NURSING FUNDAMENTALS (NUR1023C) EXAM 1 –
COURSE QUESTION BANK | 2026/2027 COMPLETE
SOLUTIONS STUDY GUIDE.
A nurse is caring for a 68-year-old patient admitted with community-acquired pneumonia.
The nurse auscultates crackles in the bilateral lower lobes, notes SpO2 of 91% on room air,
and the patient reports feeling short of breath when walking to the bathroom. The nurse
documents these findings and formulates a nursing diagnosis of "Impaired Gas Exchange."
Which phase of the nursing process has the nurse completed?
A) Assessment
B) Diagnosis
C) Planning
D) Implementation
[CORRECT: B]
Rationale: The nurse has completed both Assessment (collecting objective data: crackles,
SpO2 91%; and subjective data: dyspnea on exertion) and Diagnosis (formulating "Impaired
Gas Exchange"). Since the question asks which phase has been completed with the
formulation of the nursing diagnosis, the correct answer is Diagnosis. The nursing diagnosis
represents a clinical judgment about the patient's response to a health problem, which is the
defining characteristic of the Diagnosis phase of ADPIE.
Question 2 (Select-All-That-Apply)
A nursing student is developing a plan of care for a patient with a new colostomy. Which
actions represent the Planning phase of the nursing process? Select all that apply.
A) Establishing the goal "Patient will demonstrate independent colostomy bag change by
discharge"
B) Assessing the patient's current knowledge of ostomy care
C) Selecting the nursing intervention "Provide colostomy care instruction using teach-back
method"
D) Documenting the patient's statement "I'm worried about leaking in public"
E) Scheduling follow-up home health nursing visit for ostomy assessment
,F) Evaluating whether the patient successfully changed the bag on post-op day 3
[CORRECT: A, C, E]
Rationale: The Planning phase involves setting measurable goals/outcomes (A) and selecting
appropriate nursing interventions (C). Scheduling follow-up care (E) is also part of planning as
it coordinates resources and timelines for goal attainment. Assessing knowledge (B) and
documenting subjective concerns (D) are Assessment phase activities. Evaluating success (F) is
the Evaluation phase. In Planning, goals must be patient-centered, measurable, realistic, and
time-bound to guide subsequent Implementation and Evaluation.
Question 3 (Multiple-Choice)
During the Evaluation phase of the nursing process, a nurse reviews a patient's progress
toward the goal "Patient will maintain intact skin integrity throughout hospitalization." The
nurse observes a Stage 1 pressure injury on the patient's coccyx. Which is the nurse's priority
action?
A) Reassess all risk factors and revise the plan of care immediately
B) Document that the goal was partially met and continue current interventions
C) Terminate the plan of care since the goal was not achieved
D) Delegate wound care to the UAP while the nurse completes documentation
[CORRECT: A]
Rationale: Evaluation involves determining whether goals were met, partially met, or not met,
and then revising the plan accordingly. When a goal is not met (development of Stage 1
pressure injury indicates failure to maintain intact skin), the nurse must reassess all
contributing factors and revise interventions—not simply continue ineffective strategies (B) or
terminate the plan (C). Reassessment drives revision of the diagnosis, goals, or interventions,
which may then require returning to earlier phases of ADPIE. Delegating wound care to UAP
(D) is inappropriate as UAPs cannot perform nursing assessments or wound care requiring
clinical judgment.
1.2 Prioritization (2 Questions)
Question 4 (Multiple-Choice)
A nurse is assigned four patients on a medical-surgical unit. Which patient requires the
nurse's immediate attention?
A) A 45-year-old post-appendectomy patient requesting pain medication rated 6/10
,B) A 72-year-old with COPD whose SpO2 decreased from 94% to 89% after ambulating to the
bathroom
C) A 58-year-old newly diagnosed diabetic patient asking for dietary education before
discharge
D) A 35-year-old with a migraine who reports photophobia and requests the blinds be closed
[CORRECT: B]
Rationale: Using the ABC (Airway, Breathing, Circulation) prioritization framework, the patient
with COPD experiencing acute desaturation to 89% represents a breathing compromise
requiring immediate assessment and intervention. Oxygen saturation below 90% indicates
significant hypoxemia that threatens tissue oxygenation and organ function. While pain
management (A), patient education (C), and comfort measures (D) are important nursing
responsibilities, they do not represent immediate threats to physiological stability. The safety-
first principle and Maslow's hierarchy (physiological needs before higher-level needs) support
addressing the compromised airway/breathing issue first.
Question 5 (Multiple-Choice)
A nurse is caring for a patient who is suicidal, another who is having an acute asthma attack, a
third who needs pre-operative teaching, and a fourth who is requesting a sleeping pill. Using
Maslow's hierarchy of needs and the safety-first principle, in which order should the nurse
address these patients?
