of Nursing
Exam 3 Study Guide · Edition · 50 questions with full answer rationales
SECTION 1 · Nursing Process, Documentation & Critical Thinking Questions 1 - 10
Q1. A nurse is gathering admission data for a 58-year-old patient transferred from the emergency department. The
patient states, 'My head has been pounding since yesterday.' The spouse tells the nurse the patient vomited twice
overnight, and the transfer note documents a temperature of 101.2 F. Which piece of information is objective
data obtained from a secondary source?
A. The temperature of 101.2 F documented in the transfer note
B. The patient's report of a pounding headache
C. The spouse's description of the overnight vomiting
D. The nurse's observation that the patient's skin feels warm and flushed
Correct Answer: A
Rationale: A documented temperature is measurable, observable data, and because it comes from the medical record rather
than from the patient directly, the record is a secondary source. The spouse's account is also secondary source data, but it is
subjective because it is a reported experience rather than something measurable. The nurse's own observation is objective but
comes from direct assessment of the patient, the primary source.
Q2. During care planning, a nurse is writing diagnoses for a 72-year-old patient on strict bed rest after hip fracture
repair who has occasional urinary incontinence. The patient's skin is intact at this time. Which nursing diagnosis
should the nurse document for this situation?
A. Impaired skin integrity related to bed rest and urinary incontinence
B. Risk for impaired skin integrity related to the development of a pressure injury
C. Risk for impaired skin integrity related to limited mobility and exposure to moisture
D. Risk for impaired skin integrity related to short staffing on the nursing unit
Correct Answer: C
Rationale: A risk diagnosis is appropriate because no skin damage exists yet, and its etiology must name the actual patient
risk factors, here immobility and moisture. Option A states a problem-focused diagnosis for a condition the patient does not
have, and option B names another potential problem as the cause rather than a risk factor. Option D uses a system-level
problem as the etiology, which is not patient-centered and cannot be treated by nursing interventions.
Q3. A nurse is developing expected outcomes for a 65-year-old patient with heart failure who is learning about a
low-sodium diet. The discharge date is set for Thursday. Which expected outcome is written in a measurable,
goal-appropriate way?
A. The patient will understand why sodium should be limited before going home.
B. The patient will list five foods that are high in sodium by the end of the second teaching session.
C. The patient will be provided with printed handouts about sodium content.
D. The patient will demonstrate improved attitudes toward dietary choices.
Correct Answer: B
Rationale: This outcome is specific, observable, and time-bound, and the verb 'list' allows the nurse to measure exactly how
many foods the patient can name. Option A uses the word 'understand,' which cannot be directly observed or measured.
Option C describes a nursing action rather than a patient behavior, and option D is too vague to evaluate.
STUDY QUESTION BANK Page 2
, Q4. A nurse is planning care for a patient on the first postoperative day following colon resection. The provider has
ordered morphine for pain and early ambulation, and the nurse plans to teach coughing exercises and to
coordinate a dietary consultation for high-protein meals. Which planned action is an interdependent
(collaborative) intervention?
A. Administering the ordered morphine dose and checking its effectiveness
B. Repositioning the patient for comfort at least every two hours
C. Teaching the patient to splint the incision before coughing
D. Coordinating the dietary consultation with the registered dietitian
Correct Answer: D
Rationale: Interdependent interventions are carried out by the nurse in collaboration with other disciplines, such as working
with a dietitian to plan nutrition support. Option A is a dependent intervention because it requires a provider order, and
options B and C are independent actions the nurse is licensed to perform without any order. Recognizing this distinction helps
the nurse plan workload and use consultants appropriately.
Q5. On the day before discharge, a nurse evaluates the goal that read, 'The patient will ambulate 50 feet with a rolling
walker by day three.' The patient walked only 20 feet today with standby assistance and reports hip fatigue.
Which action reflects the correct use of the evaluation step?
