NURS 280 Final Exam
NURS 280
Final Exam Study Guide
Latest 2026/2027
Page 1
, NURS 280 Final Exam
1. Which sequence correctly reflects the five steps of the nursing process?
Answer: Assessment, Diagnosis, Planning, Implementation, Evaluation
Rationale: The nursing process is a cyclical, systematic framework beginning with data
collection (assessment), followed by identifying patient problems (diagnosis), setting goals
(planning), carrying out interventions (implementation), and finally judging outcomes
(evaluation).
2. A nurse writes the diagnosis 'Risk for falls related to age and impaired mobility.' A colleague
states this is written incorrectly. What is the error?
Answer: A 'risk for' diagnosis should not include a 'related to' etiology because risk
factors alone establish vulnerability
Rationale: NANDA-I risk diagnoses are stated as 'Risk for [problem] as evidenced by [risk
factors]' rather than using 'related to,' since the problem has not actually occurred; using
etiology language implies an existing problem rather than a potential one.
3. During evaluation, a nurse finds a patient's expected outcome of ambulating 50 feet twice
daily was not met by discharge. What is the most appropriate next step?
Answer: Reassess the patient and revise the plan of care
Rationale: Evaluation is not the end of the process; when an outcome is unmet, the nurse
must return to assessment to determine why (e.g., pain, deconditioning) and revise
diagnoses, goals, or interventions accordingly, reflecting the cyclical nature of the nursing
process.
4. A nurse is developing a care plan and identifies that the patient has 'ineffective breathing
pattern' and 'acute pain' after abdominal surgery. Which action best demonstrates prioritization
within the planning phase?
Answer: Address the ineffective breathing pattern first
Rationale: Using Maslow's hierarchy and the ABC (airway, breathing, circulation)
framework, physiologic needs threatening oxygenation take priority over pain, which—while
important—is not immediately life-threatening.
5. A patient with a new diagnosis of heart failure has the outcome 'patient will verbalize three
signs of fluid overload by discharge.' The patient can list only one sign at discharge, and the
family reports overwhelming anxiety limiting learning. What should the nurse do first before
revising the teaching plan?
Answer: Address the patient's anxiety and readiness to learn before continuing
education
Rationale: Clinical judgment requires recognizing that anxiety is a significant barrier to
learning; addressing the underlying emotional state first (therapeutic communication, coping
support) allows subsequent education to be effective, rather than repeating the same
teaching approach that already failed.
6. Which technique should be used first when performing an abdominal assessment?
Answer: Inspection
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, NURS 280 Final Exam
Rationale: Abdominal assessment follows the sequence inspection, auscultation,
percussion, and palpation—auscultation is performed before percussion and palpation
because manipulating the abdomen can artificially alter bowel sounds.
7. A nurse auscultates a new S3 heart sound in a 68-year-old admitted with shortness of breath.
What does this finding most likely indicate?
Answer: Fluid overload or early heart failure
Rationale: An S3 (ventricular gallop) occurs from rapid ventricular filling and is a classic
early sign of volume overload or decreased ventricular compliance seen in heart failure; it is
a significant finding requiring further cardiovascular assessment and provider notification.
8. When assessing capillary refill on an adult patient's finger, which finding requires further
investigation?
Answer: Refill time greater than 3 seconds
Rationale: Normal capillary refill is under 2–3 seconds; a delayed refill suggests decreased
peripheral perfusion, which can result from hypovolemia, hypothermia, or arterial
insufficiency and warrants further circulatory assessment.
9. A nurse is assessing a patient's cranial nerve function and asks the patient to smile, frown,
and puff out the cheeks. Which cranial nerve is primarily being assessed?
Answer: Cranial nerve VII (facial)
Rationale: The facial nerve controls the muscles of facial expression; asymmetry with these
movements can indicate facial nerve palsy (e.g., Bell's palsy) or a central lesion such as
stroke, distinguished by whether the forehead is spared.
10. During a focused respiratory assessment, the nurse notes tactile fremitus is decreased over
the left lower lung field. What condition is most consistent with this finding?
Answer: Pleural effusion
Rationale: Decreased fremitus occurs when fluid, air, or tissue between the lung and chest
wall dampens vibration transmission; a pleural effusion adds a fluid layer that reduces
palpable vibrations, unlike consolidation (pneumonia), which increases fremitus.
11. A nurse assesses a postoperative patient and finds new-onset confusion, respiratory rate of
10/min, and pinpoint pupils. The patient received opioid analgesia 30 minutes ago. What is the
priority nursing action?
Answer: Stimulate the patient, assess oxygen saturation, and prepare to administer
naloxone while notifying the provider
Rationale: The triad of altered mental status, bradypnea, and miosis indicates
opioid-induced respiratory depression, a medical emergency; the nurse must act
immediately to protect airway and breathing rather than simply documenting or waiting to
reassess later.
12. Which of the following is a normal finding when assessing an older adult's skin turgor?
Answer: Slightly decreased elasticity with delayed but eventual return to baseline
Rationale: Aging skin normally loses collagen and elasticity, producing a slower tenting
recovery than in younger adults; this is an expected age-related change and should not
automatically be interpreted as dehydration without other supporting findings.
