Nursing 305 Prep Exam 2 Questions
with Guaranteed Pass Solutions (2025-
2026) Updated.
7. The nurse is reviewing a patient's database for significant changes and discovers that the
patient has not voided in over 8 hours. The patient's kidney function lab results are abnormal,
and the patient's oral intake has significantly decreased since previous shifts. Which step of the
nursing process should the nurse proceed to after this review?
a. Diagnosis
b. Planning
c. Implementation
d. Evaluation - Answer ANS: A
9. A nurse administers an antihypertensive medication to a patient at the scheduled time of
0900. The nursing assistive personnel (NAP) then reports to the nurse that the patient's blood
pressure was low when it was taken at 0830. The NAP states that was busy and had not had a
chance to tell the nurse yet. The patient begins to complain of feeling dizzy and light-headed.
The blood pressure is rechecked and it has dropped even lower. In which phase of the nursing
process did the nurse first make an error?
a. Assessment
b. Diagnosis
c. Implementation
d. Evaluation - Answer a. Assessment
11. The patient database reveals that a patient has decreased oral intake, decreased oxygen
saturation when ambulating, reports of shortness of breath when getting out of bed, and a
productive cough. Which elements will the nurse identify as defining characteristics for the
diagnostic label of Activity intolerance?
a. Decreased oral intake and decreased oxygen saturation when ambulating
b. Decreased oxygen saturation when ambulating and reports of shortness of breath when
getting out of bed
c. Reports of shortness of breath when getting out of bed and a productive cough
d. Productive cough and decreased oral intake - Answer b. Decreased oxygen saturation when
ambulating and reports of shortness of breath when getting out of bed
, c. Disruption of tissue integrity
d. Dull headache - Answer Disruption of tissue integrity
13. A new nurse writes the following nursing diagnoses on a patient's care plan. Which nursing
diagnosis will cause the nurse manager to intervene?
a. Wandering
b. Hemorrhage
c. Urinary retention
d. Impaired swallowing - Answer ANS: B
15. A nurse adds a nursing diagnosis to a patient's care plan. Which information did the nurse
document?
a. Decreased cardiac output related to altered myocardial contractility.
b. Patient needs a low-fat diet related to inadequate heart perfusion.
c. Offer a low-fat diet because of heart problems.
d. Acute heart pain related to discomfort. - Answer ANS: A
16. A charge nurse is evaluating a new nurse's plan of care. Which finding will cause the charge
nurse to follow up?
a. Assigning a documented nursing diagnosis of Risk for infection for a patient on intravenous
(IV) antibiotics
b. Completing an interview and physical examination before adding a nursing diagnosis
c. Developing nursing diagnoses before completing the database
d. Including cultural and religious preferences in the database - Answer c. Developing nursing
diagnoses before completing the database
19. A nurse assesses that a patient has not voided in 6 hours. Which question should the nurse
ask to assist in establishing a nursing diagnosis of Urinary retention?
a. "Do you feel like you need to go to the bathroom?"
b. "Are you able to walk to the bathroom by yourself?"
c. "When was the last time you took your medicine?"
d. "Do you have a safety rail in your bathroom at home?" - Answer a. "Do you feel like you
need to go to the bathroom?"
with Guaranteed Pass Solutions (2025-
2026) Updated.
7. The nurse is reviewing a patient's database for significant changes and discovers that the
patient has not voided in over 8 hours. The patient's kidney function lab results are abnormal,
and the patient's oral intake has significantly decreased since previous shifts. Which step of the
nursing process should the nurse proceed to after this review?
a. Diagnosis
b. Planning
c. Implementation
d. Evaluation - Answer ANS: A
9. A nurse administers an antihypertensive medication to a patient at the scheduled time of
0900. The nursing assistive personnel (NAP) then reports to the nurse that the patient's blood
pressure was low when it was taken at 0830. The NAP states that was busy and had not had a
chance to tell the nurse yet. The patient begins to complain of feeling dizzy and light-headed.
The blood pressure is rechecked and it has dropped even lower. In which phase of the nursing
process did the nurse first make an error?
a. Assessment
b. Diagnosis
c. Implementation
d. Evaluation - Answer a. Assessment
11. The patient database reveals that a patient has decreased oral intake, decreased oxygen
saturation when ambulating, reports of shortness of breath when getting out of bed, and a
productive cough. Which elements will the nurse identify as defining characteristics for the
diagnostic label of Activity intolerance?
a. Decreased oral intake and decreased oxygen saturation when ambulating
b. Decreased oxygen saturation when ambulating and reports of shortness of breath when
getting out of bed
c. Reports of shortness of breath when getting out of bed and a productive cough
d. Productive cough and decreased oral intake - Answer b. Decreased oxygen saturation when
ambulating and reports of shortness of breath when getting out of bed
, c. Disruption of tissue integrity
d. Dull headache - Answer Disruption of tissue integrity
13. A new nurse writes the following nursing diagnoses on a patient's care plan. Which nursing
diagnosis will cause the nurse manager to intervene?
a. Wandering
b. Hemorrhage
c. Urinary retention
d. Impaired swallowing - Answer ANS: B
15. A nurse adds a nursing diagnosis to a patient's care plan. Which information did the nurse
document?
a. Decreased cardiac output related to altered myocardial contractility.
b. Patient needs a low-fat diet related to inadequate heart perfusion.
c. Offer a low-fat diet because of heart problems.
d. Acute heart pain related to discomfort. - Answer ANS: A
16. A charge nurse is evaluating a new nurse's plan of care. Which finding will cause the charge
nurse to follow up?
a. Assigning a documented nursing diagnosis of Risk for infection for a patient on intravenous
(IV) antibiotics
b. Completing an interview and physical examination before adding a nursing diagnosis
c. Developing nursing diagnoses before completing the database
d. Including cultural and religious preferences in the database - Answer c. Developing nursing
diagnoses before completing the database
19. A nurse assesses that a patient has not voided in 6 hours. Which question should the nurse
ask to assist in establishing a nursing diagnosis of Urinary retention?
a. "Do you feel like you need to go to the bathroom?"
b. "Are you able to walk to the bathroom by yourself?"
c. "When was the last time you took your medicine?"
d. "Do you have a safety rail in your bathroom at home?" - Answer a. "Do you feel like you
need to go to the bathroom?"
