NUR 316 Exam 1 Questions with 100%
Detailed Answers Latest Versions 2025
Graded A+
A nurse administers an antihypertensive medication to a patient at the scheduled time of 0900.
The nursing assistive personnel (NAP) then reports to the nurse that the patient's blood pressure
was low when it was taken at 0830. The NAP states that was busy and had not had a chance to
tell the nurse yet. The patient begins to complain of feeling dizzy and light-headed. The blood
pressure is rechecked and it has dropped even lower. In which phase of the nursing process did
the nurse first make an error?
A) Assessment
B) Diagnosis
C) Implementation
D) Evaluation correct answers A
A nurse adds the following diagnosis to a patient's care plan: Constipation related to decreased
gastrointestinal motility secondary to pain medication administration as evidenced by the patient
reporting no bowel movement in seven days, abdominal distention, and abdominal pain. Which
element did the nurse write as the defining characteristic?
A) Decreased gastrointestinal motility
B) Pain medication
C) Abdominal distention
D) Constipation correct answers C
The patient database reveals that a patient has decreased oral intake, decreased oxygen saturation
when ambulating, reports of shortness of breath when getting out of bed, and a productive cough.
Which elements will the nurse identify as defining characteristics for the diagnostic label of
Activity intolerance?
,A) Decreased oral intake and decreased oxygen saturation when ambulating
B) Decreased oxygen saturation when ambulating and reports of shortness of breath when
getting out of bed
C) Reports of shortness of breath when getting out of bed and a productive cough
D) Productive cough and decreased oral intake correct answers B
A nurse performs an assessment on a patient. Which assessment data will the nurse use as an
etiology for Acute pain?
A) Discomfort while changing position
B) Reports pain as a 7 on a 0 to 10 scale
C) Disruption of tissue integrity
D) Dull headache correct answers C
A new nurse writes the following nursing diagnoses on a patient's care plan. Which nursing
diagnosis will cause the nurse manager to intervene?
A) Wandering
B) Hemorrhage
C) Urinary retention
D) Impaired swallowing correct answers B
A patient has a bacterial infection in left lower leg. Which nursing diagnosis will the nurse add to
the patient's care plan?
A) Infection
B) Risk for infection
C) Impaired skin integrity
D) Staphylococcal leg infection correct answers C
A nurse adds a nursing diagnosis to a patient's care plan. Which information did the nurse
document?
,A) Decreased cardiac output related to altered myocardial contractility.
B) Patient needs a low-fat diet related to inadequate heart perfusion.
C) Offer a low-fat diet because of heart problems.
D) Acute heart pain related to discomfort. correct answers A
A charge nurse is evaluating a new nurse's plan of care. Which finding will cause the charge
nurse to follow up?
A) Assigning a documented nursing diagnosis of Risk for infection for a patient on intravenous
(IV) antibiotics
B) Completing an interview and physical examination before adding a nursing diagnosis
C) Developing nursing diagnoses before completing the database
D) Including cultural and religious preferences in the database correct answers C
A patient exhibits the following symptoms: tachycardia, increased thirst, headache, decreased
urine output, and increased body temperature. The nurse analyzes the data. Which nursing
diagnosis will the nurse assign to the patient?
A) Adult failure to thrive
B) Hypothermia
C) Deficient fluid volume
D) Nausea correct answers C
Which question would be most appropriate for a nurse to ask a patient to assist in establishing a
nursing diagnosis of Diarrhea?
A) "What types of foods do you think caused your upset stomach?"
B) "How many bowel movements a day have you had?"
C) "Are you able to get to the bathroom in time?"
D) "What medications are you currently taking?" correct answers B
, A nurse assesses that a patient has not voided in 6 hours. Which question should the nurse ask to
assist in establishing a nursing diagnosis of Urinary retention?
A) "Do you feel like you need to go to the bathroom?"
B) "Are you able to walk to the bathroom by yourself?"
C) "When was the last time you took your medicine?"
D) "Do you have a safety rail in your bathroom at home?" correct answers A
A nurse is developing nursing diagnoses for a patient. Beginning with the first step, place in
order the steps the nurse will use.
1. Observes the patient having dyspnea (shortness of breath) and a diagnosis of asthma
2. Writes a diagnostic label of impaired gas exchange
3. Organizes data into meaningful clusters
4. Interprets information from patient
5. Writes an etiology
A) 1, 3, 4, 2, 5
B) 1, 3, 4, 5, 2
C) 1, 4, 3, 5, 2
D) 1, 4, 3, 2, 5 correct answers A
A nurse is developing nursing diagnoses for a group of patients. Which nursing diagnoses will
the nurse use? (Select all that apply.)
A) Anxiety related to barium enema
B) Impaired gas exchange related to asthma
C) Impaired physical mobility related to incisional pain
D) Nausea related to adverse effect of cancer medication
E) Risk for falls related to nursing assistive personnel leaving bedrail down correct answers C
D
Detailed Answers Latest Versions 2025
Graded A+
A nurse administers an antihypertensive medication to a patient at the scheduled time of 0900.
