NUR 265 Exam 1 V1 and V2
Questions and Correct Answers| Galen
College of Nursing
,Q1. The nurse is prioritizing care for four clients at the start of a shift. Which client should the
nurse assess first?
A) A client who reports 5/10 incisional pain 2 hours after surgery
B) A client with a new onset of stridor and use of accessory muscles
C) A client requesting a scheduled dose of an oral antihypertensive
D) A client who wants to discuss discharge teaching
Correct Answer: B) A client with a new onset of stridor and use of accessory muscles
Rationale: Using the ABC (Airway, Breathing, Circulation) framework, a client showing signs of airway
compromise (stridor, accessory muscle use) requires immediate assessment, as this represents an actual or
imminent life threat over pain, routine medication, or teaching needs.
Q2. Which action best reflects the nursing process step of 'evaluation'?
A) Collecting vital signs and reviewing the client's chart
B) Formulating a nursing diagnosis based on collected data
C) Comparing the client's actual outcomes to the expected outcomes after an intervention
D) Writing measurable, client-centered goals
Correct Answer: C) Comparing the client's actual outcomes to the expected outcomes after an
intervention
Rationale: Evaluation is the final step of the nursing process, in which the nurse determines whether the goals of
care were met by comparing the client's actual response to the expected outcomes, and revises the plan of care
as needed.
Q3. A nurse is using Maslow's hierarchy of needs to prioritize care. Which client need should be
addressed first?
A) A client's request to call a family member
B) A client's need for oxygen due to labored breathing
C) A client's concern about body image after surgery
D) A client's desire for a quiet, private room
Correct Answer: B) A client's need for oxygen due to labored breathing
Rationale: Maslow's hierarchy places physiological needs, including oxygenation, at the base of the pyramid,
meaning they must be addressed before higher-level needs such as safety, love/belonging, esteem, or
self-actualization.
Q4. Which of the following is the correct order of steps when performing hand hygiene with
soap and water?
A) Dry hands, wet hands, apply soap, rinse
B) Wet hands, apply soap, lather and scrub for at least 20 seconds, rinse, dry
C) Apply soap to dry hands, rinse briefly, then wet hands
D) Wet hands only; soap is optional if hands appear clean
Correct Answer: B) Wet hands, apply soap, lather and scrub for at least 20 seconds, rinse, dry
Rationale: Correct hand hygiene technique involves wetting the hands first, applying soap, creating friction by
scrubbing all surfaces (including between fingers and under nails) for at least 20 seconds, rinsing thoroughly, and
drying with a clean towel to reduce transmission of microorganisms.
,Q5. A client is at risk for falls. Which intervention is the priority to include in the plan of care?
A) Restrain the client in bed at all times
B) Place the bed in the lowest position with the call light within reach
C) Discourage family visits to reduce distraction
D) Keep the room dark at all times
Correct Answer: B) Place the bed in the lowest position with the call light within reach
Rationale: Fall-prevention strategies include keeping the bed in the lowest position, ensuring the call light is
within reach, using non-skid footwear, and orienting the client to the environment; restraints are a last resort and
require specific criteria and orders, not a first-line fall precaution.
Q6. What is the primary purpose of using the SBAR
(Situation-Background-Assessment-Recommendation) communication tool?
A) To document billing information
B) To standardize and organize critical communication between healthcare providers, especially during
handoff or urgent situations
C) To replace the need for documentation
D) To schedule client appointments
Correct Answer: B) To standardize and organize critical communication between healthcare
providers, especially during handoff or urgent situations
Rationale: SBAR provides a structured, predictable framework for communicating essential clinical information
clearly and efficiently, reducing the risk of miscommunication during handoffs, physician notifications, and other
critical conversations between care team members.
Q7. Before administering any medication, which of the 'rights of medication administration'
must the nurse verify?
A) Right client, right medication, right dose, right route, right time only
B) Right client, right medication, right dose, right route, right time, right documentation, and right to refuse
C) Right insurance authorization only
D) Right client and right time only
Correct Answer: B) Right client, right medication, right dose, right route, right time, right
documentation, and right to refuse
Rationale: While the classic '5 rights' (client, medication, dose, route, time) are foundational, expanded
frameworks also include the right documentation and the client's right to refuse a medication, both of which the
nurse must respect and record appropriately.
Q8. A nurse finds a client on the floor after an unwitnessed fall. What is the priority action?
A) Immediately assist the client back into bed
B) Assess the client for injury before moving them, then call for assistance
C) Complete the incident report before assessing the client
D) Ask the client to stand up quickly to check for pain
Correct Answer: B) Assess the client for injury before moving them, then call for assistance
Rationale: After any fall, the nurse should first assess the client for injury (such as fracture, head trauma, or
bleeding) before moving them, to avoid worsening a potential injury, and should call for help to safely reposition
or transfer the client as needed.
, Q9. Which of the following best describes 'standard precautions' in infection control?
A) Precautions used only for clients with a confirmed airborne infection
B) A basic level of infection control practices used with all clients, regardless of diagnosis, including hand
hygiene and use of PPE when exposure to body fluids is anticipated
C) A precaution used only in the operating room
D) Precautions that eliminate the need for hand hygiene
Correct Answer: B) A basic level of infection control practices used with all clients, regardless of
diagnosis, including hand hygiene and use of PPE when exposure to body fluids is anticipated
Rationale: Standard precautions apply to the care of all clients at all times, regardless of known infection status,
and include practices such as hand hygiene, use of gloves and other PPE when contact with blood or body fluids
is anticipated, and safe injection practices.