Page 3
NURS 280
Final Exam Study Guide
Latest 2026/2027
Page 1
, NURS 280 Final Exam
1. Which sequence correctly reflects the five steps of the nursing process?
Answer: Assessment, Diagnosis, Planning, Implementation, Evaluation
Rationale: The nursing process is a cyclical, systematic framework beginning with data
collection (assessment), followed by identifying patient problems (diagnosis), setting goals
(planning), carrying out interventions (implementation), and finally judging outcomes
(evaluation).
2. A nurse writes the diagnosis 'Risk for falls related to age and impaired mobility.' A colleague
states this is written incorrectly. What is the error?
Answer: A 'risk for' diagnosis should not include a 'related to' etiology because risk
factors alone establish vulnerability
Rationale: NANDA-I risk diagnoses are stated as 'Risk for [problem] as evidenced by [risk
factors]' rather than using 'related to,' since the problem has not actually occurred; using
etiology language implies an existing problem rather than a potential one.
3. During evaluation, a nurse finds a patient's expected outcome of ambulating 50 feet twice
daily was not met by discharge. What is the most appropriate next step?
Answer: Reassess the patient and revise the plan of care
Rationale: Evaluation is not the end of the process; when an outcome is unmet, the nurse
must return to assessment to determine why (e.g., pain, deconditioning) and revise
diagnoses, goals, or interventions accordingly, reflecting the cyclical nature of the nursing
process.
4. A nurse is developing a care plan and identifies that the patient has 'ineffective breathing
pattern' and 'acute pain' after abdominal surgery. Which action best demonstrates prioritization
within the planning phase?
Answer: Address the ineffective breathing pattern first
Rationale: Using Maslow's hierarchy and the ABC (airway, breathing, circulation)
framework, physiologic needs threatening oxygenation take priority over pain, which—while
important—is not immediately life-threatening.
5. A patient with a new diagnosis of heart failure has the outcome 'patient will verbalize three
signs of fluid overload by discharge.' The patient can list only one sign at discharge, and the
family reports overwhelming anxiety limiting learning. What should the nurse do first before
revising the teaching plan?
Answer: Address the patient's anxiety and readiness to learn before continuing
education
Rationale: Clinical judgment requires recognizing that anxiety is a significant barrier to
learning; addressing the underlying emotional state first (therapeutic communication, coping
support) allows subsequent education to be effective, rather than repeating the same
teaching approach that already failed.
6. Which technique should be used first when performing an abdominal assessment?
Answer: Inspection
Page 2
, NURS 280 Final Exam
Rationale: Abdominal assessment follows the sequence inspection, auscultation,
percussion, and palpation—auscultation is performed before percussion and palpation
because manipulating the abdomen can artificially alter bowel sounds.
7. A nurse auscultates a new S3 heart sound in a 68-year-old admitted with shortness of breath.
What does this finding most likely indicate?
Answer: Fluid overload or early heart failure
Rationale: An S3 (ventricular gallop) occurs from rapid ventricular filling and is a classic
early sign of volume overload or decreased ventricular compliance seen in heart failure; it is
a significant finding requiring further cardiovascular assessment and provider notification.
8. When assessing capillary refill on an adult patient's finger, which finding requires further
investigation?
Answer: Refill time greater than 3 seconds
Rationale: Normal capillary refill is under 2–3 seconds; a delayed refill suggests decreased
peripheral perfusion, which can result from hypovolemia, hypothermia, or arterial
insufficiency and warrants further circulatory assessment.
9. A nurse is assessing a patient's cranial nerve function and asks the patient to smile, frown,
and puff out the cheeks. Which cranial nerve is primarily being assessed?
Answer: Cranial nerve VII (facial)
Rationale: The facial nerve controls the muscles of facial expression; asymmetry with these
movements can indicate facial nerve palsy (e.g., Bell's palsy) or a central lesion such as
stroke, distinguished by whether the forehead is spared.
10. During a focused respiratory assessment, the nurse notes tactile fremitus is decreased over
the left lower lung field. What condition is most consistent with this finding?
Answer: Pleural effusion
Rationale: Decreased fremitus occurs when fluid, air, or tissue between the lung and chest
wall dampens vibration transmission; a pleural effusion adds a fluid layer that reduces
palpable vibrations, unlike consolidation (pneumonia), which increases fremitus.
11. A nurse assesses a postoperative patient and finds new-onset confusion, respiratory rate of
10/min, and pinpoint pupils. The patient received opioid analgesia 30 minutes ago. What is the
priority nursing action?
Answer: Stimulate the patient, assess oxygen saturation, and prepare to administer
naloxone while notifying the provider
Rationale: The triad of altered mental status, bradypnea, and miosis indicates
opioid-induced respiratory depression, a medical emergency; the nurse must act
immediately to protect airway and breathing rather than simply documenting or waiting to
reassess later.
12. Which of the following is a normal finding when assessing an older adult's skin turgor?
Answer: Slightly decreased elasticity with delayed but eventual return to baseline
Rationale: Aging skin normally loses collagen and elasticity, producing a slower tenting
recovery than in younger adults; this is an expected age-related change and should not
automatically be interpreted as dehydration without other supporting findings.
Page 3
