1 M A X E • S L AT N E M A D N U F
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Nursing Fundamentals Assessment
N Comprehensive Examination — Exam 1
EST. 2026
E XC E L L E N C E I N N U RS I N G E D U C AT I O N
Fundamentals of Nursing — Exam 1
N U R S I N G P R O C E S S , A S E P S I S , V I TA L S I G N S , A S S E S S M E N T & CO M M U N I C AT I O N
INSTITUTION Nursing Fundamentals Assessment COURSE CODE Fundamentals of Nursing — Exam 1
PROGRAM Practical Nursing (PN) / Associate Degree ACADEMIC YEAR
in Nursing (ADN)
EXAM TITLE Fundamentals of Nursing Exam 1 TOTAL QUESTIONS 50 Questions
COURSE TITLE Fundamentals of Nursing FORMAT Multiple Choice — Select the Single Best
Answer
EXAMINATION INSTRUCTIONS
▸ Select the single best answer for each question unless otherwise instructed.
▸ Select all that apply questions are indicated — choose every correct option.
▸ Questions cover the nursing process, asepsis, vital signs, physical assessment, and therapeutic communication.
▸ Correct answers and clinical rationales appear below each question for review purposes.
▸ All content reflects current evidence-based nursing practice and ANA standards.
SECTION I — FUNDAMENTALS OF NURSING EXAMINATION Questions 1 – 50
1. A patient reports, "My chest feels tight." The nurse documents this statement in the medical record. What type of
data is this?
A. Objective data.
B. Subjective data.
C. Diagnostic data.
D. Laboratory data.
CORRECT ANSWER B — Subjective data.
RATIONALE Subjective data is what the patient says out loud — their personal report of symptoms, feelings, and
perceptions. It must always be documented in direct quotation marks. Secondary sources include family
members or old charts. Objective data is what the nurse can see, measure, feel, or test (vital signs, lab values,
visible rash). The statement "My chest feels tight" is the patient's verbal report, making it subjective data.
,2. Which of the following is the correct format for a nursing diagnosis?
A. Pneumonia related to bacterial infection.
B. Acute pain related to soft tissue injury as evidenced by patient stating pain is 8/10, elevated blood pressure, and
heart rate of 102.
C. Hypertension related to poor diet as evidenced by high sodium intake.
D. Diabetes mellitus related to pancreatic insufficiency.
CORRECT ANSWER B — Acute pain related to soft tissue injury as evidenced by patient stating pain is 8/10, elevated blood
pressure, and heart rate of 102.
RATIONALE A nursing diagnosis follows the PES format: Problem (NANDA-I approved nursing diagnosis) + Etiology
(related to) + Signs/Symptoms (as evidenced by/AEB). "Acute pain" is a NANDA-approved nursing diagnosis.
The other options are medical diagnoses (pneumonia, hypertension, diabetes mellitus), which identify
disease processes — not nursing problems. Nurses diagnose and treat human responses to health conditions,
not the medical conditions themselves.
3. Which goal statement best follows the Planning phase of the nursing process?
A. "Patient will feel better soon."
B. "Patient will express a decrease in pain from 8/10 to 3/10 within 1 hour after receiving pain medication."
C. "Patient will have less pain."
D. "Nurse will administer pain medication."
CORRECT ANSWER B — "Patient will express a decrease in pain from 8/10 to 3/10 within 1 hour after receiving pain
medication."
RATIONALE Goals in the Planning phase must be specific, realistic, and measurable (SMART). Option B specifies the exact
pain level change (8/10 to 3/10), a time frame (1 hour), and the intervention context (after receiving pain
medication). "Feel better soon" and "less pain" are vague and unmeasurable. "Nurse will administer"
describes a nursing intervention (Implementation), not a patient goal. Goals must be patient-centered and
use action verbs.
4. The nurse administers ordered pain medication, applies an ice bag to a swollen surgical area, and turns the patient.
Which phase of the nursing process do these actions represent?
A. Assessment.
B. Diagnosis.
C. Planning.
D. Implementation.
CORRECT ANSWER D — Implementation.
RATIONALE Implementation is the "action phase" of the nursing process — the nurse performs the planned interventions.
Administering medication, applying ice, and turning the patient are all nursing actions (interventions). Every
intervention must have a clinical rationale (the scientific reason for performing it). Assessment involves data
collection; Diagnosis identifies problems; Planning establishes goals and selects interventions; Evaluation
determines if goals were met.
