PNUR101 Final Exam – Test
Bank
Foundations of Nursing & The Nursing Process
Q1: A nurse is collecting data on a newly admitted patient. Which of the following
actions represents the "assessment" phase of the nursing process?
A. Setting a goal for the patient to ambulate twice daily.
B. Asking the patient about their medical history and current medications.
C. Administering a prescribed pain medication to the patient.
D. Documenting that the patient tolerated the procedure well.
Correct Answer: B
Rationale: Assessment is the first step of the nursing process and involves gathering
subjective and objective data, such as taking a history and performing a physical exam.
Q2: The nurse notes that a patient has shortness of breath after walking to the
bathroom. When documenting this in the patient's record, which statement is the most
accurate and objective?
A. Patient is very tired and out of breath.
B. Patient appears to be struggling to breathe after activity.
C. Patient has labored respirations and uses accessory muscles after ambulating 20
feet.
D. Patient claims they cannot breathe properly when walking.
Correct Answer: C
Rationale: Objective documentation uses measurable data and specific observations
(like distance ambulated and use of accessory muscles) rather than vague
interpretations.
Q3: During the planning phase of the nursing process, the nurse is developing a care
plan for a patient who is unable to bathe themselves independently. Who should the
nurse primarily involve in this process?
A. The physician only.
B. The patient and their family.
C. The physical therapy department.
D. The nurse manager.
Correct Answer: B
Rationale: The planning phase is a collaborative effort; involving the patient and family
ensures the care plan is individualized and patient-centered.
,Q4: A patient has a diagnosis of "acute pain related to surgical incision." The nurse
administers analgesic medication. Which phase of the nursing process is being
demonstrated?
A. Assessment
B. Planning
C. Implementation
D. Evaluation
Correct Answer: C
Rationale: Implementation involves carrying out the interventions that were planned to
address the patient's needs, such as administering medication.
Q5: Two hours after administering pain medication, the nurse asks the patient to rate
their pain on a scale of 0 to 10. This action represents which phase of the nursing
process?
A. Evaluation
B. Diagnosis
C. Assessment
D. Implementation
Correct Answer: A
Rationale: Evaluation involves determining the patient's progress toward meeting goals
and the effectiveness of the interventions implemented.
Q6: A nurse writes the following diagnosis: "Risk for impaired skin integrity related to
immobility as evidenced by inability to change position independently." Which part of
this diagnostic statement needs correction?
A. The diagnosis ("Risk for impaired skin integrity")
B. The etiology ("related to immobility")
C. The evidence ("as evidenced by inability to change position independently")
D. The statement is correct as written.
Correct Answer: C
Rationale: A "risk for" diagnosis should not have clinical signs or symptoms (evidenced
by) listed, because the problem has not occurred yet; it only has risk factors.
Q7: When establishing a goal for a patient to learn how to use a glucose meter, the
nurse writes: "Patient will understand how to check blood sugar by discharge." Why is
this goal poorly written?
A. It is not measurable.
B. It is not patient-centered.
C. It is not realistic.
D. It includes a time frame.
Correct Answer: A
, Rationale: "Understand" is a vague term that is difficult to measure. A better goal would
be "Patient will demonstrate correct use of glucose meter."
Q8: The nurse is performing an admission assessment for an older adult. Which
assessment finding requires immediate follow-up?
A. Decreased skin turgor.
B. Diminished pedal pulses.
C. Irregular radial pulse.
D. Slightly dry oral mucosa.
Correct Answer: C
Rationale: An irregular pulse can indicate a cardiac dysrhythmia, which is a priority
finding requiring immediate investigation compared to mild dehydration signs.
Q9: A nurse is reviewing the chart of a patient who speaks a different language. The
nurse notes the patient refused a procedure yesterday. What is the nurse's priority
before attempting the procedure today?
A. Verify the patient’s identity using two identifiers.
B. Check if an interpreter was used and if the patient truly understood the procedure.
C. Ask the charge nurse to perform the procedure instead.
D. Document the refusal again.
Correct Answer: B
Rationale: Ensuring informed consent is critical; if language was a barrier, the refusal
might have been due to misunderstanding, so an interpreter is needed.
Q10: Which of the following pieces of patient information is considered subjective data?
A. Heart rate of 88 beats per minute.
B. Patient states, "I have a headache."
C. Temperature of 100.4°F (38°C).
D. Presence of edema in the lower extremities.
Correct Answer: B
Rationale: Subjective data is what the patient tells you (symptoms), whereas objective
data is what the nurse measures or observes (signs).
Q11: A nurse is caring for a patient with a nursing diagnosis of "Ineffective airway
clearance." Which intervention is most appropriate for the implementation phase?