The nursing assistive personnel (NAP) then reports to the nurse that the patient's blood pressure
was low when it was taken at 0830. The NAP states that was busy and had not had a chance to
tell the nurse yet. The patient begins to complain of feeling dizzy and light-headed. The blood
pressure is rechecked and it has dropped even lower. In which phase of the nursing process did
the nurse first make an error?
A) Assessment
B) Diagnosis
C) Implementation
D) Evaluation correct answers A
A nurse adds the following diagnosis to a patient's care plan: Constipation related to decreased
gastrointestinal motility secondary to pain medication administration as evidenced by the patient
reporting no bowel movement in seven days, abdominal distention, and abdominal pain. Which
element did the nurse write as the defining characteristic?
A) Decreased gastrointestinal motility
B) Pain medication
C) Abdominal distention
D) Constipation correct answers C
The patient database reveals that a patient has decreased oral intake, decreased oxygen saturation
when ambulating, reports of shortness of breath when getting out of bed, and a productive cough.
Which elements will the nurse identify as defining characteristics for the diagnostic label of
Activity intolerance?
,A) Decreased oral intake and decreased oxygen saturation when ambulating
B) Decreased oxygen saturation when ambulating and reports of shortness of breath when
getting out of bed
C) Reports of shortness of breath when getting out of bed and a productive cough
D) Productive cough and decreased oral intake correct answers B
A nurse performs an assessment on a patient. Which assessment data will the nurse use as an
etiology for Acute pain?
A) Discomfort while changing position
B) Reports pain as a 7 on a 0 to 10 scale
C) Disruption of tissue integrity
D) Dull headache correct answers C
A new nurse writes the following nursing diagnoses on a patient's care plan. Which nursing
diagnosis will cause the nurse manager to intervene?
A) Wandering
B) Hemorrhage
C) Urinary retention
D) Impaired swallowing correct answers B
A patient has a bacterial infection in left lower leg. Which nursing diagnosis will the nurse add to
the patient's care plan?
A) Infection
B) Risk for infection
C) Impaired skin integrity
D) Staphylococcal leg infection correct answers C
A nurse adds a nursing diagnosis to a patient's care plan. Which information did the nurse
document?
,A) Decreased cardiac output related to altered myocardial contractility.
B) Patient needs a low-fat diet related to inadequate heart perfusion.
C) Offer a low-fat diet because of heart problems.
D) Acute heart pain related to discomfort. correct answers A
A charge nurse is evaluating a new nurse's plan of care. Which finding will cause the charge
nurse to follow up?
A) Assigning a documented nursing diagnosis of Risk for infection for a patient on intravenous
(IV) antibiotics
B) Completing an interview and physical examination before adding a nursing diagnosis
C) Developing nursing diagnoses before completing the database
D) Including cultural and religious preferences in the database correct answers C
A patient exhibits the following symptoms: tachycardia, increased thirst, headache, decreased
urine output, and increased body temperature. The nurse analyzes the data. Which nursing
diagnosis will the nurse assign to the patient?
A) Adult failure to thrive
B) Hypothermia
C) Deficient fluid volume
D) Nausea correct answers C
Which question would be most appropriate for a nurse to ask a patient to assist in establishing a
nursing diagnosis of Diarrhea?
A) "What types of foods do you think caused your upset stomach?"
B) "How many bowel movements a day have you had?"
C) "Are you able to get to the bathroom in time?"
D) "What medications are you currently taking?" correct answers B
, A nurse assesses that a patient has not voided in 6 hours. Which question should the nurse ask to
assist in establishing a nursing diagnosis of Urinary retention?
A) "Do you feel like you need to go to the bathroom?"
B) "Are you able to walk to the bathroom by yourself?"
C) "When was the last time you took your medicine?"
D) "Do you have a safety rail in your bathroom at home?" correct answers A
A nurse is developing nursing diagnoses for a patient. Beginning with the first step, place in
order the steps the nurse will use.
1. Observes the patient having dyspnea (shortness of breath) and a diagnosis of asthma
2. Writes a diagnostic label of impaired gas exchange
3. Organizes data into meaningful clusters
4. Interprets information from patient
5. Writes an etiology
A) 1, 3, 4, 2, 5
B) 1, 3, 4, 5, 2
C) 1, 4, 3, 5, 2
D) 1, 4, 3, 2, 5 correct answers A
A nurse is developing nursing diagnoses for a group of patients. Which nursing diagnoses will
the nurse use? (Select all that apply.)
A) Anxiety related to barium enema
B) Impaired gas exchange related to asthma
C) Impaired physical mobility related to incisional pain
D) Nausea related to adverse effect of cancer medication
E) Risk for falls related to nursing assistive personnel leaving bedrail down correct answers C
D