Questions and Correct Answers| Galen
College of Nursing
,Q1. The nurse is prioritizing care for four clients at the start of a shift. Which client should the
nurse assess first?
A) A client who reports 5/10 incisional pain 2 hours after surgery
B) A client with a new onset of stridor and use of accessory muscles
C) A client requesting a scheduled dose of an oral antihypertensive
D) A client who wants to discuss discharge teaching
Correct Answer: B) A client with a new onset of stridor and use of accessory muscles
Rationale: Using the ABC (Airway, Breathing, Circulation) framework, a client showing signs of airway
compromise (stridor, accessory muscle use) requires immediate assessment, as this represents an actual or
imminent life threat over pain, routine medication, or teaching needs.
Q2. Which action best reflects the nursing process step of 'evaluation'?
A) Collecting vital signs and reviewing the client's chart
B) Formulating a nursing diagnosis based on collected data
C) Comparing the client's actual outcomes to the expected outcomes after an intervention
D) Writing measurable, client-centered goals
Correct Answer: C) Comparing the client's actual outcomes to the expected outcomes after an
intervention
Rationale: Evaluation is the final step of the nursing process, in which the nurse determines whether the goals of
care were met by comparing the client's actual response to the expected outcomes, and revises the plan of care
as needed.
Q3. A nurse is using Maslow's hierarchy of needs to prioritize care. Which client need should be
addressed first?
A) A client's request to call a family member
B) A client's need for oxygen due to labored breathing
C) A client's concern about body image after surgery
D) A client's desire for a quiet, private room
Correct Answer: B) A client's need for oxygen due to labored breathing
Rationale: Maslow's hierarchy places physiological needs, including oxygenation, at the base of the pyramid,
meaning they must be addressed before higher-level needs such as safety, love/belonging, esteem, or
self-actualization.
Q4. Which of the following is the correct order of steps when performing hand hygiene with
soap and water?
A) Dry hands, wet hands, apply soap, rinse
B) Wet hands, apply soap, lather and scrub for at least 20 seconds, rinse, dry
C) Apply soap to dry hands, rinse briefly, then wet hands
D) Wet hands only; soap is optional if hands appear clean
Correct Answer: B) Wet hands, apply soap, lather and scrub for at least 20 seconds, rinse, dry
Rationale: Correct hand hygiene technique involves wetting the hands first, applying soap, creating friction by
scrubbing all surfaces (including between fingers and under nails) for at least 20 seconds, rinsing thoroughly, and
drying with a clean towel to reduce transmission of microorganisms.
,Q5. A client is at risk for falls. Which intervention is the priority to include in the plan of care?
A) Restrain the client in bed at all times
B) Place the bed in the lowest position with the call light within reach
C) Discourage family visits to reduce distraction
D) Keep the room dark at all times
Correct Answer: B) Place the bed in the lowest position with the call light within reach
Rationale: Fall-prevention strategies include keeping the bed in the lowest position, ensuring the call light is
within reach, using non-skid footwear, and orienting the client to the environment; restraints are a last resort and
require specific criteria and orders, not a first-line fall precaution.
Q6. What is the primary purpose of using the SBAR
(Situation-Background-Assessment-Recommendation) communication tool?
A) To document billing information
B) To standardize and organize critical communication between healthcare providers, especially during
handoff or urgent situations
C) To replace the need for documentation
D) To schedule client appointments
Correct Answer: B) To standardize and organize critical communication between healthcare
providers, especially during handoff or urgent situations
Rationale: SBAR provides a structured, predictable framework for communicating essential clinical information
clearly and efficiently, reducing the risk of miscommunication during handoffs, physician notifications, and other
critical conversations between care team members.
Q7. Before administering any medication, which of the 'rights of medication administration'
must the nurse verify?
A) Right client, right medication, right dose, right route, right time only
B) Right client, right medication, right dose, right route, right time, right documentation, and right to refuse
C) Right insurance authorization only
D) Right client and right time only
Correct Answer: B) Right client, right medication, right dose, right route, right time, right
documentation, and right to refuse
Rationale: While the classic '5 rights' (client, medication, dose, route, time) are foundational, expanded
frameworks also include the right documentation and the client's right to refuse a medication, both of which the
nurse must respect and record appropriately.
Q8. A nurse finds a client on the floor after an unwitnessed fall. What is the priority action?
A) Immediately assist the client back into bed
B) Assess the client for injury before moving them, then call for assistance
C) Complete the incident report before assessing the client
D) Ask the client to stand up quickly to check for pain
Correct Answer: B) Assess the client for injury before moving them, then call for assistance
Rationale: After any fall, the nurse should first assess the client for injury (such as fracture, head trauma, or
bleeding) before moving them, to avoid worsening a potential injury, and should call for help to safely reposition
or transfer the client as needed.
, Q9. Which of the following best describes 'standard precautions' in infection control?
A) Precautions used only for clients with a confirmed airborne infection
B) A basic level of infection control practices used with all clients, regardless of diagnosis, including hand
hygiene and use of PPE when exposure to body fluids is anticipated
C) A precaution used only in the operating room
D) Precautions that eliminate the need for hand hygiene
Correct Answer: B) A basic level of infection control practices used with all clients, regardless of
diagnosis, including hand hygiene and use of PPE when exposure to body fluids is anticipated
Rationale: Standard precautions apply to the care of all clients at all times, regardless of known infection status,
and include practices such as hand hygiene, use of gloves and other PPE when contact with blood or body fluids
is anticipated, and safe injection practices.
