NUR 104 – Nursing Concepts | Comprehensive
Nursing Concepts Study Guide Healthcare Principles,
Patient Care, Critical Thinking, and Examination
Success Questions with Detailed Rationales | Latest
2025–2026 Update
Question 1
A nurse is caring for a patient with pneumonia. The nurse identifies the following:
crackles in lung bases, temperature 101.2°F, productive cough with yellow sputum,
and respiratory rate of 28 breaths/min. This data collection represents which phase
of the nursing process?
A. Planning
B. Assessment
C. Implementation
D. Evaluation
Answer: B. Assessment
Rationale: Assessment is the systematic collection of data about the patient's
health status. This includes gathering subjective data (patient complaints) and
objective data (physical examination findings, vital signs, and laboratory results).
The data provided (crackles, temperature, cough, respiratory rate) are all
assessment findings.
Question 2
A nurse formulates the following nursing diagnosis: "Impaired Gas Exchange
related to alveolar-capillary membrane changes as evidenced by crackles, oxygen
saturation of 88%, and dyspnea." Which component represents the "as evidenced
by" (AEB) statement?
A. Impaired Gas Exchange
B. Related to alveolar-capillary membrane changes
C. Crackles, oxygen saturation of 88%, and dyspnea
D. None of the above
,Answer: C. Crackles, oxygen saturation of 88%, and dyspnea
Rationale: In a nursing diagnosis, the "as evidenced by" (AEB) statement contains
the defining characteristics or signs/symptoms that support the diagnosis. These are
the objective and subjective data that demonstrate the existence of the problem.
The "related to" (R/T) statement identifies the cause or contributing factor.
Question 3
A nurse is writing a care plan for a patient with impaired mobility. Which of the
following is an appropriate expected outcome?
A. Patient will be discharged tomorrow
B. Patient will turn from supine to side-lying independently by day 3
C. Patient will take their medications
D. Patient will eat all meals
Answer: B. Patient will turn from supine to side-lying independently by day 3
Rationale: An expected outcome must be patient-centered, specific, measurable,
realistic, and time-bound. It should describe what the patient will achieve, not what
the nurse will do. "Patient will turn from supine to side-lying independently by day
3" meets these criteria.
Question 4
Which of the following represents a correctly written nursing diagnosis using the
PES format?
A. Impaired Skin Integrity related to immobility as evidenced by stage 2
pressure injury on sacrum
B. Skin breakdown related to immobility
C. Pressure injury on sacrum
D. Patient has impaired skin integrity
Answer: A. Impaired Skin Integrity related to immobility as evidenced by
stage 2 pressure injury on sacrum
Rationale: The PES format includes: Problem (Impaired Skin Integrity), Etiology
(related to immobility), and Signs/Symptoms (as evidenced by stage 2 pressure
injury on sacrum). This is the recommended format for nursing diagnoses.
,Question 5
A patient is admitted with a new diagnosis of heart failure. The nurse's initial
assessment reveals crackles, edema, and shortness of breath. What is the nurse's
priority action?
A. Administer pain medication
B. Complete a focused respiratory and cardiovascular assessment
C. Begin discharge planning
D. Provide patient education
Answer: B. Complete a focused respiratory and cardiovascular assessment
Rationale: Assessment is the first phase of the nursing process. Based on the
patient's signs and symptoms (crackles, edema, shortness of breath), a focused
respiratory and cardiovascular assessment should be completed. This data will
guide planning and interventions.
Question 6
A nurse is evaluating a patient's response to pain medication. The patient reports
pain decreased from 8/10 to 3/10. This represents which phase of the nursing
process?
A. Assessment
B. Planning
C. Implementation
D. Evaluation
Answer: D. Evaluation
Rationale: Evaluation is the phase of the nursing process in which the nurse
determines whether the patient's goals or expected outcomes have been achieved.
In this case, the nurse is evaluating the effectiveness of the pain medication
intervention.
Question 7
Which critical thinking skill involves questioning whether the information gathered
is accurate, complete, and relevant?
, A. Analysis
B. Inference
C. Explanation
D. Self-regulation
Answer: A. Analysis
Rationale: Analysis is a critical thinking skill that involves examining and
breaking down information to identify its components, verify accuracy, and
determine relevance. It is essential for making sound clinical judgments.
Question 8
A nurse is using the nursing process to care for a patient with diabetes. Which step
involves establishing goals and expected outcomes?
A. Assessment
B. Planning
C. Implementation
D. Evaluation
Answer: B. Planning
Rationale: Planning is the phase of the nursing process in which the nurse
establishes goals and expected outcomes and develops nursing interventions to
achieve them. Goals should be patient-centered, specific, and measurable.
Question 9
Which of the following is an example of subjective data?
A. Blood pressure 142/88 mmHg
B. Heart rate 92 bpm
C. Patient states, "I feel dizzy when I stand up."
D. Crackles in the lung bases
Answer: C. Patient states, "I feel dizzy when I stand up."