A. Document the actual findings and revise the plan to include shorter, more frequent walks with rest periods.
B. Mark the goal as met because the patient was able to walk some distance today.
C. Delete the goal from the care plan because it was not achieved on schedule.
D. Complete the final evaluation after the patient is discharged home.
Correct Answer: A
Rationale: Evaluation compares the patient's actual response with the expected outcome, and when the goal is only partly
met, the nurse documents the findings and modifies the interventions rather than the goal's intent. Option B falsifies the
record by recording an outcome that was not achieved. Option C abandons a still-relevant goal instead of revising it, and
option D delays evaluation until it can no longer influence care.
Q6. During the evening shift, a nurse calls the on-call provider about a patient whose blood pressure has dropped from
118/70 to 88/50 and whose pulse has risen to 122 beats per minute. To follow the SBAR format, which statement
belongs in the Background portion of the report?
A. The patient's current blood pressure is 88/50 with a heart rate of 122.
B. The patient is two days postoperative from an open gallbladder removal and also has type 2 diabetes.
C. I am concerned the patient is bleeding internally and needs to be seen now.
D. Please come to the unit and order intravenous fluid resuscitation.
Correct Answer: B
Rationale: The Background portion of SBAR contains the admitting diagnosis, relevant history, and comorbidities that the
provider needs for context. Option A contains current assessment data, which belongs in the Assessment portion, and option
C is the nurse's concern about what is happening. Option D is a Recommendation, which is the closing step of the handoff
rather than the background.
STUDY QUESTION BANK Page 3
NU R S I NG ED U C AT I ON · STUDY QUESTION BANK
NU 136 Fundamentals of Nursing
Exam 3 Study Guide · Edition · Questions with Full Answer Rationales
50 Questions Full Rationales Answer Key Included
50 5 100%
Q UES T IO NS S ECT IO NS R AT I O N A L E S
W H AT T H I S C OV E R S
01 Nursing Process, Documentation & Critical Thinking Questions 1 - 10
02 Safety, Infection Prevention & Asepsis Questions 11 - 20
03 Vital Signs, Health Assessment & Pain Management Questions 21 - 30
04 Mobility, Skin Integrity & Wound Care Questions 31 - 40
05 Nutrition, Elimination & Fluid Balance Questions 41 - 50
A B O U T T H I S S T U DY G U I D E
This study guide contains 50 original multiple-choice questions written to support independent review of the core concepts
covered in this course. Every item was authored specifically for this guide, mapped to high-yield course topics, and paired
with a detailed answer rationale that explains both the correct response and the strongest distractor. This publication is an
independent study aid: it is not the actual examination of any institution, and it is not affiliated with or endorsed by any school
or program. Use it alongside your course materials to test application-level understanding and master the reasoning behind
every answer.
M A S T E R Y TA R G E T LE VE L F O R M AT
80% (40 of 50) Undergraduate PDF · 50 Questions
S T U D Y Q U ES T IO N B A N K Pag e 1
, NU 136 Fundamentals of Nursing
Exam 3 Study Guide · Edition · 50 questions with full answer rationales
SECTION 1 · Nursing Process, Documentation & Critical Thinking Questions 1 - 10
Q1. A nurse is gathering admission data for a 58-year-old patient transferred from the emergency department. The
patient states, 'My head has been pounding since yesterday.' The spouse tells the nurse the patient vomited twice
overnight, and the transfer note documents a temperature of 101.2 F. Which piece of information is objective
data obtained from a secondary source?
A. The temperature of 101.2 F documented in the transfer note
B. The patient's report of a pounding headache
C. The spouse's description of the overnight vomiting
D. The nurse's observation that the patient's skin feels warm and flushed
Correct Answer: A
Rationale: A documented temperature is measurable, observable data, and because it comes from the medical record rather
than from the patient directly, the record is a secondary source. The spouse's account is also secondary source data, but it is
subjective because it is a reported experience rather than something measurable. The nurse's own observation is objective but
comes from direct assessment of the patient, the primary source.
Q2. During care planning, a nurse is writing diagnoses for a 72-year-old patient on strict bed rest after hip fracture
repair who has occasional urinary incontinence. The patient's skin is intact at this time. Which nursing diagnosis
should the nurse document for this situation?