A) Suicidal patient, asthma attack, pre-operative teaching, sleeping pill
B) Asthma attack, suicidal patient, pre-operative teaching, sleeping pill
C) Suicidal patient, pre-operative teaching, asthma attack, sleeping pill
D) Asthma attack, pre-operative teaching, suicidal patient, sleeping pill
[CORRECT: A]
Rationale: According to Maslow's hierarchy and safety-first principles, the order is: (1) Suicidal
patient—safety and security needs (risk of immediate self-harm/death); (2) Asthma attack—
physiological need (breathing, immediate threat to life); (3) Pre-operative teaching—safety
and security (knowledge deficit, preparation for safe surgery); (4) Sleeping pill—physiological
need (rest/comfort, lowest priority as it is a request, not a necessity). While asthma is a
physiological need, the suicidal patient represents an imminent safety threat that takes
precedence because self-directed violence can occur instantaneously without warning signs,
whereas the asthma attack, while serious, is being managed and monitored. Safety
, (protection from harm) supersedes other needs when immediate life-threatening risk is
present.
1.3 Types of Nursing Diagnoses (2 Questions)
Question 6 (Multiple-Choice)
A nurse identifies that a patient with a family history of type 2 diabetes, sedentary lifestyle,
and BMI of 32 has not yet developed diabetes but is at significant risk. Which type of nursing
diagnosis is most appropriate?
A) Actual nursing diagnosis: Diabetes Mellitus
B) Risk nursing diagnosis: Risk for Unstable Blood Glucose Level
C) Health promotion nursing diagnosis: Readiness for Enhanced Nutrition
D) Syndrome nursing diagnosis: Chronic Confusion
[CORRECT: B]
Rationale: A risk nursing diagnosis applies when a patient has risk factors for developing a
negative health condition but has not yet manifested signs and symptoms of the problem.
This patient has major risk factors (family history, obesity, sedentary lifestyle) but has not
been diagnosed with diabetes. "Risk for Unstable Blood Glucose Level" is the appropriate risk
diagnosis. An actual diagnosis (A) requires existing signs/symptoms. A health promotion
diagnosis (C) applies when a patient desires to improve their health status beyond baseline—
while this patient might benefit from health promotion, the immediate clinical judgment
focuses on risk identification. Syndrome diagnosis (D) is inappropriate as it describes a cluster
of diagnoses, not this clinical scenario.
Question 7 (Select-All-That-Apply)
A nurse is caring for a patient who has expressed a desire to begin a daily walking program
after a recent cardiac event. The patient states, "I want to take control of my health and
prevent another heart attack." Which statements about the appropriate nursing diagnosis are
correct? Select all that apply.
A) This scenario supports a health promotion nursing diagnosis
B) "Readiness for Enhanced Cardiac Output" would be an appropriate diagnosis
C) Health promotion diagnoses describe a patient's motivation to improve their health
D) The nurse should first rule out any actual or risk diagnoses before using a health promotion
diagnosis
COURSE QUESTION BANK | 2026/2027 COMPLETE
SOLUTIONS STUDY GUIDE.
A nurse is caring for a 68-year-old patient admitted with community-acquired pneumonia.
The nurse auscultates crackles in the bilateral lower lobes, notes SpO2 of 91% on room air,
and the patient reports feeling short of breath when walking to the bathroom. The nurse
documents these findings and formulates a nursing diagnosis of "Impaired Gas Exchange."
Which phase of the nursing process has the nurse completed?
A) Assessment
B) Diagnosis
C) Planning
D) Implementation
[CORRECT: B]
Rationale: The nurse has completed both Assessment (collecting objective data: crackles,
SpO2 91%; and subjective data: dyspnea on exertion) and Diagnosis (formulating "Impaired
Gas Exchange"). Since the question asks which phase has been completed with the
formulation of the nursing diagnosis, the correct answer is Diagnosis. The nursing diagnosis
represents a clinical judgment about the patient's response to a health problem, which is the
defining characteristic of the Diagnosis phase of ADPIE.
Question 2 (Select-All-That-Apply)
A nursing student is developing a plan of care for a patient with a new colostomy. Which
actions represent the Planning phase of the nursing process? Select all that apply.
A) Establishing the goal "Patient will demonstrate independent colostomy bag change by
discharge"
B) Assessing the patient's current knowledge of ostomy care
C) Selecting the nursing intervention "Provide colostomy care instruction using teach-back
method"
D) Documenting the patient's statement "I'm worried about leaking in public"
E) Scheduling follow-up home health nursing visit for ostomy assessment
,F) Evaluating whether the patient successfully changed the bag on post-op day 3
[CORRECT: A, C, E]
Rationale: The Planning phase involves setting measurable goals/outcomes (A) and selecting
appropriate nursing interventions (C). Scheduling follow-up care (E) is also part of planning as
it coordinates resources and timelines for goal attainment. Assessing knowledge (B) and
documenting subjective concerns (D) are Assessment phase activities. Evaluating success (F) is
the Evaluation phase. In Planning, goals must be patient-centered, measurable, realistic, and
time-bound to guide subsequent Implementation and Evaluation.
Question 3 (Multiple-Choice)
During the Evaluation phase of the nursing process, a nurse reviews a patient's progress
toward the goal "Patient will maintain intact skin integrity throughout hospitalization." The
nurse observes a Stage 1 pressure injury on the patient's coccyx. Which is the nurse's priority
action?
