Running head: FUNDAMENTALS OF

Objective Tests: Design and Considerations

Fundamentals of Nursing
Jennifer Dougherty
SUNY Delhi
NURS 603-11373-201609, Measurement and Evaluation in Nursing Education
Kirsty Digger
November 6, 2016

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Question 1
In which step of the nursing process does the nurse analyze data and identify client problems?

A
B
C
D

Assessment
Diagnosis
Planning outcomes
Evaluation

Answer: (B)
Question 1 Explanation:
In the assessment phase, the nurse gathers data from many sources for analysis in
the diagnosis phase. In the diagnosis phase, the nurse identifies (which is what the
question is asking for) the clients health status. In the planning outcomes phase, the
nurse formulates goals and outcomes. In the evaluation phase, which occurs after
implementing interventions, the nurse gathers data about the clients responses to
nursing care to determine whether client outcomes were met (Wayne, 2015).
Category: Safe and effective care environment
Subcategory: Management of care
Blooms taxonomy cognitive level: Analysis
I chose analysis because this question deals with the nursing process and analyzing a
clients problem.

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Question 2
In which phase of the nursing process does the nurse decide whether her actions have
successfully treated the clients health problem?
A
B
C
D

Assessment
Diagnosis
Planning outcomes
Evaluation

Answer: (D)
Question 2 Explanation:
In the assessment phase, the nurse gathers data from many sources for analysis in
the diagnosis phase. In the diagnosis phase, the nurse identifies the clients health
status. In the planning outcomes phase, the nurse and client decide on goals they
want to achieve. In the intervention planning phase, the nurse identifies specific
interventions to help achieve the identified goal. During the implementation phase,
the nurse carries out the interventions or delegates them to other health care team
members. During the evaluation phase, the nurse judges whether her actions have
been successful in treating or preventing the identified client health problem
(Wayne, 2015). Which is what the question is asking.
Category: Safe and effective care environment
Subcategory: Management of care
Blooms taxonomy cognitive level: Analysis
I chose analysis for this question as the student needs to analyze her actions to see
which part of the nursing process this question pertains too.

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Question 3
What is the most basic reason that self-knowledge is important for nurses? Because it helps the
nurse to:
A
B
C
D

Identify personal biases that may affect his thinking and actions
Identify the most effective interventions for a patient
Communicate more efficiently with colleagues, patients, and families
Learn and remember new procedures and techniques

Answer: (A)
Question 3 Explanation:
The most basic reason is that self-knowledge directly affects the nurses thinking
and the actions he chooses. Indirectly, thinking is involved in identifying effective
interventions, communicating, and learning procedures. However, because
identifying personal biases affects all the other nursing actions, it is the most basic
reason (Wayne, 2015).
Category: Safe and effective care environment
Subcategory: Management of care
Blooms taxonomy cognitive level: Evaluation
I chose evaluation for this questions because it deals with self-knowledge which
falls into judging or critiquing per blooms theory.
Question 4
Arrange the steps of the nursing process in the sequence in which they generally occur. A.
Assessment B. Evaluation C. Planning outcomes D. Planning interventions E. Diagnosis
A
B
C

E, B, A, D, C
A, B, C, D, E
A, E, C, D, B

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D, A, B, E, C

Answer: (C)
Question 4 Explanation:
Logically, the steps are assessment, diagnosis, planning outcomes, planning
interventions, and evaluation. Keep in mind that steps are not always performed in
this order, depending on the patients needs, and that steps overlap (Wayne, 2015).
Category: Safe and effective care environment
Subcategory: Management of care
Blooms taxonomy cognitive level: Application
I chose application for this question because the student will need to use principles
learned about the nursing process to apply and order the nursing process.
Question 5
Which organizations standards require that all patients be assessed specifically for pain?
A
B
C
D

American Nurses Association (ANA)

State nurse practice acts
National Council of State Boards of Nursing (NCSBN)
The Joint Commission

Answer: (D)
Question 5 Explanation:
The Joint Commission has developed assessment standards, including that all clients
be assessed for pain. The ANA has developed standards for clinical practice,
including those for assessment, but not specifically for pain. State nurse practice acts
regulate nursing practice in individual states. The NCSBN asserts that the scope of
nursing includes a comprehensive assessment but does not specifically include pain
(Wayne, 2015).
Category: Physiological integrity
Subcategory: Pharmacological and parenteral therapies
Blooms taxonomy cognitive level: Comprehension I chose comprehension for this

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question because the student needs to interpret information learned about each of
these organizations to describe the standards used by them to address pain.
Question 6
Which of the following is an example of data that should be validated?
A
B
C

The urinalysis report indicates there are white blood cells in the urine.
The client states she feels feverish; you measure the oral temperature at 98F.
The client has clear breath sounds; you count a respiratory rate of 18.