, 5. The nurse documents "Goal met: Patient states pain is reduced to 2/10." Which phase of the nursing process does
this represent?
A. Assessment.
B. Implementation.
C. Planning.
D. Evaluation.
CORRECT ANSWER D — Evaluation.
RATIONALE Evaluation is looking back at the planning goal to determine if it was achieved. The nurse compares the actual
outcome (pain 2/10) to the expected outcome. If the goal was met, it is documented clearly. If the goal was
not met, the nurse revises the plan. This phase completes one cycle of the nursing process, which is ongoing
and cyclical — if goals are not met, the process begins again with reassessment.
6. A patient's blood pressure reading is 180/94 with an auscultatory gap from 176–158. What is the clinical
significance of documenting the auscultatory gap?
A. It indicates the patient has normal blood pressure.
B. If missed, it causes massive underestimation of systolic pressure or overestimation of diastolic pressure.
C. It confirms the patient has hypotension.
D. It is only relevant in pediatric patients.
CORRECT ANSWER B — If missed, it causes massive underestimation of systolic pressure or overestimation of diastolic
pressure.
RATIONALE An auscultatory gap is a temporary silent period between the first and second Korotkoff sounds, highly
common in chronic hypertension. The silent gap can last up to 40 mmHg. If the nurse does not first palpate
the radial pulse to estimate systolic pressure, they may begin auscultation within the gap, missing the true
systolic reading entirely. The gap must be explicitly charted (e.g., "180/94 with an auscultatory gap from 176–
158") to prevent confusion among providers.
7. Which practice is an example of medical asepsis (clean technique)?
A. Inserting an indwelling urinary catheter.
B. Performing surgical hand scrub.
C. Handwashing before putting on clean gloves to empty a drain.
D. Setting up a sterile field for a procedure.
CORRECT ANSWER C — Handwashing before putting on clean gloves to empty a drain.
RATIONALE Medical asepsis (clean technique) involves practices that reduce the number and spread of microorganisms —
handwashing, using hand sanitizer, wearing clean gloves for non-sterile procedures. Surgical asepsis (sterile
technique) eliminates ALL microorganisms including spores and is required for invasive procedures like
catheter insertion (A), surgical scrubbing (B), and setting up sterile fields (D). Emptying a drain is a clean
procedure, not a sterile one.
★ ★
Nursing Fundamentals Assessment
N Comprehensive Examination — Exam 1
EST. 2026
E XC E L L E N C E I N N U RS I N G E D U C AT I O N
Fundamentals of Nursing — Exam 1
N U R S I N G P R O C E S S , A S E P S I S , V I TA L S I G N S , A S S E S S M E N T & CO M M U N I C AT I O N
INSTITUTION Nursing Fundamentals Assessment COURSE CODE Fundamentals of Nursing — Exam 1
PROGRAM Practical Nursing (PN) / Associate Degree ACADEMIC YEAR
in Nursing (ADN)
EXAM TITLE Fundamentals of Nursing Exam 1 TOTAL QUESTIONS 50 Questions
COURSE TITLE Fundamentals of Nursing FORMAT Multiple Choice — Select the Single Best
Answer
EXAMINATION INSTRUCTIONS
▸ Select the single best answer for each question unless otherwise instructed.
▸ Select all that apply questions are indicated — choose every correct option.
▸ Questions cover the nursing process, asepsis, vital signs, physical assessment, and therapeutic communication.
▸ Correct answers and clinical rationales appear below each question for review purposes.
▸ All content reflects current evidence-based nursing practice and ANA standards.
SECTION I — FUNDAMENTALS OF NURSING EXAMINATION Questions 1 – 50
1. A patient reports, "My chest feels tight." The nurse documents this statement in the medical record. What type of
data is this?
A. Objective data.
B. Subjective data.
C. Diagnostic data.
D. Laboratory data.
CORRECT ANSWER B — Subjective data.
RATIONALE Subjective data is what the patient says out loud — their personal report of symptoms, feelings, and
perceptions. It must always be documented in direct quotation marks. Secondary sources include family
members or old charts. Objective data is what the nurse can see, measure, feel, or test (vital signs, lab values,
visible rash). The statement "My chest feels tight" is the patient's verbal report, making it subjective data.
,2. Which of the following is the correct format for a nursing diagnosis?
A. Pneumonia related to bacterial infection.
B. Acute pain related to soft tissue injury as evidenced by patient stating pain is 8/10, elevated blood pressure, and
heart rate of 102.
