NURS 103 Fundamentals of Nursing: Nursing Process (ADPIE) Mastery
Exam 2026 |WCU
1. A nurse is conducting a health history for a patient newly admitted to the
unit. Which of the following data should the nurse categorize as subjective?
A. The patient stating, ‘My chest feels like an elephant is sitting on it.’
B. Blood pressure reading of 145/92 mmHg
C. Presence of a 2 cm stage II pressure injury on the coccyx
D. Oxygen saturation level of 88% on room air
Answer: A
Rationale: Subjective data are information provided by the patient that cannot be
measured or observed by the nurse, such as feelings or symptoms. Blood pressure, skin
integrity, and oxygen levels are objective data.
2. In which phase of the nursing process does the nurse establish priorities and
identify expected patient outcomes?
A. Assessment
B. Implementation
C. Planning
D. Diagnosis
Answer: C
Rationale: The Planning phase involves setting priorities based on the nursing diagnoses,
identifying patient-centered goals/outcomes, and selecting nursing interventions.
,3. A patient has a nursing diagnosis of ‘Ineffective Airway Clearance related to
excessive secretions.’ Which of the following is a correctly stated SMART goal?
A. The patient will feel better after coughing more effectively.
B. The patient’s lungs will be clear to auscultation within 24 hours.
C. The nurse will suction the patient every 4 hours.
D. The patient will use the incentive spirometer as often as possible.
Answer: B
Rationale: A SMART goal must be Specific, Measurable, Attainable, Relevant, and Time-
bound. Option C specifies a measurable result and a time frame.
4. When applying Maslow’s Hierarchy of Needs to prioritize nursing diagnoses,
which of the following should the nurse address first?
A. Risk for Loneliness
B. Impaired Gas Exchange
C. Deficient Knowledge
D. Disturbed Body Image
Answer: B
Rationale: According to Maslow’s, physiological needs like oxygenation (Impaired Gas
Exchange) take precedence over safety, social, or self-esteem needs.
5. A nurse identifies that a patient’s surgical incision is red, swollen, and
draining yellow fluid. The nurse documents this under which component of the
ADPIE process?
A. Diagnosis
B. Assessment
C. Evaluation
D. Implementation
Answer: B
, Rationale: Assessment is the systematic collection of data regarding a patient’s health
status. Observing physical signs of infection is part of the assessment.
6. Which part of a three-part nursing diagnosis (PES format) describes the
patient’s response to a health condition?
A. Etiology
B. Problem
C. Signs and Symptoms
D. Intervention
Answer: B
Rationale: The Problem (P) identifies the patient’s response or current health state.
Etiology (E) is the cause, and Signs/Symptoms (S) are the evidence.
7. A nurse is reviewing a patient’s care plan and notices that the expected
outcome of ‘Patient will walk 50 feet by the end of shift’ was not met. What is
the nurse’s next best action?
A. Reassess the patient and revise the care plan if necessary.
B. Document that the patient was non-compliant.
C. Terminate the care plan since the goal was failed.
D. Continue the same interventions until the goal is eventually met.
Answer: A
Rationale: Evaluation is an ongoing process. If outcomes are not met, the nurse must
reassess the patient, determine the barriers, and modify the plan.
Exam 2026 |WCU
1. A nurse is conducting a health history for a patient newly admitted to the
unit. Which of the following data should the nurse categorize as subjective?
A. The patient stating, ‘My chest feels like an elephant is sitting on it.’
B. Blood pressure reading of 145/92 mmHg
C. Presence of a 2 cm stage II pressure injury on the coccyx
D. Oxygen saturation level of 88% on room air
Answer: A
Rationale: Subjective data are information provided by the patient that cannot be
measured or observed by the nurse, such as feelings or symptoms. Blood pressure, skin
integrity, and oxygen levels are objective data.
2. In which phase of the nursing process does the nurse establish priorities and
identify expected patient outcomes?
A. Assessment
B. Implementation
C. Planning
D. Diagnosis
Answer: C
Rationale: The Planning phase involves setting priorities based on the nursing diagnoses,
identifying patient-centered goals/outcomes, and selecting nursing interventions.
,3. A patient has a nursing diagnosis of ‘Ineffective Airway Clearance related to
excessive secretions.’ Which of the following is a correctly stated SMART goal?
A. The patient will feel better after coughing more effectively.
B. The patient’s lungs will be clear to auscultation within 24 hours.
C. The nurse will suction the patient every 4 hours.
D. The patient will use the incentive spirometer as often as possible.
Answer: B
Rationale: A SMART goal must be Specific, Measurable, Attainable, Relevant, and Time-
bound. Option C specifies a measurable result and a time frame.
4. When applying Maslow’s Hierarchy of Needs to prioritize nursing diagnoses,
which of the following should the nurse address first?
A. Risk for Loneliness
B. Impaired Gas Exchange
C. Deficient Knowledge
D. Disturbed Body Image
Answer: B
Rationale: According to Maslow’s, physiological needs like oxygenation (Impaired Gas
Exchange) take precedence over safety, social, or self-esteem needs.
5. A nurse identifies that a patient’s surgical incision is red, swollen, and
draining yellow fluid. The nurse documents this under which component of the
ADPIE process?
A. Diagnosis
B. Assessment
C. Evaluation
D. Implementation
Answer: B
, Rationale: Assessment is the systematic collection of data regarding a patient’s health
status. Observing physical signs of infection is part of the assessment.
6. Which part of a three-part nursing diagnosis (PES format) describes the
patient’s response to a health condition?
A. Etiology
B. Problem
C. Signs and Symptoms
D. Intervention
Answer: B
Rationale: The Problem (P) identifies the patient’s response or current health state.
Etiology (E) is the cause, and Signs/Symptoms (S) are the evidence.
7. A nurse is reviewing a patient’s care plan and notices that the expected
outcome of ‘Patient will walk 50 feet by the end of shift’ was not met. What is
the nurse’s next best action?
A. Reassess the patient and revise the care plan if necessary.
B. Document that the patient was non-compliant.
C. Terminate the care plan since the goal was failed.
D. Continue the same interventions until the goal is eventually met.
Answer: A
Rationale: Evaluation is an ongoing process. If outcomes are not met, the nurse must
reassess the patient, determine the barriers, and modify the plan.
