NU 136 EXAM 2 – FUNDAMENTALS OF NURSING EXAM QUESTIONS
AND ANSWERS WITH DETAILED RATIONALES EACH | CURRENTLY
TESTING AND FREQUENTLY TESTED QUESTIONS |
EXPERT VERIFIED FOR GUARANTEED PASS
(GALEN COLLEGE OF NURSING)
Topics Covered:
- Nursing Process (ADPIE)
- Patient Safety & Fall Prevention
- Infection Control & Aseptic Technique
- Health Assessment & Vital Signs
- Fluid, Electrolyte, & Nutrition
- Urinary Elimination & Catheterization
- Wound Care & Skin Integrity
- Mobility, Oxygenation, & Medication Administration
- Perioperative Care
- Legal, Ethical, Documentation & Pain Management
SECTION 1: NURSING PROCESS (ADPIE) — Questions 1–30
Q1: A nurse is caring for a client who has a new diagnosis of diabetes
mellitus. Which of the following actions demonstrates the assessment phase of
the nursing process?
A) Administer insulin as prescribed
B) Check the client's blood glucose level
C) Teach the client how to use a glucometer
D) Evaluate the effectiveness of dietary changes
Correct Answer: B
Rationale: Assessment is the first phase and involves collecting subjective and
objective data. Checking blood glucose is data collection. Administration (A)
and teaching (C) are implementation. Evaluation (D) is the evaluation phase.
Q2: Which of the following best describes the primary purpose of a
comprehensive health assessment?
A) To establish a baseline for comparison and identify potential health problems
1
,B) To provide data for medical diagnosis only
C) To satisfy hospital admission requirements
D) To determine the patient's financial eligibility for care
Correct Answer: A
Rationale: A comprehensive assessment establishes a baseline and identifies
actual or potential health problems. It is continuous, not just for admission
or diagnosis.
Q3: In the nursing process, which statement best describes the assessment
phase?
A) Setting measurable goals for patient outcomes
B) Carrying out the planned nursing interventions
C) Collecting subjective and objective data systematically
D) Determining whether patient goals have been met
Correct Answer: C
Rationale: Assessment = systematic collection of subjective (reported) and
objective (observable) data. Goal-setting is planning (A). Implementing is (B).
Evaluation is (D).
Q4: A nurse is formulating a nursing diagnosis for a patient with impaired
mobility. Which of the following is an appropriately written nursing diagnosis?
A) "Risk for falls related to muscle weakness as evidenced by unsteady gait"
B) "Impaired physical mobility related to decreased muscle strength"
C) "Patient will walk with a cane within 3 days"
D) "Provide assistance with ambulation every shift"
Correct Answer: B
Rationale: A nursing diagnosis includes the problem and etiology (related to).
Option A has a risk diagnosis but incorrectly includes evidence (for risk dx,
evidence is not required). C is a goal, D is an intervention.
Q5: During the planning phase of the nursing process, the nurse should:
A) Collect data about the patient's condition
2
,B) Identify patient problems based on assessment data
C) Develop specific, measurable, and realistic patient goals
D) Evaluate the effectiveness of nursing interventions
Correct Answer: C
Rationale: Planning involves setting goals and expected outcomes. A is
assessment,
B is diagnosis, D is evaluation.
Q6: The nurse evaluates a patient's response to a pain management intervention.
This occurs during which phase of the nursing process?
A) Assessment
B) Diagnosis
C) Implementation
D) Evaluation
Correct Answer: D
Rationale: Evaluation is the final phase where the nurse determines if goals were
met and interventions were effective.
Q7: Which of the following is an example of objective data obtained during a
health assessment?
A) The patient reports feeling nauseated
B) The patient states they have a headache
C) The patient's blood pressure is 142/90 mmHg
D) The patient describes pain as "sharp and stabbing"
Correct Answer: C
Rationale: Objective data are measurable and observable (vital signs, lab
results, physical exam findings). The others are subjective data reported by the
patient.
Q8: The nurse is writing a care plan for a patient with a new colostomy. Which
outcome is correctly written as a measurable goal?
A) Patient will adjust to the new ostomy
3
, B) Patient will demonstrate proper stoma care by the time of discharge
C) Patient will feel better about their body image
D) Patient will understand how to change the pouch
Correct Answer: B
Rationale: A measurable goal includes a specific action and a timeframe.
"Demonstrate proper stoma care by discharge" is measurable. "Adjust," "feel
better," and "understand" are vague and not easily measured.
Q9: A nurse obtains a patient's vital signs, reviews lab results, and listens
to lung sounds. This collection of data is part of which nursing process
component?
A) Evaluation
B) Planning
C) Assessment
D) Implementation
Correct Answer: C
Rationale: Collecting data via vital signs, labs, and physical exam is assessment.
Q10: The nursing diagnosis "Disturbed body image related to surgical removal
of breast" is an example of which type of nursing diagnosis?
A) Health promotion diagnosis
B) Risk diagnosis
C) Actual diagnosis
D) Syndrome diagnosis
Correct Answer: C
Rationale: An actual diagnosis describes a current problem (evidence present).
"Disturbed body image" is currently occurring. Risk diagnoses use "Risk for..."
Health promotion uses "Readiness for enhanced..."
Q11: After implementing a fall prevention protocol, the nurse reassesses the
patient and finds they have not fallen. The nurse determines the goal was met.
