Fundamentals of Nursing Comprehensive Exam 4:
Clinical Judgment & Patient Care Review Questions with
Answers and Rationales
Question 1
A nurse enters a patient's room and finds the patient sitting on the floor. What should the nurse
do first?
A. Complete an incident report
B. Assess the patient for injuries
C. Notify the patient's family
D. Document the fall immediately
Answer: B. Assess the patient for injuries
Rationale:
The priority after a patient fall is assessment of the patient's condition and possible injuries.
Patient safety comes before documentation or notifications.
Option A is completed after immediate care is provided.
Option C is not the priority.
Option D should occur after assessment.
Question 2
A nurse receives report on four patients. Which patient should the nurse assess first?
A. Patient requesting a new blanket
B. Patient with oxygen saturation of 86%
C. Patient waiting for discharge instructions
D. Patient asking for assistance choosing food
Answer: B. Patient with oxygen saturation of 86%
Rationale:
A low oxygen saturation indicates possible respiratory compromise. Airway and breathing
problems require immediate attention.
,Question 3
A nurse is caring for a patient whose condition is worsening. Which action demonstrates clinical
judgment?
A. Recognizing changes and taking appropriate action
B. Waiting until the next shift to report changes
C. Ignoring abnormal findings
D. Following routine care only
Answer: A. Recognizing changes and taking appropriate action
Rationale:
Clinical judgment requires recognizing patient changes, interpreting findings, and responding
appropriately.
Question 4
A nurse is prioritizing patient care. Which patient should be seen first?
A. Patient with mild nausea
B. Patient requesting pain medication refill
C. Patient experiencing difficulty breathing
D. Patient asking about visiting hours
Answer: C. Patient experiencing difficulty breathing
Rationale:
Breathing problems threaten life and take priority according to ABC principles.
Question 5
A nurse delegates a task to nursing assistive personnel (NAP). Which task is appropriate?
,A. Assisting a stable patient with bathing
B. Assessing a patient's pain level
C. Teaching medication administration
D. Developing a nursing care plan
Answer: A. Assisting a stable patient with bathing
Rationale:
Basic care tasks for stable patients may be delegated. Assessment, teaching, and care planning
remain nursing responsibilities.
Question 6
A nurse notices a patient has become confused suddenly. What should the nurse do first?
A. Assess for possible causes of the change
B. Ignore the behavior
C. Tell the patient to calm down
D. Document without assessment
Answer: A. Assess for possible causes of the change
Rationale:
A sudden change in mental status may indicate a serious problem requiring assessment.
Question 7
A nurse is caring for a patient who reports chest discomfort. Which action is priority?
A. Assess the patient's condition immediately
B. Ask about meal preferences
C. Schedule discharge teaching
D. Leave the room to find paperwork
Answer: A. Assess the patient's condition immediately
Rationale:
, Chest discomfort may indicate a life-threatening condition and requires immediate assessment.
Question 8
A nurse is planning care for a patient. Which step occurs first in the nursing process?
A. Assessment
B. Planning
C. Implementation
D. Evaluation
Answer: A. Assessment
Rationale:
Assessment is the first step of the nursing process and provides information needed for planning
care.
Question 9
A nurse is evaluating whether a nursing intervention was successful. Which action is
appropriate?
A. Compare patient outcomes with expected goals
B. Ignore patient responses
C. Repeat the intervention without evaluation
D. Document only the intervention
Answer: A. Compare patient outcomes with expected goals
Rationale:
Evaluation determines whether care goals were achieved and whether changes are needed.
Question 10
Clinical Judgment & Patient Care Review Questions with
Answers and Rationales
Question 1
A nurse enters a patient's room and finds the patient sitting on the floor. What should the nurse
do first?
A. Complete an incident report
B. Assess the patient for injuries
C. Notify the patient's family
D. Document the fall immediately
Answer: B. Assess the patient for injuries
Rationale:
The priority after a patient fall is assessment of the patient's condition and possible injuries.
Patient safety comes before documentation or notifications.
Option A is completed after immediate care is provided.
Option C is not the priority.
Option D should occur after assessment.
Question 2
A nurse receives report on four patients. Which patient should the nurse assess first?
A. Patient requesting a new blanket
B. Patient with oxygen saturation of 86%
C. Patient waiting for discharge instructions
D. Patient asking for assistance choosing food
Answer: B. Patient with oxygen saturation of 86%
Rationale:
A low oxygen saturation indicates possible respiratory compromise. Airway and breathing
problems require immediate attention.
,Question 3
A nurse is caring for a patient whose condition is worsening. Which action demonstrates clinical
judgment?
A. Recognizing changes and taking appropriate action
B. Waiting until the next shift to report changes
C. Ignoring abnormal findings
D. Following routine care only
Answer: A. Recognizing changes and taking appropriate action
Rationale:
Clinical judgment requires recognizing patient changes, interpreting findings, and responding
appropriately.
Question 4
A nurse is prioritizing patient care. Which patient should be seen first?
A. Patient with mild nausea
B. Patient requesting pain medication refill
C. Patient experiencing difficulty breathing
D. Patient asking about visiting hours
Answer: C. Patient experiencing difficulty breathing
Rationale:
Breathing problems threaten life and take priority according to ABC principles.
Question 5
A nurse delegates a task to nursing assistive personnel (NAP). Which task is appropriate?
,A. Assisting a stable patient with bathing
B. Assessing a patient's pain level
C. Teaching medication administration
D. Developing a nursing care plan
Answer: A. Assisting a stable patient with bathing
Rationale:
Basic care tasks for stable patients may be delegated. Assessment, teaching, and care planning
remain nursing responsibilities.
Question 6
A nurse notices a patient has become confused suddenly. What should the nurse do first?
A. Assess for possible causes of the change
B. Ignore the behavior
C. Tell the patient to calm down
D. Document without assessment
Answer: A. Assess for possible causes of the change
Rationale:
A sudden change in mental status may indicate a serious problem requiring assessment.
Question 7
A nurse is caring for a patient who reports chest discomfort. Which action is priority?
A. Assess the patient's condition immediately
B. Ask about meal preferences
C. Schedule discharge teaching
D. Leave the room to find paperwork
Answer: A. Assess the patient's condition immediately
Rationale:
, Chest discomfort may indicate a life-threatening condition and requires immediate assessment.
Question 8
A nurse is planning care for a patient. Which step occurs first in the nursing process?
A. Assessment
B. Planning
C. Implementation
D. Evaluation
Answer: A. Assessment
Rationale:
Assessment is the first step of the nursing process and provides information needed for planning
care.
Question 9
A nurse is evaluating whether a nursing intervention was successful. Which action is
appropriate?
A. Compare patient outcomes with expected goals
B. Ignore patient responses
C. Repeat the intervention without evaluation
D. Document only the intervention
Answer: A. Compare patient outcomes with expected goals
Rationale:
Evaluation determines whether care goals were achieved and whether changes are needed.
Question 10
