Page 1 of 102
RNSG 1327 EXAM 1 WITH VERIFIED ANSWERS DETAILED
RATIONALES GRADED A+
Section 1: Nursing Process (Questions 1-30)
1. What is the correct sequential order of the steps of the nursing process?
A. Assessment, Planning, Diagnosis, Evaluation, Implementation
B. Diagnosis, Assessment, Planning, Evaluation, Implementation
C. Planning, Assessment, Diagnosis, Implementation, Evaluation
D. Assessment, Diagnosis, Planning, Implementation, Evaluation
Rationale: The nursing process follows the ADPIE mnemonic: Assessment, Diagnosis,
Planning, Implementation, and Evaluation.
2. Which type of assessment is performed immediately after a patient reports
sudden chest pain?
A. Time-lapsed assessment
B. Focused assessment
1|Page
,Page 2 of 102
C. Initial assessment
D. Comprehensive assessment
Rationale: A focused assessment targets a specific problem as it arises, such as sudden
chest pain.
3. A patient states, "I feel nauseated and dizzy." This is an example of which type
of data?
A. Secondary data
B. Objective data
C. Validated data
D. Subjective data
Rationale: Subjective data are symptoms reported by the patient in their own words.
4. A blood pressure reading of 168/94 mmHg obtained by the nurse is an example
of which type of data?
A. Subjective data
B. Objective data
C. Inferred data
D. Retrospective data
Rationale: Objective data are measurable, observable findings gathered by the
examiner.
2|Page
,Page 3 of 102
5. Which source of patient data is considered a primary source?
A. The patient's spouse
B. The medical record
C. The patient
D. The laboratory report
Rationale: The patient is always the primary source of data. All other sources are
secondary.
6. Which activity falls within RN scope but not LVN scope under differentiated
practice?
A. Documenting intake and output
B. Collecting admission vital signs
C. Reinforcing patient teaching already initiated
D. Formulating the initial nursing diagnosis and plan of care
Rationale: Initiating nursing diagnoses and the plan of care requires RN-level judgment
and falls outside LVN scope.
7. Which nursing diagnosis is correctly written using NANDA-I structure for an
actual diagnosis?
3|Page
, Page 4 of 102
A. Impaired skin integrity related to immobility as evidenced by a stage II pressure injury
B. Risk for impaired skin integrity as evidenced by redness
C. Impaired skin integrity related to pressure injury
D. Pressure injury related to impaired skin integrity
Rationale: Actual diagnoses use the PES format: Problem, Etiology (related to), and
Signs/Symptoms (as evidenced by).
8. A "risk for" nursing diagnosis differs from an actual nursing diagnosis because
it:
A. Requires no related factors
B. Has no "as evidenced by" clause since no signs or symptoms are present
C. Cannot be included on a care plan
D. Is written only by physicians
Rationale: Risk diagnoses identify vulnerability before symptoms develop, so no
defining characteristics exist yet.
9. During the planning step of the nursing process, the nurse primarily:
A. Collects baseline vital signs
B. Establishes goals and expected outcomes with the patient
C. Carries out prescribed treatments
D. Determines whether goals were met
4|Page
RNSG 1327 EXAM 1 WITH VERIFIED ANSWERS DETAILED
RATIONALES GRADED A+
Section 1: Nursing Process (Questions 1-30)
1. What is the correct sequential order of the steps of the nursing process?
A. Assessment, Planning, Diagnosis, Evaluation, Implementation
B. Diagnosis, Assessment, Planning, Evaluation, Implementation
C. Planning, Assessment, Diagnosis, Implementation, Evaluation
D. Assessment, Diagnosis, Planning, Implementation, Evaluation
Rationale: The nursing process follows the ADPIE mnemonic: Assessment, Diagnosis,
Planning, Implementation, and Evaluation.
2. Which type of assessment is performed immediately after a patient reports
sudden chest pain?
A. Time-lapsed assessment
B. Focused assessment
1|Page
,Page 2 of 102
C. Initial assessment
D. Comprehensive assessment
Rationale: A focused assessment targets a specific problem as it arises, such as sudden
chest pain.
3. A patient states, "I feel nauseated and dizzy." This is an example of which type
of data?
A. Secondary data
B. Objective data
C. Validated data
D. Subjective data
Rationale: Subjective data are symptoms reported by the patient in their own words.
4. A blood pressure reading of 168/94 mmHg obtained by the nurse is an example
of which type of data?
A. Subjective data
B. Objective data
C. Inferred data
D. Retrospective data
Rationale: Objective data are measurable, observable findings gathered by the
examiner.
2|Page
,Page 3 of 102
5. Which source of patient data is considered a primary source?
A. The patient's spouse
B. The medical record
C. The patient
D. The laboratory report
Rationale: The patient is always the primary source of data. All other sources are
secondary.
6. Which activity falls within RN scope but not LVN scope under differentiated
practice?
A. Documenting intake and output
B. Collecting admission vital signs
C. Reinforcing patient teaching already initiated
D. Formulating the initial nursing diagnosis and plan of care
Rationale: Initiating nursing diagnoses and the plan of care requires RN-level judgment
and falls outside LVN scope.
7. Which nursing diagnosis is correctly written using NANDA-I structure for an
actual diagnosis?
3|Page
, Page 4 of 102
A. Impaired skin integrity related to immobility as evidenced by a stage II pressure injury
B. Risk for impaired skin integrity as evidenced by redness
C. Impaired skin integrity related to pressure injury
D. Pressure injury related to impaired skin integrity
Rationale: Actual diagnoses use the PES format: Problem, Etiology (related to), and
Signs/Symptoms (as evidenced by).
8. A "risk for" nursing diagnosis differs from an actual nursing diagnosis because
it:
A. Requires no related factors
B. Has no "as evidenced by" clause since no signs or symptoms are present
C. Cannot be included on a care plan
D. Is written only by physicians
Rationale: Risk diagnoses identify vulnerability before symptoms develop, so no
defining characteristics exist yet.
9. During the planning step of the nursing process, the nurse primarily:
A. Collects baseline vital signs
B. Establishes goals and expected outcomes with the patient
C. Carries out prescribed treatments
D. Determines whether goals were met
4|Page