A. Impaired skin integrity related to bed rest and urinary incontinence
B. Risk for impaired skin integrity related to the development of a pressure injury
C. Risk for impaired skin integrity related to limited mobility and exposure to moisture
D. Risk for impaired skin integrity related to short staffing on the nursing unit
Correct Answer: C
Rationale: A risk diagnosis is appropriate because no skin damage exists yet, and its etiology must name the actual patient
risk factors, here immobility and moisture. Option A states a problem-focused diagnosis for a condition the patient does not
have, and option B names another potential problem as the cause rather than a risk factor. Option D uses a system-level
problem as the etiology, which is not patient-centered and cannot be treated by nursing interventions.
Q3. A nurse is developing expected outcomes for a 65-year-old patient with heart failure who is learning about a
low-sodium diet. The discharge date is set for Thursday. Which expected outcome is written in a measurable,
goal-appropriate way?
A. The patient will understand why sodium should be limited before going home.
B. The patient will list five foods that are high in sodium by the end of the second teaching session.
C. The patient will be provided with printed handouts about sodium content.
D. The patient will demonstrate improved attitudes toward dietary choices.
Correct Answer: B
Rationale: This outcome is specific, observable, and time-bound, and the verb 'list' allows the nurse to measure exactly how
many foods the patient can name. Option A uses the word 'understand,' which cannot be directly observed or measured.
Option C describes a nursing action rather than a patient behavior, and option D is too vague to evaluate.
STUDY QUESTION BANK Page 2
, Q4. A nurse is planning care for a patient on the first postoperative day following colon resection. The provider has
ordered morphine for pain and early ambulation, and the nurse plans to teach coughing exercises and to
coordinate a dietary consultation for high-protein meals. Which planned action is an interdependent
(collaborative) intervention?
A. Administering the ordered morphine dose and checking its effectiveness
B. Repositioning the patient for comfort at least every two hours
C. Teaching the patient to splint the incision before coughing
D. Coordinating the dietary consultation with the registered dietitian
Correct Answer: D
Rationale: Interdependent interventions are carried out by the nurse in collaboration with other disciplines, such as working
with a dietitian to plan nutrition support. Option A is a dependent intervention because it requires a provider order, and
options B and C are independent actions the nurse is licensed to perform without any order. Recognizing this distinction helps
the nurse plan workload and use consultants appropriately.
Q5. On the day before discharge, a nurse evaluates the goal that read, 'The patient will ambulate 50 feet with a rolling
walker by day three.' The patient walked only 20 feet today with standby assistance and reports hip fatigue.
Which action reflects the correct use of the evaluation step?
A. Document the actual findings and revise the plan to include shorter, more frequent walks with rest periods.
B. Mark the goal as met because the patient was able to walk some distance today.
C. Delete the goal from the care plan because it was not achieved on schedule.
D. Complete the final evaluation after the patient is discharged home.
Correct Answer: A
Rationale: Evaluation compares the patient's actual response with the expected outcome, and when the goal is only partly
met, the nurse documents the findings and modifies the interventions rather than the goal's intent. Option B falsifies the
record by recording an outcome that was not achieved. Option C abandons a still-relevant goal instead of revising it, and
option D delays evaluation until it can no longer influence care.
Q6. During the evening shift, a nurse calls the on-call provider about a patient whose blood pressure has dropped from
118/70 to 88/50 and whose pulse has risen to 122 beats per minute. To follow the SBAR format, which statement
belongs in the Background portion of the report?
A. The patient's current blood pressure is 88/50 with a heart rate of 122.
B. The patient is two days postoperative from an open gallbladder removal and also has type 2 diabetes.
C. I am concerned the patient is bleeding internally and needs to be seen now.
D. Please come to the unit and order intravenous fluid resuscitation.
Correct Answer: B
Rationale: The Background portion of SBAR contains the admitting diagnosis, relevant history, and comorbidities that the
provider needs for context. Option A contains current assessment data, which belongs in the Assessment portion, and option
C is the nurse's concern about what is happening. Option D is a Recommendation, which is the closing step of the handoff
rather than the background.
STUDY QUESTION BANK Page 3