This action is an example of:
4
AND ANSWERS WITH DETAILED RATIONALES EACH | CURRENTLY
TESTING AND FREQUENTLY TESTED QUESTIONS |
EXPERT VERIFIED FOR GUARANTEED PASS
(GALEN COLLEGE OF NURSING)
Topics Covered:
- Nursing Process (ADPIE)
- Patient Safety & Fall Prevention
- Infection Control & Aseptic Technique
- Health Assessment & Vital Signs
- Fluid, Electrolyte, & Nutrition
- Urinary Elimination & Catheterization
- Wound Care & Skin Integrity
- Mobility, Oxygenation, & Medication Administration
- Perioperative Care
- Legal, Ethical, Documentation & Pain Management
SECTION 1: NURSING PROCESS (ADPIE) — Questions 1–30
Q1: A nurse is caring for a client who has a new diagnosis of diabetes
mellitus. Which of the following actions demonstrates the assessment phase of
the nursing process?
A) Administer insulin as prescribed
B) Check the client's blood glucose level
C) Teach the client how to use a glucometer
D) Evaluate the effectiveness of dietary changes
Correct Answer: B
Rationale: Assessment is the first phase and involves collecting subjective and
objective data. Checking blood glucose is data collection. Administration (A)
and teaching (C) are implementation. Evaluation (D) is the evaluation phase.
Q2: Which of the following best describes the primary purpose of a
comprehensive health assessment?
A) To establish a baseline for comparison and identify potential health problems
1
,B) To provide data for medical diagnosis only
C) To satisfy hospital admission requirements
D) To determine the patient's financial eligibility for care
Correct Answer: A
Rationale: A comprehensive assessment establishes a baseline and identifies
actual or potential health problems. It is continuous, not just for admission
or diagnosis.
Q3: In the nursing process, which statement best describes the assessment
phase?
A) Setting measurable goals for patient outcomes
B) Carrying out the planned nursing interventions
C) Collecting subjective and objective data systematically
D) Determining whether patient goals have been met
Correct Answer: C
Rationale: Assessment = systematic collection of subjective (reported) and
objective (observable) data. Goal-setting is planning (A). Implementing is (B).
Evaluation is (D).
Q4: A nurse is formulating a nursing diagnosis for a patient with impaired
mobility. Which of the following is an appropriately written nursing diagnosis?
A) "Risk for falls related to muscle weakness as evidenced by unsteady gait"
B) "Impaired physical mobility related to decreased muscle strength"
C) "Patient will walk with a cane within 3 days"
D) "Provide assistance with ambulation every shift"
Correct Answer: B
Rationale: A nursing diagnosis includes the problem and etiology (related to).
Option A has a risk diagnosis but incorrectly includes evidence (for risk dx,
evidence is not required). C is a goal, D is an intervention.
Q5: During the planning phase of the nursing process, the nurse should:
A) Collect data about the patient's condition
2
,B) Identify patient problems based on assessment data
C) Develop specific, measurable, and realistic patient goals
D) Evaluate the effectiveness of nursing interventions
Correct Answer: C
Rationale: Planning involves setting goals and expected outcomes. A is
assessment,
B is diagnosis, D is evaluation.
Q6: The nurse evaluates a patient's response to a pain management intervention.
This occurs during which phase of the nursing process?
A) Assessment
B) Diagnosis
C) Implementation
D) Evaluation
Correct Answer: D
Rationale: Evaluation is the final phase where the nurse determines if goals were
met and interventions were effective.
Q7: Which of the following is an example of objective data obtained during a
health assessment?
A) The patient reports feeling nauseated
B) The patient states they have a headache
C) The patient's blood pressure is 142/90 mmHg
D) The patient describes pain as "sharp and stabbing"
Correct Answer: C
Rationale: Objective data are measurable and observable (vital signs, lab
results, physical exam findings). The others are subjective data reported by the
patient.
Q8: The nurse is writing a care plan for a patient with a new colostomy. Which
outcome is correctly written as a measurable goal?
A) Patient will adjust to the new ostomy
3
, B) Patient will demonstrate proper stoma care by the time of discharge
C) Patient will feel better about their body image
D) Patient will understand how to change the pouch
Correct Answer: B
Rationale: A measurable goal includes a specific action and a timeframe.
"Demonstrate proper stoma care by discharge" is measurable. "Adjust," "feel
better," and "understand" are vague and not easily measured.
Q9: A nurse obtains a patient's vital signs, reviews lab results, and listens
to lung sounds. This collection of data is part of which nursing process
component?
A) Evaluation
B) Planning
C) Assessment
D) Implementation
Correct Answer: C
Rationale: Collecting data via vital signs, labs, and physical exam is assessment.
Q10: The nursing diagnosis "Disturbed body image related to surgical removal
of breast" is an example of which type of nursing diagnosis?
A) Health promotion diagnosis
B) Risk diagnosis
C) Actual diagnosis
D) Syndrome diagnosis
Correct Answer: C
Rationale: An actual diagnosis describes a current problem (evidence present).
"Disturbed body image" is currently occurring. Risk diagnoses use "Risk for..."
Health promotion uses "Readiness for enhanced..."
Q11: After implementing a fall prevention protocol, the nurse reassesses the
patient and finds they have not fallen. The nurse determines the goal was met.
This action is an example of:
4
