FUNDAMENTALS OF NURSING NURSING PROCESS
NURSING COURSE 2026/2027 | COMPLETE MASTER
REVIEW | GRADED A+ | 100% CORRECT | VERIFIED STUDY
SET FOR GUARANTEED SUCCESS | HIGH-YIELD
CONCEPTS, CLINICAL SKILLS & PATIENT CARE INSIGHTS
FOR EXCELLENCE
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 - CORRECT ANSWER - 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 -
CORRECT ANSWER - 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?
A. Use the previous, less restrictive policy conscientiously
B. Express immediate disagreement with the new policy
C. Ask for the rationale behind the new policy
D. Obey the policy but continue to voice disapproval of it to co-workers -
CORRECT ANSWER - C. Ask for the rationale behind the new policy
Rationale: Understanding the rationale behind a decision helps the nurse
analyze the proposed change and understand its purpose. Options 1, 2, and 4
represent unprofessional behavior. Option 1 also places a client's safety at risk.
The nurse assigned to care for a postoperative client has asked an unlicensed
assistive person (UAP) to help the client ambulate in the hall. Before delegating
this task, the nurse must do which of the following?
A. Assess the client to be sure ambulation with assistance is an appropriate care
measure
, B. Ask the client if he or she is ready to ambulate
C. Ask whether the UAP has time to assist the client
D. Ask the charge nurse whether UAPs have ambulated the client during this
shift - CORRECT ANSWER - A. Assess the client to be sure ambulation with
assistance is an appropriate care measure
Rationale: Prior to delegating any client care responsibilities, the nurse must
assess the client to assure that the delegation is appropriate to his or her care.
Options 2, 3, and 4 would not constitute an assessment of the client's current
status.
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. Reexamine the nursing orders
D. Write a new nursing diagnosis - CORRECT ANSWER - B. Reexamine the
nursing orders
A client comes to the walk-in clinic with reports of abdominal pain and
diarrhea. While taking the client's vital signs, the nurse is implementing which
phase of the nursing process?
A. Assessment
B. Diagnosis
C. Planning
D. Implementation - CORRECT ANSWER - A. Assessment
Rationale: The first step in the nursing process is assessment, the process of
collecting data. All subsequent phases of the nursing process (options 2, 3, and
4) rely on accurate and complete data.
NURSING COURSE 2026/2027 | COMPLETE MASTER
REVIEW | GRADED A+ | 100% CORRECT | VERIFIED STUDY
SET FOR GUARANTEED SUCCESS | HIGH-YIELD
CONCEPTS, CLINICAL SKILLS & PATIENT CARE INSIGHTS
FOR EXCELLENCE
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 - CORRECT ANSWER - 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 -
CORRECT ANSWER - 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?
A. Use the previous, less restrictive policy conscientiously
B. Express immediate disagreement with the new policy
C. Ask for the rationale behind the new policy
D. Obey the policy but continue to voice disapproval of it to co-workers -
CORRECT ANSWER - C. Ask for the rationale behind the new policy
Rationale: Understanding the rationale behind a decision helps the nurse
analyze the proposed change and understand its purpose. Options 1, 2, and 4
represent unprofessional behavior. Option 1 also places a client's safety at risk.
The nurse assigned to care for a postoperative client has asked an unlicensed
assistive person (UAP) to help the client ambulate in the hall. Before delegating
this task, the nurse must do which of the following?
A. Assess the client to be sure ambulation with assistance is an appropriate care
measure
, B. Ask the client if he or she is ready to ambulate
C. Ask whether the UAP has time to assist the client
D. Ask the charge nurse whether UAPs have ambulated the client during this
shift - CORRECT ANSWER - A. Assess the client to be sure ambulation with
assistance is an appropriate care measure
Rationale: Prior to delegating any client care responsibilities, the nurse must
assess the client to assure that the delegation is appropriate to his or her care.
Options 2, 3, and 4 would not constitute an assessment of the client's current
status.
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. Reexamine the nursing orders
D. Write a new nursing diagnosis - CORRECT ANSWER - B. Reexamine the
nursing orders
A client comes to the walk-in clinic with reports of abdominal pain and
diarrhea. While taking the client's vital signs, the nurse is implementing which
phase of the nursing process?
A. Assessment
B. Diagnosis
C. Planning
D. Implementation - CORRECT ANSWER - A. Assessment
Rationale: The first step in the nursing process is assessment, the process of
collecting data. All subsequent phases of the nursing process (options 2, 3, and
4) rely on accurate and complete data.
