Fundamentals of Nursing Exam

On the exam, this material maps mainly to the Management of Care client needs category, with some overlap into Safety and Infection Prevention and Control. In this guide's practice tests, 16 of the 100 questions in each test come from this section. Expect many of them to be "which client first," "which task can be delegated," "what should the nurse do first" and "what is the nurse's legal responsibility" items. The skills here also help you answer questions in every other section, because priority and judgment rules apply everywhere.

This chapter explains the five steps of the nursing process, how to tell subjective from objective data, how to write a nursing diagnosis and a measurable outcome, the types of nursing interventions, and how the NCSBN Clinical Judgment Measurement Model describes the thinking that sits behind every safe decision.

The nursing process is a systematic, client-centered problem-solving method. It is often remembered as ADPIE: Assessment, Diagnosis, Planning, Implementation and Evaluation. The steps are listed in order, but in real practice they overlap and cycle. A nurse who finds new data during implementation goes back to assessment, and evaluation feeds directly into a revised plan.

The Five Steps of the Nursing Process

Memory Aid: ADPIE. "A Delicious Pie Is Easy." Assessment always comes first, and evaluation closes the loop.

Assessment is the foundation of the process. Every later step depends on accurate, complete data. Assessment can be comprehensive (a full admission database), focused (a single problem such as pain or breathing), ongoing (each shift), or emergency (a rapid check of airway, breathing and circulation).

Data come from two kinds of sources. The primary source is the client. Secondary sources include family members, the health record, other team members, and diagnostic results. Data are also either subjective or objective.

Subjective data are what the client says or feels. Only the client can verify them. Examples: "My chest feels tight," pain rated 7 on a 0-10 scale, nausea, dizziness, worry about surgery.

Objective data are what the nurse can observe, measure, or verify. Examples: BP 148/92 mm Hg, a 3 cm reddened area on the sacrum, a client grimacing, a potassium of 3.1 mEq/L, crackles in both lung bases.

Common Trap: A pain rating is subjective even though it is a number, because only the client can report it. Grimacing, guarding and an elevated pulse are objective because the nurse observes or measures them.

After collecting data, the nurse validates it (for example, rechecking a surprising BP with a manual cuff), clusters related findings, and documents it. Validating unexpected data before acting on it is a classic "assess first" principle.

A nursing diagnosis is a clinical judgment about the client's response to a health problem or life process. It differs from a medical diagnosis. A medical diagnosis names a disease (pneumonia, heart failure) and stays the same while the disease is present. A nursing diagnosis names the client's response (impaired gas exchange, activity intolerance) and can change from day to day as the client responds.

NANDA International (NANDA-I) provides a standard list of nursing diagnosis labels. An actual (problem-focused) diagnosis uses a three-part format, often called PES:

Types of Nursing Diagnoses

Common Trap: Never use a medical diagnosis as the etiology. "Impaired gas exchange related to pneumonia" is weak, because nurses cannot treat pneumonia independently. A better statement links the problem to something nursing can address, such as alveolar fluid or ineffective airway clearance. Also, a risk diagnosis has no "as evidenced by" signs, because the problem has not happened yet.

Planning has three tasks: set priorities among the client's problems, write expected outcomes, and select interventions.

Priority setting uses frameworks covered in detail in Chapter 1.2: airway, breathing and circulation first, physiologic needs before psychosocial ones, actual problems before risk problems, and the client's own priorities when they do not conflict with safety.

Replace "understand," which cannot be observed, with a measurable verb: "identify."

Interventions are the actions that move the client toward the outcomes. They fall into three groups.

Types of Nursing Interventions

Before implementing, the nurse reassesses the client to confirm the planned action is still safe. For example, the nurse checks the respiratory rate before giving an opioid and the apical pulse before a medication that slows the heart. Implementation also includes delegating tasks, supervising, and documenting the care given and the client's response.

Common Trap: Exam items often ask for the nurse's independent action. Choose an action the nurse can do without an order, such as elevating the head of the bed or teaching pursed-lip breathing, rather than "administer furosemide" or "insert a nasogastric tube."

Evaluation compares the client's actual response with the expected outcome. The nurse decides whether the outcome was met, partially met, or not met, and then continues, revises, or ends the plan. If the outcome was not met, the nurse asks why: Was the diagnosis wrong? Was the goal unrealistic? Were the interventions not done or not effective? Evaluation always uses new data from the client, not a simple statement that the task was completed.

Clinical Example: The outcome was "The client will report pain at or below 3 on a 0-10 scale within 1 hour of medication." One hour after an oral analgesic, the client rates pain 6. The outcome is not met. The nurse reassesses the pain (location, character, new causes), tries nonpharmacologic measures, and contacts the provider if the ordered medication is not effective.

Clinical Example: A client with heart failure says, "I can't catch my breath when I lie down" (subjective). The nurse finds RR 26, SpO2 91% on room air, crackles in both bases, and 2+ ankle edema (objective). The nurse writes Excess fluid volume related to reduced cardiac output as evidenced by crackles, edema and orthopnea. The outcome is "The client will have clear breath sounds and an SpO2 of at least 95% within 24 hours." Interventions include raising the head of the bed (independent), giving the prescribed diuretic (dependent), and consulting the dietitian about sodium limits (collaborative). The nurse evaluates by rechecking lung sounds, SpO2, daily weight and intake and output.

Critical thinking is purposeful, reasoned thinking that questions assumptions, considers alternatives and uses evidence. In nursing it means asking: What does this finding mean? What else could explain it? What could go wrong? What should I do first? Traits of a critical thinker include curiosity, humility (knowing the limits of one's knowledge), confidence to speak up, and willingness to change a plan when new data appear.

Clinical judgment is the observable outcome of critical thinking and decision making. NCSBN developed the Clinical Judgment Measurement Model (CJMM) to describe how nurses reach safe decisions, and the NCLEX uses it to build Next Generation (NGN) items. Fundamentals exams increasingly include questions shaped by this model.

The model's core layer describes six cognitive skills. They overlap with the nursing process but describe the thinking more precisely.

The Six Clinical Judgment Skills

The model also recognizes that individual factors (the nurse's knowledge, experience and skills) and environmental factors (staffing, time pressure, the client's culture, resources) influence the decision.

Clinical Example: A postoperative client is restless, has a pulse of 118 (up from 84), BP 98/60 (down from 132/80) and a saturated dressing. Recognize cues: rising pulse, falling BP, restlessness, bleeding. Analyze cues: these together suggest hypovolemia from hemorrhage. Prioritize hypotheses: hemorrhage is more urgent than pain or anxiety. Generate solutions: control bleeding, support circulation, get help. Take action: apply pressure if appropriate, lower the head of the bed per protocol, call the rapid response team or provider, and prepare for fluids. Evaluate outcomes: recheck vital signs, dressing and mental status.

Exam Tip: In NGN-style items, "recognize cues" questions ask which findings require follow-up. Pick findings that are abnormal and clinically important for this client, not every abnormal value. A slightly low hemoglobin in a client with chronic kidney disease is less important than a new drop in BP after surgery.

ADPIE moves from assessment to evaluation, and assessment always comes first when data are missing or unexpected.

Subjective data are what the client reports; objective data are what the nurse observes or measures.

Outcomes are client-centered, measurable and time-bound; avoid "understand" and "know."

Independent interventions need no order; dependent ones need a provider's order; collaborative ones involve other disciplines.

The CJMM skills are recognize cues, analyze cues, prioritize hypotheses, generate solutions, take action, and evaluate outcomes.