WGU Fundamentals of Nursing Process EXAM 104
QUESTIONS WITH VERIFIED ANSWER 2026
A. Assessment
Rationale: The first step in the nursing process is assessment, the process of
collecting data. All subsequent phases of the nursing process (options 2, 3, and 4)
rely on accurate and complete data. - CORRECT ANSWER A client comes to the
walk-in clinic with reports of abdominal pain and diarrhea. While taking the
client's vital signs, the nurse is implementing which phase of the nursing process?
A. Assessment
B. Diagnosis
C. Planning
D. Implementation
B. The client's urine output was 450 milk
Rationale: Objective data is measurable data that can be seen, heard, or verified
by the nurse. The objective data is the measurement of the urine output. A
client's statements and reports of symptoms are documented as subjective data,
such as the data found in options 1, 3, and 4. - CORRECT ANSWER The nurse is
measuring the client's urine output and straining the urine to assess for stones.
Which of the following should the nurse record as objective data?
A. The client reports abdominal pain
B. The client's urine output was 450 mL
C. The client states, "I didn't see any stones in my urine."
,D. The client states, "I feel like I have passed a stone."
A. Compare this reading against defined
Rationale: Analysis of the client's BP requires knowledge of the normal BP range
for an older adult. The nurse compares the client's data against identified
standards to determine whether this reading is normal or abnormal. Measuring
the BP in the other arm (option 2) and comparing the reading to previous ones
(option 4) will give additional client data, but the comparison alone will not
determine whether the BP is normal. Gaps in the record (option 3) will not aid in
interpreting the current measurement. - CORRECT ANSWER When evaluating an
elderly client's blood pressure (BP) of 146/78 mmHg, the nurse does which of the
following before determining whether the BP is normal or represents
hypertension?
A. Compare this reading against defined standards
B. Compare the reading with one taken in the opposite arm
C. Determine gaps in the vital signs in the client record
D. Compare the current measurement with previous ones
A. Admitting not knowing how to do a procedure and requesting help
E. Gathering three assistants to transfer the client to a stretcher after noting the
client weighs 300 lbs.
Rationale: Critical thinking in nursing is self-directed, supporting what nurses
know and making clear what they do not know. It is important for nurses to
recognize when they lack the knowledge they need to provide safe care for a
client (option 1). Nurses must also utilize their resources to acquire the support
,they need to care for a client safely (option 5). Options 2, 3, and 4 do not
demonstrate critical thinking. - CORRECT ANSWER Which of the following
behaviors by the nurse demonstrates that the nurse is participating in critical
thinking? Select all that apply.
A. Admitting not knowing how to do a procedure and requesting help
B. Using clever and persuasive remarks to support an opinion or position
C. Accepting without question the values acquired in nursing school
D. Finding a quick and logical answer, even to complex questions
E. Gathering three assistants to transfer the client to a stretcher after noting the
client weighs 300 lbs.
D. Target time
Rationale: The outcome goal does not state the target timeframe for when the
nurse should expect to see the client behavior ("transfer"). The condition or
modifier is present ("with two assists"). The performance criterion is "from bed to
chair." - CORRECT ANSWER The nurse has documented the following outcome
goal in the care plan: "The client will transfer from bed to chair with two-person
assist." The charge nurse tells the nurse to add which of the following to complete
the goal?
A. Client behavior
B. Conditions or modifiers
C. Performance criteria
D. Target time
, B. Planning
Rationale: The planning step of the nursing process involves formulating client
goals and designing the nursing interventions required to prevent, reduce, or
eliminate the client's health problems. Outcome goals are documented on the
client's care plan. Assessment data (option 1) is used to help identify a client's
human response, and once a plan is established, the interventions are
implemented (option 3) and evaluated (option 4). - CORRECT ANSWER The nurse
who documents on the client's care plan the outcome goal "Anxiety will be
relieved within 20 to 40 minutes following administration of lorazepam (Ativan)" is
engaged in which step of the nursing process?
A. Assessment
B. Planning
C. Implementation
D. Evaluation
B. Suggesting the medication can be diluted in a beverage
Rationale: Diluting the medication in a beverage may make the medication more
palatable. Using critical thinking skills, the nurse should try to problem-solve in a
situation such as this before asking for the assistance of the nurse manager.
Suggesting an alternative method of taking the medication (provided that there
are no contraindications to diluting the medication) should improve the likelihood
of the client taking the medication. - CORRECT ANSWER When the client resists
taking a liquid medication that is essential to treatment, the nurse demonstrates
critical thinking by doing which of the following first?
