1
FUNDAMENTALS OF NURSING EXAM LATEST VERSION -
2025/2026- 100+ Q AND ANS ALL THE BEST
When evaluating an elderly client's blood pressure (BP) of 146/78 mmHg, the
nurse does which of the following before determining whether the BP is normal or
represents hypertension?
A. Compare this reading against defined standards
B. Compare the reading with one taken in the opposite arm
C. Determine gaps in the vital signs in the client record
D. Compare the current measurement with previous ones
A. Compare this reading against defined
Rationale: Analysis of the client's BP requires knowledge of the normal BP range
for an older adult. The nurse compares the client's data against identified
standards to determine whether this reading is normal or abnormal. Measuring
the BP in the other arm (option 2) and comparing the reading to previous ones
(option 4) will give additional client data, but the comparison alone will not
determine whether the BP is normal. Gaps in the record (option 3) will not aid in
interpreting the current measurement.
Which of the following behaviors by the nurse demonstrates that the nurse is
participating in critical thinking? Select all that apply.
A. Admitting not knowing how to do a procedure and requesting help
B. Using clever and persuasive remarks to support an opinion or position
C. Accepting without question the values acquired in nursing school
, 2
D. Finding a quick and logical answer, even to complex questions
E. Gathering three assistants to transfer the client to a stretcher after noting the
client weighs 300 lbs.
A. Admitting not knowing how to do a procedure and requesting help
E. Gathering three assistants to transfer the client to a stretcher after noting the
client weighs 300 lbs.
Rationale: Critical thinking in nursing is self-directed, supporting what nurses
know and making clear what they do not know. It is important for nurses to
recognize when they lack the knowledge they need to provide safe care for a
client (option 1). Nurses must also utilize their resources to acquire the support
they need to care for a client safely (option 5). Options 2, 3, and 4 do not
demonstrate critical thinking.
The nurse is measuring the client's urine output and straining the urine to assess
for stones. Which of the following should the nurse record as objective data?
A. The client reports abdominal pain
B. The client's urine output was 450 mL
C. The client states, "I didn't see any stones in my urine."
D. The client states, "I feel like I have passed a stone."
B. The client's urine output was 450 mL.
Rationale: Objective data is measurable data that can be seen, heard, or verified
by the nurse. The objective data is the measurement of the urine output. A
client's statements and reports of symptoms are documented as subjective data,
such as the data found in options 1, 3, and 4.
, 3
The nurse has documented the following outcome goal in the care plan: "The
client will transfer from bed to chair with two-person assist." The charge nurse
tells the nurse to add which of the following to complete the goal?
A. Client behavior
B. Conditions or modifiers
C. Performance criteria
D. Target time
D. Target time
Rationale: The outcome goal does not state the target timeframe for when the
nurse should expect to see the client behavior ("transfer"). The condition or
modifier is present ("with two assists"). The performance criterion is "from bed to
chair."
The nurse who documents on the client's care plan the outcome goal "Anxiety will
be relieved within 20 to 40 minutes following administration of lorazepam
(Ativan)" is engaged in which step of the nursing process?
A. Assessment
B. Planning
C. Implementation
D. Evaluation
, 4
B. Planning
Rationale: The planning step of the nursing process involves formulating client
goals and designing the nursing interventions required to prevent, reduce, or
eliminate the client's health problems. Outcome goals are documented on the
client's care plan. Assessment data (option 1) is used to help identify a client's
human response, and once a plan is established, the interventions are
implemented (option 3) and evaluated (option 4).
When the client resists taking a liquid medication that is essential to treatment,
the nurse demonstrates critical thinking by doing which of the following first?
A. Omitting this dose of medication and waiting until the client is more
cooperative
B. Suggesting the medication can be diluted in a beverage
C. Asking the nurse manager about how to approach the situation
D. Notifying the physician inability to give the client this medication
B. Suggesting the medication can be diluted in a beverage
Rationale: Diluting the medication in a beverage may make the medication more
palatable. Using critical thinking skills, the nurse should try to problem-solve in a
situation such as this before asking for the assistance of the nurse manager.
Suggesting an alternative method of taking the medication (provided that there
are no contraindications to diluting the medication) should improve the likelihood
of the client taking the medication.
Which professionally appropriate response should the nurse make when a more
stringent policy for the use of restraints is introduced on a surgical unit?
