WGU D439 Foundations of Nursing Exam |
150 Questions with Verified Answers |
Objective Assessment Prep | Western
Governors University
Total Questions: 150 | Course: D439 – Foundations of Nursing | Institution: Western
Governors University (WGU)
Section 1: Nursing Process & Critical Thinking
1. A nurse is assessing a patient who is 1 day post-operative. The patient rates pain
9/10 and the surgical site is draining yellow fluid. In which phase of the nursing
process is the nurse working?
a) Planning
b) Evaluation
c) Assessment
d) Implementation
c) Assessment
Assessment is the first phase of the nursing process where the nurse collects subjective
and objective data about the patient. Pain rating (subjective) and wound drainage
(objective) are both assessment data .
2. After reviewing assessment data, a nurse identifies that a patient's wound is
infected and writes the nursing diagnosis "Impaired Skin Integrity." This occurs
during which step of the nursing process?
a) Assessment
b) Diagnosis
,c) Planning
d) Evaluation
b) Diagnosis
The diagnosis phase involves analyzing assessment data to identify patient problems and
formulating nursing diagnoses. Impaired Skin Integrity is a nursing diagnosis that guides
subsequent care planning .
3. A nurse sets a goal for a patient with activity intolerance: "Patient will ambulate 50
feet in the hallway by the end of the shift." This is part of which nursing process
phase?
a) Assessment
b) Diagnosis
c) Planning
d) Implementation
c) Planning
Planning involves setting measurable, realistic goals and expected outcomes. SMART goals
(Specific, Measurable, Attainable, Realistic, Timely) are written during this phase .
4. The nurse administers morphine 4 mg IV as ordered. This action occurs during
which phase of the nursing process?
a) Planning
b) Implementation
c) Evaluation
d) Assessment
b) Implementation
Implementation is the action phase where the nurse carries out the interventions identified
in the care plan. Administering medication is a direct nursing intervention .
5. After teaching a patient how to self-administer insulin, the nurse observes the
patient draw up and inject saline correctly. The nurse documents "goal met." This is
an example of which nursing process phase?
,a) Assessment
b) Planning
c) Implementation
d) Evaluation
d) Evaluation
Evaluation determines whether patient goals have been met after interventions. Observing
the patient's return demonstration and documenting "goal met" is evaluation .
6. A patient's oxygen saturation drops to 88%. The nurse increases the oxygen flow
rate. Which step comes immediately after this intervention?
a) Document the intervention
b) Notify the provider
c) Update the care plan
d) Reassess the patient
d) Reassess the patient
After implementing an intervention, the nurse must reassess the patient to evaluate its
effectiveness. Reassessment follows implementation in the nursing process .
7. Which of the following is an example of subjective data?
a) Heart rate 110 bpm
b) Patient states "I feel dizzy"
c) Wound appears red and swollen
d) Blood pressure 140/90 mmHg
b) Patient states "I feel dizzy"
Subjective data is information the patient tells the nurse, including feelings, sensations, and
perceptions. Objective data is measurable and observable. "I feel dizzy" is subjective; heart
rate, wound appearance, and BP are objective .
8. A nurse is prioritizing care for four patients. According to the nursing process,
which action should the nurse take first?
a) Evaluate the effectiveness of pain medication given an hour ago
, b) Auscultate lung sounds on a patient reporting shortness of breath
c) Document a patient's refusal of breakfast
d) Update the care plan for a patient being discharged
b) Auscultate lung sounds on a patient reporting shortness of breath
Assessment is the first step of the nursing process. A patient with shortness of breath
requires immediate assessment to identify the cause and implement appropriate
interventions .
9. What is the purpose of the nursing process?
a) To provide a framework for medical diagnosis
b) To serve as a standardized method for nursing care that integrates critical thinking and
clinical reasoning
c) To replace physician orders
d) To document only physical assessment findings
b) To serve as a standardized method for nursing care that integrates critical thinking
and clinical reasoning
The nursing process is one of the major guidelines for nursing practice. It helps nurses
implement their roles, integrates the art and science of nursing, allows nurses to use critical
thinking and clinical reasoning, and defines the areas of care within the domain of nursing .
10. A nurse is using SBAR to communicate with a provider about a patient's change
in condition. What does SBAR stand for?
a) Situation, Background, Assessment, Recommendation
b) Symptoms, Baseline, Action, Response
c) Subjective, Objective, Assessment, Plan
d) Safety, Behavior, Attitude, Response
a) Situation, Background, Assessment, Recommendation
SBAR is a model for effective communication used to communicate a patient's change in
condition. It identifies: Situation (what is happening), Background (relevant history),
Assessment (nurse's findings), and Recommendation (what the nurse thinks should be
done) .