QUESTIONS WITH VERIFIED ANSWER 2026
A. Assessment
Rationale: The first step in the nursing process is assessment, the process of
collecting data. All subsequent phases of the nursing process (options 2, 3, and 4)
rely on accurate and complete data. - CORRECT ANSWER A client comes to the
walk-in clinic with reports of abdominal pain and diarrhea. While taking the
client's vital signs, the nurse is implementing which phase of the nursing process?
A. Assessment
B. Diagnosis
C. Planning
D. Implementation
B. The client's urine output was 450 milk
Rationale: Objective data is measurable data that can be seen, heard, or verified
by the nurse. The objective data is the measurement of the urine output. A
client's statements and reports of symptoms are documented as subjective data,
such as the data found in options 1, 3, and 4. - CORRECT ANSWER The nurse is
measuring the client's urine output and straining the urine to assess for stones.
Which of the following should the nurse record as objective data?
A. The client reports abdominal pain
B. The client's urine output was 450 mL
C. The client states, "I didn't see any stones in my urine."
,D. The client states, "I feel like I have passed a stone."
A. Compare this reading against defined
Rationale: Analysis of the client's BP requires knowledge of the normal BP range
for an older adult. The nurse compares the client's data against identified
standards to determine whether this reading is normal or abnormal. Measuring
the BP in the other arm (option 2) and comparing the reading to previous ones
(option 4) will give additional client data, but the comparison alone will not
determine whether the BP is normal. Gaps in the record (option 3) will not aid in
interpreting the current measurement. - CORRECT ANSWER When evaluating an
elderly client's blood pressure (BP) of 146/78 mmHg, the nurse does which of the
following before determining whether the BP is normal or represents
hypertension?
A. Compare this reading against defined standards
B. Compare the reading with one taken in the opposite arm
C. Determine gaps in the vital signs in the client record
D. Compare the current measurement with previous ones
A. Admitting not knowing how to do a procedure and requesting help
E. Gathering three assistants to transfer the client to a stretcher after noting the
client weighs 300 lbs.
Rationale: Critical thinking in nursing is self-directed, supporting what nurses
know and making clear what they do not know. It is important for nurses to
recognize when they lack the knowledge they need to provide safe care for a
client (option 1). Nurses must also utilize their resources to acquire the support
,they need to care for a client safely (option 5). Options 2, 3, and 4 do not
demonstrate critical thinking. - CORRECT ANSWER Which of the following
behaviors by the nurse demonstrates that the nurse is participating in critical
thinking? Select all that apply.
A. Admitting not knowing how to do a procedure and requesting help
B. Using clever and persuasive remarks to support an opinion or position
C. Accepting without question the values acquired in nursing school
D. Finding a quick and logical answer, even to complex questions
E. Gathering three assistants to transfer the client to a stretcher after noting the
client weighs 300 lbs.
D. Target time
Rationale: The outcome goal does not state the target timeframe for when the
nurse should expect to see the client behavior ("transfer"). The condition or
modifier is present ("with two assists"). The performance criterion is "from bed to
chair." - CORRECT ANSWER The nurse has documented the following outcome
goal in the care plan: "The client will transfer from bed to chair with two-person
assist." The charge nurse tells the nurse to add which of the following to complete
the goal?
A. Client behavior
B. Conditions or modifiers
C. Performance criteria
D. Target time
, B. Planning
Rationale: The planning step of the nursing process involves formulating client
goals and designing the nursing interventions required to prevent, reduce, or
eliminate the client's health problems. Outcome goals are documented on the
client's care plan. Assessment data (option 1) is used to help identify a client's
human response, and once a plan is established, the interventions are
implemented (option 3) and evaluated (option 4). - CORRECT ANSWER The nurse
who documents on the client's care plan the outcome goal "Anxiety will be
relieved within 20 to 40 minutes following administration of lorazepam (Ativan)" is
engaged in which step of the nursing process?
A. Assessment
B. Planning
C. Implementation
D. Evaluation
B. Suggesting the medication can be diluted in a beverage
Rationale: Diluting the medication in a beverage may make the medication more
palatable. Using critical thinking skills, the nurse should try to problem-solve in a
situation such as this before asking for the assistance of the nurse manager.
Suggesting an alternative method of taking the medication (provided that there
are no contraindications to diluting the medication) should improve the likelihood
of the client taking the medication. - CORRECT ANSWER When the client resists
taking a liquid medication that is essential to treatment, the nurse demonstrates
critical thinking by doing which of the following first?