A. Auscultate lung sounds every 4 hours.
B. Encourage deep breathing and coughing exercises.
C. Monitor oxygen saturation levels.
D. Assess respiratory rate daily.
Correct Answer: B
Bank
Foundations of Nursing & The Nursing Process
Q1: A nurse is collecting data on a newly admitted patient. Which of the following
actions represents the "assessment" phase of the nursing process?
A. Setting a goal for the patient to ambulate twice daily.
B. Asking the patient about their medical history and current medications.
C. Administering a prescribed pain medication to the patient.
D. Documenting that the patient tolerated the procedure well.
Correct Answer: B
Rationale: Assessment is the first step of the nursing process and involves gathering
subjective and objective data, such as taking a history and performing a physical exam.
Q2: The nurse notes that a patient has shortness of breath after walking to the
bathroom. When documenting this in the patient's record, which statement is the most
accurate and objective?
A. Patient is very tired and out of breath.
B. Patient appears to be struggling to breathe after activity.
C. Patient has labored respirations and uses accessory muscles after ambulating 20
feet.
D. Patient claims they cannot breathe properly when walking.
Correct Answer: C
Rationale: Objective documentation uses measurable data and specific observations
(like distance ambulated and use of accessory muscles) rather than vague
interpretations.
Q3: During the planning phase of the nursing process, the nurse is developing a care
plan for a patient who is unable to bathe themselves independently. Who should the
nurse primarily involve in this process?
A. The physician only.
B. The patient and their family.
C. The physical therapy department.
D. The nurse manager.
Correct Answer: B
Rationale: The planning phase is a collaborative effort; involving the patient and family
ensures the care plan is individualized and patient-centered.
,Q4: A patient has a diagnosis of "acute pain related to surgical incision." The nurse
administers analgesic medication. Which phase of the nursing process is being
demonstrated?
A. Assessment
B. Planning
C. Implementation
D. Evaluation
Correct Answer: C
Rationale: Implementation involves carrying out the interventions that were planned to
address the patient's needs, such as administering medication.
Q5: Two hours after administering pain medication, the nurse asks the patient to rate
their pain on a scale of 0 to 10. This action represents which phase of the nursing
process?
A. Evaluation
B. Diagnosis
C. Assessment
D. Implementation
Correct Answer: A
Rationale: Evaluation involves determining the patient's progress toward meeting goals
and the effectiveness of the interventions implemented.
Q6: A nurse writes the following diagnosis: "Risk for impaired skin integrity related to
immobility as evidenced by inability to change position independently." Which part of
this diagnostic statement needs correction?
A. The diagnosis ("Risk for impaired skin integrity")
B. The etiology ("related to immobility")
C. The evidence ("as evidenced by inability to change position independently")
D. The statement is correct as written.
Correct Answer: C
Rationale: A "risk for" diagnosis should not have clinical signs or symptoms (evidenced
by) listed, because the problem has not occurred yet; it only has risk factors.
Q7: When establishing a goal for a patient to learn how to use a glucose meter, the
nurse writes: "Patient will understand how to check blood sugar by discharge." Why is
this goal poorly written?
A. It is not measurable.
B. It is not patient-centered.
C. It is not realistic.
D. It includes a time frame.
Correct Answer: A
, Rationale: "Understand" is a vague term that is difficult to measure. A better goal would
be "Patient will demonstrate correct use of glucose meter."
Q8: The nurse is performing an admission assessment for an older adult. Which
assessment finding requires immediate follow-up?
A. Decreased skin turgor.
B. Diminished pedal pulses.
C. Irregular radial pulse.
D. Slightly dry oral mucosa.
Correct Answer: C
Rationale: An irregular pulse can indicate a cardiac dysrhythmia, which is a priority
finding requiring immediate investigation compared to mild dehydration signs.
Q9: A nurse is reviewing the chart of a patient who speaks a different language. The
nurse notes the patient refused a procedure yesterday. What is the nurse's priority
before attempting the procedure today?
A. Verify the patient’s identity using two identifiers.
B. Check if an interpreter was used and if the patient truly understood the procedure.
C. Ask the charge nurse to perform the procedure instead.
D. Document the refusal again.
Correct Answer: B
Rationale: Ensuring informed consent is critical; if language was a barrier, the refusal
might have been due to misunderstanding, so an interpreter is needed.
Q10: Which of the following pieces of patient information is considered subjective data?
A. Heart rate of 88 beats per minute.
B. Patient states, "I have a headache."
C. Temperature of 100.4°F (38°C).
D. Presence of edema in the lower extremities.
Correct Answer: B
Rationale: Subjective data is what the patient tells you (symptoms), whereas objective
data is what the nurse measures or observes (signs).
Q11: A nurse is caring for a patient with a nursing diagnosis of "Ineffective airway
clearance." Which intervention is most appropriate for the implementation phase?
A. Auscultate lung sounds every 4 hours.
B. Encourage deep breathing and coughing exercises.
C. Monitor oxygen saturation levels.
D. Assess respiratory rate daily.
Correct Answer: B
