Fundamentals
Fundamentals of Nursing, Nursing
Process Exam Questions Graded A+
The nurse makes the following entry on the client's care plan: "Goal not met. Client
refuses to ambulate, stating, 'I am too afraid I will fall.' " The nurse should take which of
the following actions?
A. Notify the physician
B. Reassign the client to another nurse
C. Re-examine the nursing orders
D. Write a new nursing diagnosis - ANS ✓B. Re-examine the nursing orders
Rationale: The plan needs to be reassessed whenever goals are not met. Nursing
interventions should be examined to ensure the best interventions were selected to
assist the client achieve the goal. The goal may be appropriate, but the client may need
more time to achieve the desired outcome. The manner in which the nursing
interventions were implemented may have interfered with achieving the outcome.
In developing a plan of care for a client with chronic hypertension, which nursing activity
would be most important?
A. Set incremental goals for blood pressure reduction
B. Instruct the client to make dietary changes by reducing sodium intake
C. Include the client and family when setting goals and formulating the plan of care
D. Assess past compliance to medication regimens - ANS ✓C. Include the client and
family when setting goals and formulating the plan of care
Fundamentals of Nursing, Nursing Process
,Fundamentals
Rationale: In developing a plan of care, nurses engage in a partnership with the client
and family. Nurses do not plan care for clients; instead they plan care with clients and
families. Assessment (option 4), goal setting (option 1), and interventions (option 2) will
be most accurate and effective when carried out in partnership with the client and family.
The other options represent other actions to take, but they will have less overall
effectiveness if the client and family are not part of the plan.
Which nurse is demonstrating the assessment phase of the nursing process?
A.The nurse who observes that the client's pain was relieved with pain medication
B. The nurse who turns the client to a more comfortable position
C. The nurse who ask the client how much lunch he or she ate
D. The nurse who works with the client to set desired outcome goals - ANS ✓C. The
nurse who ask the client how much lunch he or she ate
Rationale: Assessment involves collecting, organizing, validating, and documenting data
about a client. Option 1 represents the evaluation phase. Option 2 represents the
implementation phase. Option 4 represents the planning phase.
The client states, "My chest hurts and my left arm feels numb." The nurse interprets that
this data is of which type and source?
A. Subjective data from a primary source
B. Subjective data from a secondary source
C. Objective data from a primary source
D. Objective data from a secondary source - ANS ✓A. Subjective data from a primary
source
Fundamentals of Nursing, Nursing Process
, Fundamentals
Rationale: The client states, "My chest hurts and my left arm feels numb." The nurse
interprets that this data is of which type and source?
The nurse feels a client is at risk for skin breakdown because he has only had clear
liquids for the last 10 days (and essentially no protein intake). The nurse would formulate
which diagnostic statement that would best reflect this problem?
A. Risk for malnutrition related to clear liquid diet
B. Impaired skin integrity related to no protein intake
C. Risk for impaired skin integrity related to malnutrition
D. Impaired nutrition related to current illness - ANS ✓C. Risk for impaired skin integrity
related to malnutrition
Rationale: This is a risk diagnosis, and the diagnostic statement has two parts: the
human response (impaired skin integrity) and the related/risk factor (malnutrition).
Options 1 and 2 do not have related factors that are under the control of the nurse (i.e.,
type of diet ordered). The diagnosis in option 4 does not specify the type of impairment
(greater than or less than body requirements) and is therefore incomplete. It also does
not provide direction for development of goals and interventions.
The nurse would place which correctly written nursing diagnostic statement into the
client's care plan?
A. Cancer relater to cigarette smoking
B. Impaired gas exchange related to aspiration of foreign matter as evidenced by oxygen
saturation of 91%
C. Imbalance nutrition: more than body requirement related to overweight status
D. Impaired physical mobility related to generalized weakness and pain - ANS ✓B.
Impaired gas exchange related to aspiration of foreign matter as evidence by oxygen
saturation of 91%
Fundamentals of Nursing, Nursing Process
Fundamentals of Nursing, Nursing
Process Exam Questions Graded A+
The nurse makes the following entry on the client's care plan: "Goal not met. Client
refuses to ambulate, stating, 'I am too afraid I will fall.' " The nurse should take which of
the following actions?
