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NIGHTINGALE COLLGE BSN 206 Final
EXAM 2026|ACTUAL
300+Qs&As|GRADED A+|FALL-
SPRING
Q1. A nurse is caring for a patient with hypertension. Which of
the following nursing actions represents the “assessment” phase
of the nursing process?
a) Administering lisinopril 10 mg PO
b) Measuring blood pressure in both arms
c) Setting a goal to reduce BP to <130/80 mmHg
d) Evaluating the effectiveness of dietary teaching
Correct Answer: b) Measuring blood pressure in both arms
Rationale: Assessment is the systematic collection of subjective and
objective data. Measuring BP is objective data collection.
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Administering medication is implementation; setting goals is
planning; evaluation is evaluation.
Q2. A nurse formulates the following diagnosis: “Risk for falls as
evidenced by unsteady gait and history of two falls in the past
month.” Which part of this statement is the “defining
characteristic”?
a) Risk for falls
b) As evidenced by
c) Unsteady gait and history of two falls
d) There is no etiology
Correct Answer: c) Unsteady gait and history of two falls
Rationale: In a risk diagnosis, “as evidenced by” is followed by the
risk factors. Defining characteristics are the signs/symptoms that
support the diagnosis. “Risk for falls” is the problem.
Q3. A patient reports chest pain rated 7/10. The nurse
administers morphine as ordered. This action occurs during which
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phase of the nursing process?
a) Assessment
b) Diagnosis
c) Planning
d) Implementation
Correct Answer: d) Implementation
Rationale: Implementation is the phase where nursing interventions
are performed. Assessment would be asking about pain; diagnosis
would be identifying the problem; planning would be setting goals.
Q4. After administering pain medication, the nurse reassesses the
patient’s pain level 30 minutes later. This is an example of:
a) Assessment
b) Evaluation
c) Diagnosis
d) Planning
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Correct Answer: b) Evaluation
Rationale: Evaluation measures the effectiveness of interventions.
Reassessing after an intervention determines whether the goal was
met.
Q5. A nurse prioritizes nursing diagnoses for a patient with
multiple problems. The highest priority is:
a) Ineffective airway clearance
b) Activity intolerance
c) Disturbed body image
d) Ineffective coping
Correct Answer: a) Ineffective airway clearance
Rationale: Maslow’s hierarchy: airway, breathing, circulation
(ABCs) take priority over mobility, psychological, and social needs.
Q6. Which of the following statements by a patient is an
example of subjective data?
a) Temperature 38.5°C orally
NIGHTINGALE COLLGE BSN 206 Final
EXAM 2026|ACTUAL
300+Qs&As|GRADED A+|FALL-
SPRING
Q1. A nurse is caring for a patient with hypertension. Which of
the following nursing actions represents the “assessment” phase
of the nursing process?
a) Administering lisinopril 10 mg PO
b) Measuring blood pressure in both arms
c) Setting a goal to reduce BP to <130/80 mmHg
d) Evaluating the effectiveness of dietary teaching
Correct Answer: b) Measuring blood pressure in both arms
Rationale: Assessment is the systematic collection of subjective and
objective data. Measuring BP is objective data collection.
,Page 2 of 57
Administering medication is implementation; setting goals is
planning; evaluation is evaluation.
Q2. A nurse formulates the following diagnosis: “Risk for falls as
evidenced by unsteady gait and history of two falls in the past
month.” Which part of this statement is the “defining
characteristic”?
a) Risk for falls
b) As evidenced by
c) Unsteady gait and history of two falls
d) There is no etiology
Correct Answer: c) Unsteady gait and history of two falls
Rationale: In a risk diagnosis, “as evidenced by” is followed by the
risk factors. Defining characteristics are the signs/symptoms that
support the diagnosis. “Risk for falls” is the problem.
Q3. A patient reports chest pain rated 7/10. The nurse
administers morphine as ordered. This action occurs during which
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phase of the nursing process?
a) Assessment
b) Diagnosis
c) Planning
d) Implementation
Correct Answer: d) Implementation
Rationale: Implementation is the phase where nursing interventions
are performed. Assessment would be asking about pain; diagnosis
would be identifying the problem; planning would be setting goals.
Q4. After administering pain medication, the nurse reassesses the
patient’s pain level 30 minutes later. This is an example of:
a) Assessment
b) Evaluation
c) Diagnosis
d) Planning
, Page 4 of 57
Correct Answer: b) Evaluation
Rationale: Evaluation measures the effectiveness of interventions.
Reassessing after an intervention determines whether the goal was
met.
Q5. A nurse prioritizes nursing diagnoses for a patient with
multiple problems. The highest priority is:
a) Ineffective airway clearance
b) Activity intolerance
c) Disturbed body image
d) Ineffective coping
Correct Answer: a) Ineffective airway clearance
Rationale: Maslow’s hierarchy: airway, breathing, circulation
(ABCs) take priority over mobility, psychological, and social needs.
Q6. Which of the following statements by a patient is an
example of subjective data?
a) Temperature 38.5°C orally