Rationale: Subjective data are information reported by the patient (or family) that
cannot be observed or measured directly by the nurse. Symptoms such as pain,
Nursing Concepts Study Guide Healthcare Principles,
Patient Care, Critical Thinking, and Examination
Success Questions with Detailed Rationales | Latest
2025–2026 Update
Question 1
A nurse is caring for a patient with pneumonia. The nurse identifies the following:
crackles in lung bases, temperature 101.2°F, productive cough with yellow sputum,
and respiratory rate of 28 breaths/min. This data collection represents which phase
of the nursing process?
A. Planning
B. Assessment
C. Implementation
D. Evaluation
Answer: B. Assessment
Rationale: Assessment is the systematic collection of data about the patient's
health status. This includes gathering subjective data (patient complaints) and
objective data (physical examination findings, vital signs, and laboratory results).
The data provided (crackles, temperature, cough, respiratory rate) are all
assessment findings.
Question 2
A nurse formulates the following nursing diagnosis: "Impaired Gas Exchange
related to alveolar-capillary membrane changes as evidenced by crackles, oxygen
saturation of 88%, and dyspnea." Which component represents the "as evidenced
by" (AEB) statement?
A. Impaired Gas Exchange
B. Related to alveolar-capillary membrane changes
C. Crackles, oxygen saturation of 88%, and dyspnea
D. None of the above
,Answer: C. Crackles, oxygen saturation of 88%, and dyspnea
Rationale: In a nursing diagnosis, the "as evidenced by" (AEB) statement contains
the defining characteristics or signs/symptoms that support the diagnosis. These are
the objective and subjective data that demonstrate the existence of the problem.
The "related to" (R/T) statement identifies the cause or contributing factor.
Question 3
A nurse is writing a care plan for a patient with impaired mobility. Which of the
following is an appropriate expected outcome?
A. Patient will be discharged tomorrow
B. Patient will turn from supine to side-lying independently by day 3
C. Patient will take their medications
D. Patient will eat all meals
Answer: B. Patient will turn from supine to side-lying independently by day 3
Rationale: An expected outcome must be patient-centered, specific, measurable,
realistic, and time-bound. It should describe what the patient will achieve, not what
the nurse will do. "Patient will turn from supine to side-lying independently by day
3" meets these criteria.
Question 4
Which of the following represents a correctly written nursing diagnosis using the
PES format?
A. Impaired Skin Integrity related to immobility as evidenced by stage 2
pressure injury on sacrum
B. Skin breakdown related to immobility
C. Pressure injury on sacrum
D. Patient has impaired skin integrity
Answer: A. Impaired Skin Integrity related to immobility as evidenced by
stage 2 pressure injury on sacrum
Rationale: The PES format includes: Problem (Impaired Skin Integrity), Etiology
(related to immobility), and Signs/Symptoms (as evidenced by stage 2 pressure
injury on sacrum). This is the recommended format for nursing diagnoses.
,Question 5
A patient is admitted with a new diagnosis of heart failure. The nurse's initial
assessment reveals crackles, edema, and shortness of breath. What is the nurse's
priority action?
A. Administer pain medication
B. Complete a focused respiratory and cardiovascular assessment
C. Begin discharge planning
D. Provide patient education
Answer: B. Complete a focused respiratory and cardiovascular assessment
Rationale: Assessment is the first phase of the nursing process. Based on the
patient's signs and symptoms (crackles, edema, shortness of breath), a focused
respiratory and cardiovascular assessment should be completed. This data will
guide planning and interventions.
Question 6
A nurse is evaluating a patient's response to pain medication. The patient reports
pain decreased from 8/10 to 3/10. This represents which phase of the nursing
process?
A. Assessment
B. Planning
C. Implementation
D. Evaluation
Answer: D. Evaluation
Rationale: Evaluation is the phase of the nursing process in which the nurse
determines whether the patient's goals or expected outcomes have been achieved.
In this case, the nurse is evaluating the effectiveness of the pain medication
intervention.
Question 7
Which critical thinking skill involves questioning whether the information gathered
is accurate, complete, and relevant?
, A. Analysis
B. Inference
C. Explanation
D. Self-regulation
Answer: A. Analysis
Rationale: Analysis is a critical thinking skill that involves examining and
breaking down information to identify its components, verify accuracy, and
determine relevance. It is essential for making sound clinical judgments.
Question 8
A nurse is using the nursing process to care for a patient with diabetes. Which step
involves establishing goals and expected outcomes?
A. Assessment
B. Planning
C. Implementation
D. Evaluation
Answer: B. Planning
Rationale: Planning is the phase of the nursing process in which the nurse
establishes goals and expected outcomes and develops nursing interventions to
achieve them. Goals should be patient-centered, specific, and measurable.
Question 9
Which of the following is an example of subjective data?
A. Blood pressure 142/88 mmHg
B. Heart rate 92 bpm
C. Patient states, "I feel dizzy when I stand up."
D. Crackles in the lung bases
Answer: C. Patient states, "I feel dizzy when I stand up."
Rationale: Subjective data are information reported by the patient (or family) that
cannot be observed or measured directly by the nurse. Symptoms such as pain,