C. Hypertension related to poor diet as evidenced by high sodium intake.
D. Diabetes mellitus related to pancreatic insufficiency.
CORRECT ANSWER B — Acute pain related to soft tissue injury as evidenced by patient stating pain is 8/10, elevated blood
pressure, and heart rate of 102.
RATIONALE A nursing diagnosis follows the PES format: Problem (NANDA-I approved nursing diagnosis) + Etiology
(related to) + Signs/Symptoms (as evidenced by/AEB). "Acute pain" is a NANDA-approved nursing diagnosis.
The other options are medical diagnoses (pneumonia, hypertension, diabetes mellitus), which identify
disease processes — not nursing problems. Nurses diagnose and treat human responses to health conditions,
not the medical conditions themselves.
3. Which goal statement best follows the Planning phase of the nursing process?
A. "Patient will feel better soon."
B. "Patient will express a decrease in pain from 8/10 to 3/10 within 1 hour after receiving pain medication."
C. "Patient will have less pain."
D. "Nurse will administer pain medication."
CORRECT ANSWER B — "Patient will express a decrease in pain from 8/10 to 3/10 within 1 hour after receiving pain
medication."
RATIONALE Goals in the Planning phase must be specific, realistic, and measurable (SMART). Option B specifies the exact
pain level change (8/10 to 3/10), a time frame (1 hour), and the intervention context (after receiving pain
medication). "Feel better soon" and "less pain" are vague and unmeasurable. "Nurse will administer"
describes a nursing intervention (Implementation), not a patient goal. Goals must be patient-centered and
use action verbs.
4. The nurse administers ordered pain medication, applies an ice bag to a swollen surgical area, and turns the patient.
Which phase of the nursing process do these actions represent?
A. Assessment.
B. Diagnosis.
C. Planning.
D. Implementation.
CORRECT ANSWER D — Implementation.
RATIONALE Implementation is the "action phase" of the nursing process — the nurse performs the planned interventions.
Administering medication, applying ice, and turning the patient are all nursing actions (interventions). Every
intervention must have a clinical rationale (the scientific reason for performing it). Assessment involves data
collection; Diagnosis identifies problems; Planning establishes goals and selects interventions; Evaluation
determines if goals were met.
, 5. The nurse documents "Goal met: Patient states pain is reduced to 2/10." Which phase of the nursing process does
this represent?
A. Assessment.
B. Implementation.
C. Planning.
D. Evaluation.
CORRECT ANSWER D — Evaluation.
RATIONALE Evaluation is looking back at the planning goal to determine if it was achieved. The nurse compares the actual
outcome (pain 2/10) to the expected outcome. If the goal was met, it is documented clearly. If the goal was
not met, the nurse revises the plan. This phase completes one cycle of the nursing process, which is ongoing
and cyclical — if goals are not met, the process begins again with reassessment.
6. A patient's blood pressure reading is 180/94 with an auscultatory gap from 176–158. What is the clinical
significance of documenting the auscultatory gap?
A. It indicates the patient has normal blood pressure.
B. If missed, it causes massive underestimation of systolic pressure or overestimation of diastolic pressure.
C. It confirms the patient has hypotension.
D. It is only relevant in pediatric patients.
CORRECT ANSWER B — If missed, it causes massive underestimation of systolic pressure or overestimation of diastolic
pressure.
RATIONALE An auscultatory gap is a temporary silent period between the first and second Korotkoff sounds, highly
common in chronic hypertension. The silent gap can last up to 40 mmHg. If the nurse does not first palpate
the radial pulse to estimate systolic pressure, they may begin auscultation within the gap, missing the true
systolic reading entirely. The gap must be explicitly charted (e.g., "180/94 with an auscultatory gap from 176–
158") to prevent confusion among providers.
7. Which practice is an example of medical asepsis (clean technique)?
A. Inserting an indwelling urinary catheter.
B. Performing surgical hand scrub.
C. Handwashing before putting on clean gloves to empty a drain.
D. Setting up a sterile field for a procedure.
CORRECT ANSWER C — Handwashing before putting on clean gloves to empty a drain.
RATIONALE Medical asepsis (clean technique) involves practices that reduce the number and spread of microorganisms —
handwashing, using hand sanitizer, wearing clean gloves for non-sterile procedures. Surgical asepsis (sterile
technique) eliminates ALL microorganisms including spores and is required for invasive procedures like
catheter insertion (A), surgical scrubbing (B), and setting up sterile fields (D). Emptying a drain is a clean
procedure, not a sterile one.