FUNDAMENTALS OF NURSING EXAM LATEST VERSION -
2025/2026- 100+ Q AND ANS ALL THE BEST
When evaluating an elderly client's blood pressure (BP) of 146/78 mmHg, the
nurse does which of the following before determining whether the BP is normal or
represents hypertension?
A. Compare this reading against defined standards
B. Compare the reading with one taken in the opposite arm
C. Determine gaps in the vital signs in the client record
D. Compare the current measurement with previous ones
A. Compare this reading against defined
Rationale: Analysis of the client's BP requires knowledge of the normal BP range
for an older adult. The nurse compares the client's data against identified
standards to determine whether this reading is normal or abnormal. Measuring
the BP in the other arm (option 2) and comparing the reading to previous ones
(option 4) will give additional client data, but the comparison alone will not
determine whether the BP is normal. Gaps in the record (option 3) will not aid in
interpreting the current measurement.
Which of the following behaviors by the nurse demonstrates that the nurse is
participating in critical thinking? Select all that apply.
A. Admitting not knowing how to do a procedure and requesting help
B. Using clever and persuasive remarks to support an opinion or position
C. Accepting without question the values acquired in nursing school
, 2
D. Finding a quick and logical answer, even to complex questions
E. Gathering three assistants to transfer the client to a stretcher after noting the
client weighs 300 lbs.
A. Admitting not knowing how to do a procedure and requesting help
E. Gathering three assistants to transfer the client to a stretcher after noting the
client weighs 300 lbs.
Rationale: Critical thinking in nursing is self-directed, supporting what nurses
know and making clear what they do not know. It is important for nurses to
recognize when they lack the knowledge they need to provide safe care for a
client (option 1). Nurses must also utilize their resources to acquire the support
they need to care for a client safely (option 5). Options 2, 3, and 4 do not
demonstrate critical thinking.
The nurse is measuring the client's urine output and straining the urine to assess
for stones. Which of the following should the nurse record as objective data?
A. The client reports abdominal pain
B. The client's urine output was 450 mL
C. The client states, "I didn't see any stones in my urine."
D. The client states, "I feel like I have passed a stone."
B. The client's urine output was 450 mL.
Rationale: Objective data is measurable data that can be seen, heard, or verified
by the nurse. The objective data is the measurement of the urine output. A
client's statements and reports of symptoms are documented as subjective data,
such as the data found in options 1, 3, and 4.
, 3
The nurse has documented the following outcome goal in the care plan: "The
client will transfer from bed to chair with two-person assist." The charge nurse
tells the nurse to add which of the following to complete the goal?
A. Client behavior
B. Conditions or modifiers
C. Performance criteria
D. Target time
D. Target time
Rationale: The outcome goal does not state the target timeframe for when the
nurse should expect to see the client behavior ("transfer"). The condition or
modifier is present ("with two assists"). The performance criterion is "from bed to
chair."
The nurse who documents on the client's care plan the outcome goal "Anxiety will
be relieved within 20 to 40 minutes following administration of lorazepam
(Ativan)" is engaged in which step of the nursing process?
A. Assessment
B. Planning
C. Implementation
D. Evaluation
, 4
B. Planning
Rationale: The planning step of the nursing process involves formulating client
goals and designing the nursing interventions required to prevent, reduce, or
eliminate the client's health problems. Outcome goals are documented on the
client's care plan. Assessment data (option 1) is used to help identify a client's
human response, and once a plan is established, the interventions are
implemented (option 3) and evaluated (option 4).
When the client resists taking a liquid medication that is essential to treatment,
the nurse demonstrates critical thinking by doing which of the following first?
A. Omitting this dose of medication and waiting until the client is more
cooperative
B. Suggesting the medication can be diluted in a beverage
C. Asking the nurse manager about how to approach the situation
D. Notifying the physician inability to give the client this medication
B. Suggesting the medication can be diluted in a beverage
Rationale: Diluting the medication in a beverage may make the medication more
palatable. Using critical thinking skills, the nurse should try to problem-solve in a
situation such as this before asking for the assistance of the nurse manager.
Suggesting an alternative method of taking the medication (provided that there
are no contraindications to diluting the medication) should improve the likelihood
of the client taking the medication.
Which professionally appropriate response should the nurse make when a more
stringent policy for the use of restraints is introduced on a surgical unit?