150 Questions with Verified Answers |
Objective Assessment Prep | Western
Governors University
Total Questions: 150 | Course: D439 – Foundations of Nursing | Institution: Western
Governors University (WGU)
Section 1: Nursing Process & Critical Thinking
1. A nurse is assessing a patient who is 1 day post-operative. The patient rates pain
9/10 and the surgical site is draining yellow fluid. In which phase of the nursing
process is the nurse working?
a) Planning
b) Evaluation
c) Assessment
d) Implementation
c) Assessment
Assessment is the first phase of the nursing process where the nurse collects subjective
and objective data about the patient. Pain rating (subjective) and wound drainage
(objective) are both assessment data .
2. After reviewing assessment data, a nurse identifies that a patient's wound is
infected and writes the nursing diagnosis "Impaired Skin Integrity." This occurs
during which step of the nursing process?
a) Assessment
b) Diagnosis
,c) Planning
d) Evaluation
b) Diagnosis
The diagnosis phase involves analyzing assessment data to identify patient problems and
formulating nursing diagnoses. Impaired Skin Integrity is a nursing diagnosis that guides
subsequent care planning .
3. A nurse sets a goal for a patient with activity intolerance: "Patient will ambulate 50
feet in the hallway by the end of the shift." This is part of which nursing process
phase?
a) Assessment
b) Diagnosis
c) Planning
d) Implementation
c) Planning
Planning involves setting measurable, realistic goals and expected outcomes. SMART goals
(Specific, Measurable, Attainable, Realistic, Timely) are written during this phase .
4. The nurse administers morphine 4 mg IV as ordered. This action occurs during
which phase of the nursing process?
a) Planning
b) Implementation
c) Evaluation
d) Assessment
b) Implementation
Implementation is the action phase where the nurse carries out the interventions identified
in the care plan. Administering medication is a direct nursing intervention .
5. After teaching a patient how to self-administer insulin, the nurse observes the
patient draw up and inject saline correctly. The nurse documents "goal met." This is
an example of which nursing process phase?
,a) Assessment
b) Planning
c) Implementation
d) Evaluation
d) Evaluation
Evaluation determines whether patient goals have been met after interventions. Observing
the patient's return demonstration and documenting "goal met" is evaluation .
6. A patient's oxygen saturation drops to 88%. The nurse increases the oxygen flow
rate. Which step comes immediately after this intervention?
a) Document the intervention
b) Notify the provider
c) Update the care plan
d) Reassess the patient
d) Reassess the patient
After implementing an intervention, the nurse must reassess the patient to evaluate its
effectiveness. Reassessment follows implementation in the nursing process .
7. Which of the following is an example of subjective data?
a) Heart rate 110 bpm
b) Patient states "I feel dizzy"
c) Wound appears red and swollen
d) Blood pressure 140/90 mmHg
b) Patient states "I feel dizzy"
Subjective data is information the patient tells the nurse, including feelings, sensations, and
perceptions. Objective data is measurable and observable. "I feel dizzy" is subjective; heart
rate, wound appearance, and BP are objective .
8. A nurse is prioritizing care for four patients. According to the nursing process,
which action should the nurse take first?
a) Evaluate the effectiveness of pain medication given an hour ago
, b) Auscultate lung sounds on a patient reporting shortness of breath
c) Document a patient's refusal of breakfast
d) Update the care plan for a patient being discharged
b) Auscultate lung sounds on a patient reporting shortness of breath
Assessment is the first step of the nursing process. A patient with shortness of breath
requires immediate assessment to identify the cause and implement appropriate
interventions .
9. What is the purpose of the nursing process?
a) To provide a framework for medical diagnosis
b) To serve as a standardized method for nursing care that integrates critical thinking and
clinical reasoning
c) To replace physician orders
d) To document only physical assessment findings
b) To serve as a standardized method for nursing care that integrates critical thinking
and clinical reasoning
The nursing process is one of the major guidelines for nursing practice. It helps nurses
implement their roles, integrates the art and science of nursing, allows nurses to use critical
thinking and clinical reasoning, and defines the areas of care within the domain of nursing .
10. A nurse is using SBAR to communicate with a provider about a patient's change
in condition. What does SBAR stand for?
a) Situation, Background, Assessment, Recommendation
b) Symptoms, Baseline, Action, Response
c) Subjective, Objective, Assessment, Plan
d) Safety, Behavior, Attitude, Response
a) Situation, Background, Assessment, Recommendation
SBAR is a model for effective communication used to communicate a patient's change in
condition. It identifies: Situation (what is happening), Background (relevant history),
Assessment (nurse's findings), and Recommendation (what the nurse thinks should be
done) .