A) Reassess all risk factors and revise the plan of care immediately
B) Document that the goal was partially met and continue current interventions
C) Terminate the plan of care since the goal was not achieved
D) Delegate wound care to the UAP while the nurse completes documentation
[CORRECT: A]
Rationale: Evaluation involves determining whether goals were met, partially met, or not met,
and then revising the plan accordingly. When a goal is not met (development of Stage 1
pressure injury indicates failure to maintain intact skin), the nurse must reassess all
contributing factors and revise interventions—not simply continue ineffective strategies (B) or
terminate the plan (C). Reassessment drives revision of the diagnosis, goals, or interventions,
which may then require returning to earlier phases of ADPIE. Delegating wound care to UAP
(D) is inappropriate as UAPs cannot perform nursing assessments or wound care requiring
clinical judgment.
1.2 Prioritization (2 Questions)
Question 4 (Multiple-Choice)
A nurse is assigned four patients on a medical-surgical unit. Which patient requires the
nurse's immediate attention?
A) A 45-year-old post-appendectomy patient requesting pain medication rated 6/10
,B) A 72-year-old with COPD whose SpO2 decreased from 94% to 89% after ambulating to the
bathroom
C) A 58-year-old newly diagnosed diabetic patient asking for dietary education before
discharge
D) A 35-year-old with a migraine who reports photophobia and requests the blinds be closed
[CORRECT: B]
Rationale: Using the ABC (Airway, Breathing, Circulation) prioritization framework, the patient
with COPD experiencing acute desaturation to 89% represents a breathing compromise
requiring immediate assessment and intervention. Oxygen saturation below 90% indicates
significant hypoxemia that threatens tissue oxygenation and organ function. While pain
management (A), patient education (C), and comfort measures (D) are important nursing
responsibilities, they do not represent immediate threats to physiological stability. The safety-
first principle and Maslow's hierarchy (physiological needs before higher-level needs) support
addressing the compromised airway/breathing issue first.
Question 5 (Multiple-Choice)
A nurse is caring for a patient who is suicidal, another who is having an acute asthma attack, a
third who needs pre-operative teaching, and a fourth who is requesting a sleeping pill. Using
Maslow's hierarchy of needs and the safety-first principle, in which order should the nurse
address these patients?
A) Suicidal patient, asthma attack, pre-operative teaching, sleeping pill
B) Asthma attack, suicidal patient, pre-operative teaching, sleeping pill
C) Suicidal patient, pre-operative teaching, asthma attack, sleeping pill
D) Asthma attack, pre-operative teaching, suicidal patient, sleeping pill
[CORRECT: A]
Rationale: According to Maslow's hierarchy and safety-first principles, the order is: (1) Suicidal
patient—safety and security needs (risk of immediate self-harm/death); (2) Asthma attack—
physiological need (breathing, immediate threat to life); (3) Pre-operative teaching—safety
and security (knowledge deficit, preparation for safe surgery); (4) Sleeping pill—physiological
need (rest/comfort, lowest priority as it is a request, not a necessity). While asthma is a
physiological need, the suicidal patient represents an imminent safety threat that takes
precedence because self-directed violence can occur instantaneously without warning signs,
whereas the asthma attack, while serious, is being managed and monitored. Safety
, (protection from harm) supersedes other needs when immediate life-threatening risk is
present.
1.3 Types of Nursing Diagnoses (2 Questions)
Question 6 (Multiple-Choice)
A nurse identifies that a patient with a family history of type 2 diabetes, sedentary lifestyle,
and BMI of 32 has not yet developed diabetes but is at significant risk. Which type of nursing
diagnosis is most appropriate?
A) Actual nursing diagnosis: Diabetes Mellitus
B) Risk nursing diagnosis: Risk for Unstable Blood Glucose Level
C) Health promotion nursing diagnosis: Readiness for Enhanced Nutrition
D) Syndrome nursing diagnosis: Chronic Confusion
[CORRECT: B]
Rationale: A risk nursing diagnosis applies when a patient has risk factors for developing a
negative health condition but has not yet manifested signs and symptoms of the problem.
This patient has major risk factors (family history, obesity, sedentary lifestyle) but has not
been diagnosed with diabetes. "Risk for Unstable Blood Glucose Level" is the appropriate risk
diagnosis. An actual diagnosis (A) requires existing signs/symptoms. A health promotion
diagnosis (C) applies when a patient desires to improve their health status beyond baseline—
while this patient might benefit from health promotion, the immediate clinical judgment
focuses on risk identification. Syndrome diagnosis (D) is inappropriate as it describes a cluster
of diagnoses, not this clinical scenario.
Question 7 (Select-All-That-Apply)
A nurse is caring for a patient who has expressed a desire to begin a daily walking program
after a recent cardiac event. The patient states, "I want to take control of my health and
prevent another heart attack." Which statements about the appropriate nursing diagnosis are
correct? Select all that apply.
A) This scenario supports a health promotion nursing diagnosis
B) "Readiness for Enhanced Cardiac Output" would be an appropriate diagnosis
C) Health promotion diagnoses describe a patient's motivation to improve their health
D) The nurse should first rule out any actual or risk diagnoses before using a health promotion
diagnosis