A. Notify the physician
B. Reassign the client to another nurse
C. Re-examine the nursing orders
D. Write a new nursing diagnosis - ANS ✓B. Re-examine the nursing orders
Rationale: The plan needs to be reassessed whenever goals are not met. Nursing
interventions should be examined to ensure the best interventions were selected to
assist the client achieve the goal. The goal may be appropriate, but the client may need
more time to achieve the desired outcome. The manner in which the nursing
interventions were implemented may have interfered with achieving the outcome.
In developing a plan of care for a client with chronic hypertension, which nursing activity
would be most important?
A. Set incremental goals for blood pressure reduction
B. Instruct the client to make dietary changes by reducing sodium intake
C. Include the client and family when setting goals and formulating the plan of care
D. Assess past compliance to medication regimens - ANS ✓C. Include the client and
family when setting goals and formulating the plan of care
Fundamentals of Nursing, Nursing Process
,Fundamentals
Rationale: In developing a plan of care, nurses engage in a partnership with the client
and family. Nurses do not plan care for clients; instead they plan care with clients and
families. Assessment (option 4), goal setting (option 1), and interventions (option 2) will
be most accurate and effective when carried out in partnership with the client and family.
The other options represent other actions to take, but they will have less overall
effectiveness if the client and family are not part of the plan.
Which nurse is demonstrating the assessment phase of the nursing process?
A.The nurse who observes that the client's pain was relieved with pain medication
B. The nurse who turns the client to a more comfortable position
C. The nurse who ask the client how much lunch he or she ate
D. The nurse who works with the client to set desired outcome goals - ANS ✓C. The
nurse who ask the client how much lunch he or she ate
Rationale: Assessment involves collecting, organizing, validating, and documenting data
about a client. Option 1 represents the evaluation phase. Option 2 represents the
implementation phase. Option 4 represents the planning phase.
The client states, "My chest hurts and my left arm feels numb." The nurse interprets that
this data is of which type and source?
A. Subjective data from a primary source
B. Subjective data from a secondary source
C. Objective data from a primary source
D. Objective data from a secondary source - ANS ✓A. Subjective data from a primary
source
Fundamentals of Nursing, Nursing Process
, Fundamentals
Rationale: The client states, "My chest hurts and my left arm feels numb." The nurse
interprets that this data is of which type and source?
The nurse feels a client is at risk for skin breakdown because he has only had clear
liquids for the last 10 days (and essentially no protein intake). The nurse would formulate
which diagnostic statement that would best reflect this problem?
A. Risk for malnutrition related to clear liquid diet
B. Impaired skin integrity related to no protein intake
C. Risk for impaired skin integrity related to malnutrition
D. Impaired nutrition related to current illness - ANS ✓C. Risk for impaired skin integrity
related to malnutrition
Rationale: This is a risk diagnosis, and the diagnostic statement has two parts: the
human response (impaired skin integrity) and the related/risk factor (malnutrition).
Options 1 and 2 do not have related factors that are under the control of the nurse (i.e.,
type of diet ordered). The diagnosis in option 4 does not specify the type of impairment
(greater than or less than body requirements) and is therefore incomplete. It also does
not provide direction for development of goals and interventions.
The nurse would place which correctly written nursing diagnostic statement into the
client's care plan?
A. Cancer relater to cigarette smoking
B. Impaired gas exchange related to aspiration of foreign matter as evidenced by oxygen
saturation of 91%
C. Imbalance nutrition: more than body requirement related to overweight status
D. Impaired physical mobility related to generalized weakness and pain - ANS ✓B.
Impaired gas exchange related to aspiration of foreign matter as evidence by oxygen
saturation of 91%
Fundamentals of Nursing, Nursing Process