The chest x-ray report indicates the client has pneumonia in the right lower
D lobe.
Answer: (B)
Question 6 Explanation:
Validation should be done when subjective and objective data do not make sense.
For instance, it is inconsistent data when the patient feels feverish and you obtain a
normal temperature. The other distractors do not offer conflicting data. Validation is
not usually necessary for laboratory test results (Wayne, 2015).
Category: Physiological integrity
Subcategory: Pharmacological and parenteral therapies
Blooms taxonomy cognitive level: Application
I chose application for this question because the student needs to principles to solve
this problem.

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Question 7
Which of the following would be priority assessment data to gather from a client who has been
diagnosed with pneumonia? (Select all that apply).
A
B
C
D
E

Auscultation of breath sounds

Auscultation of bowel sounds
Presence of chest pain.
Presence of peripheral edema
Color of nail beds

Answer: (A, C)
Question 7 Explanation:
A respiratory assessment, which includes auscultation of breath sounds and assessing the color of
the nail beds, is a priority for clients with pneumonia. Assessing for the presence of chest pain is
also an important respiratory assessment as chest pain can interfere with the clients ability to
breathe deeply. Auscultate bowel sounds and assessing for peripheral edema may be appropriate
assessments, but these are not priority assessments for the patient with pneumonia (Vera, 2014)
Category: Physiological integrity
Subcategory: Reduction of risk potential
Blooms taxonomy cognitive level: Analysis
I chose analysis for this question because the student needs to be able to analyze the steps of an
assessment as well as needs to be able to prioritize to obtain the answer.

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Question 8:
Which of the following nursing interventions are written correctly? (Select all that apply.)
A
B
C
D

Apply continuous passive motion machine during day.

Perform neurovascular checks.
Elevate head of bed 30 degrees before meals.
Change dressing once a shift.

Answer: (C)
Explanation Question 8:
It is specific in what to do and when (Vera, 2014).
Category: Safe and effective care environment
Subcategory: Safety and infection control
Blooms taxonomy cognitive level: Analysis
I chose analysis because the student needs to be able to analyze and categorize the nursing
intervention listed to lead them to the answer.
Question 9
A nurse is assisting a client with an advance directive. Which of the following nursing
responsibilities should be included regarding advance directives? (Select all that apply).
Select one or more:
a. Confirm that the advance directive is current.
b. Document the client's advance directive in the medical chart.
c. Inform all members of the client's family of the client's wishes.
d. Provide written information to the client about advance directives.
e. Ensure that each family member receives a copy of the advance directive.

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Answer: (A, B, D)

Explanation Question 9:
The nursing responsibility regarding advance directives is to ensure that the advance directive is
current and reflective of the client's current decisions; document the client's advance directives
status, and to provide written information regarding advance directives (Quizlet Inc., 2016). C
and E are incorrect because giving a copy of the clients advance directives to family members or
informing them of the clients wishes is a HIPAA violation.
Category: Safe and effective care environment
Subcategory: Management of care
Blooms taxonomy cognitive level: Application
I chose application for this question because the student needs to apply the information about
HIPAA to come to the answer for this question. Therefore, using principles to complete the
problem.

Question 10
A nurse is managing client care. Which of the following should be
implemented when prioritizing care? Select all that apply.
Select one or more:
a. Postpone items that do not have immediate deadlines.
b. Avoid delegation of difficult tasks.
c. Take on a task when inspired.
d. Respond to needs as soon as they arise.
e. Prepare a written list.

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10

Answer: (A, E)
Explanation Question 10:
Preparing a written list is a function considered in prioritizing client care. Items that are marked
as to do later reflect trivial problems or those that do not have immediate deadlines; thus, they
may be postponed when prioritizing care (Quizlet Inc., 2016).
Category: Safe and effective care environment
Subcategory: Safety and infection control
Blooms taxonomy cognitive level: Synthesis
I chose synthesis for this question because the student needs to implement the understanding of
prioritizing in order to answer this question. They are also combining ideas of client care and
integrating nursing care.

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References
Huitt, W. (2011). Bloom et al.'s taxonomy of the cognitive domain. Educational Psychology
Interactive. Valdosta, GA: Valdosta State University. Retrieved from
http://www.edpsycinteractive.org
National Council of State Boards of Nursing. (2016). NCLEX-RN examination test plan for the
national council licensure examination for registered nurses. Retrieved from
https://www.ncsbn.org
Quizlet Inc. (2016). Fundamentals alternative item format quiz (select all that apply). Retrieved
from https://quizlet.com/143477512/fundamentals-alternative-item-format-quiz-selectall-that-apply-flash-cards/
Vera, M. (2014). NCLEX select all that apply practice exam 1 (30 items). Retrieved from
http://nurseslabs.com/nclex-select-all-that-apply-practice-exam-1-30-questions/
Wayne, G. (2015). Fundamentals of nursing NCLEX practice quiz 4 (20 items). Retrieved from
http://nurseslabs.com/nclex-exam-fundamentals-nursing-4-20-items/