Fundamentals
Fundamentals of Nursing, Nursing
Process Exam Questions with Correct
Verified Solutions 100% Guaranteed Pass
The nurse makes the following entry on the client's care plan: "Goal
not met. Client refuses to ambulate, stating, 'I am too afraid I will fall.'
" The nurse should take which of the following actions?
A. Notify the physician
B. Reassign the client to another nurse
C. Re-examine the nursing orders
D. Write a new nursing diagnosis - ANS ✓B. Re-examine the nursing
orders
Rationale: The plan needs to be reassessed whenever goals are not
met. Nursing interventions should be examined to ensure the best
interventions were selected to assist the client achieve the goal. The
goal may be appropriate, but the client may need more time to
achieve the desired outcome. The manner in which the nursing
interventions were implemented may have interfered with achieving
the outcome.
In developing a plan of care for a client with chronic hypertension,
which nursing activity would be most important?
A. Set incremental goals for blood pressure reduction
Fundamentals of Nursing, Nursing Process
,Fundamentals
B. Instruct the client to make dietary changes by reducing sodium
intake
C. Include the client and family when setting goals and formulating the
plan of care
D. Assess past compliance to medication regimens - ANS ✓C. Include
the client and family when setting goals and formulating the plan of care
Rationale: In developing a plan of care, nurses engage in a partnership
with the client and family. Nurses do not plan care for clients; instead
they plan care with clients and families. Assessment (option 4), goal
setting (option 1), and interventions (option 2) will be most accurate
and effective when carried out in partnership with the client and
family. The other options represent other actions to take, but they will
have less overall effectiveness if the client and family are not part of
the plan.
Which nurse is demonstrating the assessment phase of the nursing
process?
A.The nurse who observes that the client's pain was relieved with
pain medication
B. The nurse who turns the client to a more comfortable position
C. The nurse who ask the client how much lunch he or she ate
D. The nurse who works with the client to set desired outcome goals -
ANS ✓C. The nurse who ask the client how much lunch he or she ate
Rationale: Assessment involves collecting, organizing, validating, and
documenting data about a client. Option 1 represents the evaluation
phase. Option 2 represents the implementation phase. Option 4
represents the planning phase.
Fundamentals of Nursing, Nursing Process
, Fundamentals
The client states, "My chest hurts and my left arm feels numb." The
nurse interprets that this data is of which type and source?
A. Subjective data from a primary source
B. Subjective data from a secondary source
C. Objective data from a primary source
D. Objective data from a secondary source - ANS ✓A. Subjective data
from a primary source
Rationale: The client states, "My chest hurts and my left arm feels
numb." The nurse interprets that this data is of which type and
source?
The nurse feels a client is at risk for skin breakdown because he has
only had clear liquids for the last 10 days (and essentially no protein
intake). The nurse would formulate which diagnostic statement that
would best reflect this problem?
A. Risk for malnutrition related to clear liquid diet
B. Impaired skin integrity related to no protein intake
C. Risk for impaired skin integrity related to malnutrition
D. Impaired nutrition related to current illness - ANS ✓C. Risk for
impaired skin integrity related to malnutrition
Rationale: This is a risk diagnosis, and the diagnostic statement has
two parts: the human response (impaired skin integrity) and the
related/risk factor (malnutrition). Options 1 and 2 do not have
related factors that are under the control of the nurse (i.e., type of diet
ordered). The diagnosis in option 4 does not specify the type of
impairment (greater than or less than body requirements) and is
Fundamentals of Nursing, Nursing Process
Fundamentals of Nursing, Nursing
Process Exam Questions with Correct
Verified Solutions 100% Guaranteed Pass
The nurse makes the following entry on the client's care plan: "Goal
not met. Client refuses to ambulate, stating, 'I am too afraid I will fall.'
" The nurse should take which of the following actions?
A. Notify the physician
B. Reassign the client to another nurse
C. Re-examine the nursing orders
D. Write a new nursing diagnosis - ANS ✓B. Re-examine the nursing
orders
Rationale: The plan needs to be reassessed whenever goals are not
met. Nursing interventions should be examined to ensure the best
interventions were selected to assist the client achieve the goal. The
goal may be appropriate, but the client may need more time to
achieve the desired outcome. The manner in which the nursing
interventions were implemented may have interfered with achieving
the outcome.
In developing a plan of care for a client with chronic hypertension,
which nursing activity would be most important?
A. Set incremental goals for blood pressure reduction
Fundamentals of Nursing, Nursing Process
,Fundamentals
B. Instruct the client to make dietary changes by reducing sodium
intake
C. Include the client and family when setting goals and formulating the
plan of care
D. Assess past compliance to medication regimens - ANS ✓C. Include
the client and family when setting goals and formulating the plan of care
Rationale: In developing a plan of care, nurses engage in a partnership
with the client and family. Nurses do not plan care for clients; instead
they plan care with clients and families. Assessment (option 4), goal
setting (option 1), and interventions (option 2) will be most accurate
and effective when carried out in partnership with the client and
family. The other options represent other actions to take, but they will
have less overall effectiveness if the client and family are not part of
the plan.
Which nurse is demonstrating the assessment phase of the nursing
process?
A.The nurse who observes that the client's pain was relieved with
pain medication
B. The nurse who turns the client to a more comfortable position
C. The nurse who ask the client how much lunch he or she ate
D. The nurse who works with the client to set desired outcome goals -
ANS ✓C. The nurse who ask the client how much lunch he or she ate
Rationale: Assessment involves collecting, organizing, validating, and
documenting data about a client. Option 1 represents the evaluation
phase. Option 2 represents the implementation phase. Option 4
represents the planning phase.
Fundamentals of Nursing, Nursing Process
, Fundamentals
The client states, "My chest hurts and my left arm feels numb." The
nurse interprets that this data is of which type and source?
A. Subjective data from a primary source
B. Subjective data from a secondary source
C. Objective data from a primary source
D. Objective data from a secondary source - ANS ✓A. Subjective data
from a primary source
Rationale: The client states, "My chest hurts and my left arm feels
numb." The nurse interprets that this data is of which type and
source?
The nurse feels a client is at risk for skin breakdown because he has
only had clear liquids for the last 10 days (and essentially no protein
intake). The nurse would formulate which diagnostic statement that
would best reflect this problem?
A. Risk for malnutrition related to clear liquid diet
B. Impaired skin integrity related to no protein intake
C. Risk for impaired skin integrity related to malnutrition
D. Impaired nutrition related to current illness - ANS ✓C. Risk for
impaired skin integrity related to malnutrition
Rationale: This is a risk diagnosis, and the diagnostic statement has
two parts: the human response (impaired skin integrity) and the
related/risk factor (malnutrition). Options 1 and 2 do not have
related factors that are under the control of the nurse (i.e., type of diet
ordered). The diagnosis in option 4 does not specify the type of
impairment (greater than or less than body requirements) and is
Fundamentals of Nursing, Nursing Process
