Fundamentals of Nursing, Nursing
Process Exam A+ Guide Question and
Answer
A client comes to the walk-in clinic with reports of
abdominal pain and diarrhea. While taking the client's
vital signs, the nurse is implementing which phase of the
nursing process?
A. Assessment
B. Diagnosis
C. Planning
D. Implementation - correct answer ✅✅A. Assessment
Rationale: The first step in the nursing process is
assessment, the process of collecting data. All
subsequent phases of the nursing process (options 2, 3,
and 4) rely on accurate and complete data.
The nurse is measuring the client's urine output and
straining the urine to assess for stones. Which of the
following should the nurse record as objective data?
A. The client reports abdominal pain
B. The client's urine output was 450 mL
C. The client states, "I didn't see any stones in my urine."
,Fundamentals of Nursing, Nursing
Process Exam A+ Guide Question and
Answer
D. The client states, "I feel like I have passed a stone." -
correct answer ✅✅B. The client's urine output was
450 mL.
Rationale: Objective data is measurable data that can be
seen, heard, or verified by the nurse. The objective data
is the measurement of the urine output. A client's
statements and reports of symptoms are documented as
subjective data, such as the data found in options 1, 3,
and 4.
When evaluating an elderly client's blood pressure (BP) of
146/78 mmHg, the nurse does which of the following
before determining whether the BP is normal or
represents hypertension?
A. Compare this reading against defined standards
B. Compare the reading with one taken in the opposite
arm
C. Determine gaps in the vital signs in the client record
D. Compare the current measurement with previous ones
- correct answer ✅✅A. Compare this reading against
defined
Rationale: Analysis of the client's BP requires knowledge
of the normal BP range for an older adult. The nurse
,Fundamentals of Nursing, Nursing
Process Exam A+ Guide Question and
Answer
compares the client's data against identified standards to
determine whether this reading is normal or abnormal.
Measuring the BP in the other arm (option 2) and
comparing the reading to previous ones (option 4) will
give additional client data, but the comparison alone will
not determine whether the BP is normal. Gaps in the
record (option 3) will not aid in interpreting the current
measurement.
Which of the following behaviors by the nurse
demonstrates that the nurse is participating in critical
thinking? Select all that apply.
A. Admitting not knowing how to do a procedure and
requesting help
B. Using clever and persuasive remarks to support an
opinion or position
C. Accepting without question the values acquired in
nursing school
D. Finding a quick and logical answer, even to complex
questions
E. Gathering three assistants to transfer the client to a
stretcher after noting the client weighs 300 lbs. - correct
, Fundamentals of Nursing, Nursing
Process Exam A+ Guide Question and
Answer
answer ✅✅A. Admitting not knowing how to do a
procedure and requesting help
E. Gathering three assistants to transfer the client to a
stretcher after noting the client weighs 300 lbs.
Rationale: Critical thinking in nursing is self-directed,
supporting what nurses know and making clear what they
do not know. It is important for nurses to recognize when
they lack the knowledge they need to provide safe care
for a client (option 1). Nurses must also utilize their
resources to acquire the support they need to care for a
client safely (option 5). Options 2, 3, and 4 do not
demonstrate critical thinking.
The nurse has documented the following outcome goal in
the care plan: "The client will transfer from bed to chair
with two-person assist." The charge nurse tells the nurse
to add which of the following to complete the goal?
A. Client behavior
B. Conditions or modifiers
C. Performance criteria
D. Target time - correct answer ✅✅D. Target time
Process Exam A+ Guide Question and
Answer
A client comes to the walk-in clinic with reports of
abdominal pain and diarrhea. While taking the client's
vital signs, the nurse is implementing which phase of the
nursing process?
A. Assessment
B. Diagnosis
C. Planning
D. Implementation - correct answer ✅✅A. Assessment
Rationale: The first step in the nursing process is
assessment, the process of collecting data. All
subsequent phases of the nursing process (options 2, 3,
and 4) rely on accurate and complete data.
The nurse is measuring the client's urine output and
straining the urine to assess for stones. Which of the
following should the nurse record as objective data?
A. The client reports abdominal pain
B. The client's urine output was 450 mL
C. The client states, "I didn't see any stones in my urine."
,Fundamentals of Nursing, Nursing
Process Exam A+ Guide Question and
Answer
D. The client states, "I feel like I have passed a stone." -
correct answer ✅✅B. The client's urine output was
450 mL.
Rationale: Objective data is measurable data that can be
seen, heard, or verified by the nurse. The objective data
is the measurement of the urine output. A client's
statements and reports of symptoms are documented as
subjective data, such as the data found in options 1, 3,
and 4.
When evaluating an elderly client's blood pressure (BP) of
146/78 mmHg, the nurse does which of the following
before determining whether the BP is normal or
represents hypertension?
A. Compare this reading against defined standards
B. Compare the reading with one taken in the opposite
arm
C. Determine gaps in the vital signs in the client record
D. Compare the current measurement with previous ones
- correct answer ✅✅A. Compare this reading against
defined
Rationale: Analysis of the client's BP requires knowledge
of the normal BP range for an older adult. The nurse
,Fundamentals of Nursing, Nursing
Process Exam A+ Guide Question and
Answer
compares the client's data against identified standards to
determine whether this reading is normal or abnormal.
Measuring the BP in the other arm (option 2) and
comparing the reading to previous ones (option 4) will
give additional client data, but the comparison alone will
not determine whether the BP is normal. Gaps in the
record (option 3) will not aid in interpreting the current
measurement.
Which of the following behaviors by the nurse
demonstrates that the nurse is participating in critical
thinking? Select all that apply.
A. Admitting not knowing how to do a procedure and
requesting help
B. Using clever and persuasive remarks to support an
opinion or position
C. Accepting without question the values acquired in
nursing school
D. Finding a quick and logical answer, even to complex
questions
E. Gathering three assistants to transfer the client to a
stretcher after noting the client weighs 300 lbs. - correct
, Fundamentals of Nursing, Nursing
Process Exam A+ Guide Question and
Answer
answer ✅✅A. Admitting not knowing how to do a
procedure and requesting help
E. Gathering three assistants to transfer the client to a
stretcher after noting the client weighs 300 lbs.
Rationale: Critical thinking in nursing is self-directed,
supporting what nurses know and making clear what they
do not know. It is important for nurses to recognize when
they lack the knowledge they need to provide safe care
for a client (option 1). Nurses must also utilize their
resources to acquire the support they need to care for a
client safely (option 5). Options 2, 3, and 4 do not
demonstrate critical thinking.
The nurse has documented the following outcome goal in
the care plan: "The client will transfer from bed to chair
with two-person assist." The charge nurse tells the nurse
to add which of the following to complete the goal?
A. Client behavior
B. Conditions or modifiers
C. Performance criteria
D. Target time - correct answer ✅✅D. Target time
