NACE FOUNDATIONS OF NURSING EXAM
300 ACTUAL QUESTIONS AND CRRECT
ANSWERS WITH RATIONALE LATEST
UPDATE ALREADY GRADED A+ ASSURED
PASS
Section 1: Nursing Process & Clinical Judgment (Questions 1–
40)
1. A nurse is caring for a patient admitted with dehydration. In which order of the
nursing process (ADPIE) should the nurse perform the following actions? 1)
Develop a plan to increase oral fluid intake, 2) Measure intake and output, 3) Ask
the patient about usual daily fluid consumption, 4) Administer prescribed IV fluids,
5) Compare intake and output values to assess progress.
A. 3, 2, 1, 4, 5
B. 3, 1, 4, 2, 5
C. 1, 3, 2, 4, 5
D. 2, 3, 1, 4, 5
Answer: A
Rationale: The ADPIE sequence is: Assessment (ask about fluid habits — step 3),
Diagnosis (identify dehydration from data), Planning (develop fluid increase plan
— step 1), Implementation (measure I&O — step 2, then administer IV fluids —
step 4), Evaluation (compare I&O — step 5). Option A correctly follows the
ADPIE framework.
2. A nursing student is learning about the NCSBN Clinical Judgment Measurement
Model (CJMM). Which cognitive process occurs IMMEDIATELY after the nurse
analyzes cues?
A. Recognize Cues
,B. Generate Solutions
C. Prioritize Hypotheses
D. Evaluate Outcomes
Answer: C
Rationale: The NCSBN CJMM layers in order are: Recognize Cues → Analyze
Cues → Prioritize Hypotheses → Generate Solutions → Take Action → Evaluate
Outcomes. After analyzing cues, the nurse must prioritize hypotheses to determine
which potential problems are most urgent.
3. A nurse is formulating a nursing diagnosis for a patient who is post-operative
and refuses to cough and deep breathe due to incisional pain. Which NANDA
diagnosis is MOST appropriate?
A. Ineffective Airway Clearance related to incisional pain
B. Ineffective Coping related to surgical recovery
C. Impaired Gas Exchange related to shallow breathing
D. Acute Pain related to surgical incision as evidenced by guarding and refusal to
cough
Answer: D
Rationale: NANDA diagnoses follow the format: Problem + related to + as
evidenced by. The patient's primary problem driving the behavior is acute pain,
which causes the refusal to cough. While Ineffective Airway Clearance (A) and
Impaired Gas Exchange (B) are potential complications, they are not yet the
primary problem.
4. Which nursing-process step involves collecting subjective and objective data?
A. Planning
B. Assessment
C. Implementation
D. Evaluation
Answer: B
Rationale: Assessment is the systematic collection of information about the
patient's physical, psychological, social, cultural, and functional status.
5. A nurse identifies that a patient's oxygen saturation has fallen from 96% to 88%.
What should the nurse do first?
A. Document the finding at the end of the shift
B. Assess the patient's respiratory status
,C. Call the patient's family
D. Prepare discharge instructions
Answer: B
Rationale: A significant change in oxygen saturation requires prompt assessment to
determine the patient's condition and appropriate intervention. Assessment is the
priority before documentation or other actions.
6. Which outcome is written correctly?
A. Patient will feel better.
B. Patient will have improved health.
C. Patient will ambulate 50 feet with a walker by 1400 today.
D. Nurse will encourage ambulation.
Answer: C
Rationale: A correctly written patient outcome is specific, measurable, observable,
and time-limited. Option C includes all these elements, whereas the other options
are vague or nurse-focused.
7. Which patient should the nurse assess first?
A. Patient requesting a blanket
B. Patient reporting sudden difficulty breathing
C. Patient requesting discharge paperwork
D. Patient waiting for a routine bath
Answer: B
Rationale: Airway and breathing concerns take priority because oxygenation is
essential for life. This patient requires immediate assessment based on the ABC
(Airway, Breathing, Circulation) priority framework.
8. Which action represents the implementation phase of the nursing process?
A. Collecting patient history
B. Administering a prescribed medication
C. Determining whether a goal was achieved
D. Identifying a nursing diagnosis
Answer: B
Rationale: Implementation involves carrying out the appropriate nursing
interventions that were identified during the planning phase.
, 9. A nurse is evaluating a patient's response to pain medication. Which finding
indicates the intervention was effective?
A. Patient reports pain decreased from 8/10 to 3/10
B. Patient is sleeping
C. Patient requests more medication
D. Patient's heart rate increases
Answer: A
Rationale: Evaluation involves determining whether the patient's goals were met. A
decrease in reported pain level indicates the intervention was effective.
10. Which of the following is a subjective data finding?
A. Blood pressure 120/80 mmHg
B. Patient reports nausea
C. Heart rate 88 beats per minute
D. Temperature 98.6°F
Answer: B
Rationale: Subjective data are what the patient reports or describes. Objective data
are measurable and observable.
11. A nurse is developing a plan of care for a patient with impaired mobility.
Which goal is most appropriate?
A. Patient will not fall.
B. Patient will ambulate 20 feet with a walker by discharge.
C. Nurse will assist patient with ambulation.
D. Patient will feel stronger.
Answer: B
Rationale: A measurable, patient-centered goal includes specific, observable
criteria and a time frame.
12. Which nursing diagnosis takes priority for a patient who is experiencing
anaphylaxis?
A. Anxiety
B. Impaired Gas Exchange
C. Risk for Infection
D. Imbalanced Nutrition
Answer: B
300 ACTUAL QUESTIONS AND CRRECT
ANSWERS WITH RATIONALE LATEST
UPDATE ALREADY GRADED A+ ASSURED
PASS
Section 1: Nursing Process & Clinical Judgment (Questions 1–
40)
1. A nurse is caring for a patient admitted with dehydration. In which order of the
nursing process (ADPIE) should the nurse perform the following actions? 1)
Develop a plan to increase oral fluid intake, 2) Measure intake and output, 3) Ask
the patient about usual daily fluid consumption, 4) Administer prescribed IV fluids,
5) Compare intake and output values to assess progress.
A. 3, 2, 1, 4, 5
B. 3, 1, 4, 2, 5
C. 1, 3, 2, 4, 5
D. 2, 3, 1, 4, 5
Answer: A
Rationale: The ADPIE sequence is: Assessment (ask about fluid habits — step 3),
Diagnosis (identify dehydration from data), Planning (develop fluid increase plan
— step 1), Implementation (measure I&O — step 2, then administer IV fluids —
step 4), Evaluation (compare I&O — step 5). Option A correctly follows the
ADPIE framework.
2. A nursing student is learning about the NCSBN Clinical Judgment Measurement
Model (CJMM). Which cognitive process occurs IMMEDIATELY after the nurse
analyzes cues?
A. Recognize Cues
,B. Generate Solutions
C. Prioritize Hypotheses
D. Evaluate Outcomes
Answer: C
Rationale: The NCSBN CJMM layers in order are: Recognize Cues → Analyze
Cues → Prioritize Hypotheses → Generate Solutions → Take Action → Evaluate
Outcomes. After analyzing cues, the nurse must prioritize hypotheses to determine
which potential problems are most urgent.
3. A nurse is formulating a nursing diagnosis for a patient who is post-operative
and refuses to cough and deep breathe due to incisional pain. Which NANDA
diagnosis is MOST appropriate?
A. Ineffective Airway Clearance related to incisional pain
B. Ineffective Coping related to surgical recovery
C. Impaired Gas Exchange related to shallow breathing
D. Acute Pain related to surgical incision as evidenced by guarding and refusal to
cough
Answer: D
Rationale: NANDA diagnoses follow the format: Problem + related to + as
evidenced by. The patient's primary problem driving the behavior is acute pain,
which causes the refusal to cough. While Ineffective Airway Clearance (A) and
Impaired Gas Exchange (B) are potential complications, they are not yet the
primary problem.
4. Which nursing-process step involves collecting subjective and objective data?
A. Planning
B. Assessment
C. Implementation
D. Evaluation
Answer: B
Rationale: Assessment is the systematic collection of information about the
patient's physical, psychological, social, cultural, and functional status.
5. A nurse identifies that a patient's oxygen saturation has fallen from 96% to 88%.
What should the nurse do first?
A. Document the finding at the end of the shift
B. Assess the patient's respiratory status
,C. Call the patient's family
D. Prepare discharge instructions
Answer: B
Rationale: A significant change in oxygen saturation requires prompt assessment to
determine the patient's condition and appropriate intervention. Assessment is the
priority before documentation or other actions.
6. Which outcome is written correctly?
A. Patient will feel better.
B. Patient will have improved health.
C. Patient will ambulate 50 feet with a walker by 1400 today.
D. Nurse will encourage ambulation.
Answer: C
Rationale: A correctly written patient outcome is specific, measurable, observable,
and time-limited. Option C includes all these elements, whereas the other options
are vague or nurse-focused.
7. Which patient should the nurse assess first?
A. Patient requesting a blanket
B. Patient reporting sudden difficulty breathing
C. Patient requesting discharge paperwork
D. Patient waiting for a routine bath
Answer: B
Rationale: Airway and breathing concerns take priority because oxygenation is
essential for life. This patient requires immediate assessment based on the ABC
(Airway, Breathing, Circulation) priority framework.
8. Which action represents the implementation phase of the nursing process?
A. Collecting patient history
B. Administering a prescribed medication
C. Determining whether a goal was achieved
D. Identifying a nursing diagnosis
Answer: B
Rationale: Implementation involves carrying out the appropriate nursing
interventions that were identified during the planning phase.
, 9. A nurse is evaluating a patient's response to pain medication. Which finding
indicates the intervention was effective?
A. Patient reports pain decreased from 8/10 to 3/10
B. Patient is sleeping
C. Patient requests more medication
D. Patient's heart rate increases
Answer: A
Rationale: Evaluation involves determining whether the patient's goals were met. A
decrease in reported pain level indicates the intervention was effective.
10. Which of the following is a subjective data finding?
A. Blood pressure 120/80 mmHg
B. Patient reports nausea
C. Heart rate 88 beats per minute
D. Temperature 98.6°F
Answer: B
Rationale: Subjective data are what the patient reports or describes. Objective data
are measurable and observable.
11. A nurse is developing a plan of care for a patient with impaired mobility.
Which goal is most appropriate?
A. Patient will not fall.
B. Patient will ambulate 20 feet with a walker by discharge.
C. Nurse will assist patient with ambulation.
D. Patient will feel stronger.
Answer: B
Rationale: A measurable, patient-centered goal includes specific, observable
criteria and a time frame.
12. Which nursing diagnosis takes priority for a patient who is experiencing
anaphylaxis?
A. Anxiety
B. Impaired Gas Exchange
C. Risk for Infection
D. Imbalanced Nutrition
Answer: B
