NSG 240 Fundamentals Exam 1 with correct answers plus rationales 2026/2027
version
1. The nurse is assessing a newly admitted client. Which action should the nurse perform
first?
A. Establish a nursing diagnosis
B. Collect assessment data
C. Develop a nursing care plan
D. Evaluate the client's response to treatment
Answer: B. Collect assessment data
Rationale: Assessment is the first step of the nursing process. The nurse must collect relevant
subjective and objective data before identifying problems or planning interventions.
2. Which statement best describes the purpose of the nursing process?
A. To replace the healthcare provider's treatment plan
B. To provide a systematic approach to individualized nursing care
C. To ensure that every client receives identical care
D. To eliminate the need for clinical judgment
Answer: B. To provide a systematic approach to individualized nursing care
Rationale: The nursing process provides a systematic framework for assessment, diagnosis,
planning, implementation, and evaluation of individualized care.
3. A client states, "I have severe pain in my abdomen." This information is classified as:
A. Objective data
B. Subjective data
C. Laboratory data
D. Secondary data
Answer: B. Subjective data
Rationale: Subjective data are symptoms or information reported by the client that cannot be
directly measured by the nurse.
,4. Which finding is an example of objective data?
A. "I feel dizzy."
B. "My pain is 8 out of 10."
C. Blood pressure of 150/90 mmHg
D. "I feel nauseated."
Answer: C. Blood pressure of 150/90 mmHg
Rationale: Objective data are observable or measurable findings obtained through physical
assessment, vital signs, laboratory tests, and other measurements.
5. Which nursing diagnosis is written correctly?
A. Pneumonia related to infection
B. Impaired physical mobility related to pain as evidenced by difficulty walking
C. Antibiotics related to infection
D. Fever related to pneumonia
Answer: B. Impaired physical mobility related to pain as evidenced by difficulty walking
Rationale: A nursing diagnosis identifies a client response or problem and may include related
factors and defining characteristics.
6. Which phase of the nursing process determines whether the client's goals have been
achieved?
A. Assessment
B. Diagnosis
C. Implementation
D. Evaluation
Answer: D. Evaluation
Rationale: During evaluation, the nurse determines whether expected outcomes were achieved
and whether the plan of care needs modification.
7. A nurse identifies that a client has an increased risk for falls. Which intervention is most
appropriate?
,A. Keep the bed in the lowest position
B. Keep all four side rails raised at all times
C. Encourage the client to walk without assistance
D. Place frequently used items out of reach
Answer: A. Keep the bed in the lowest position
Rationale: A low bed reduces injury risk if the client attempts to get out of bed and is an
important fall-prevention measure.
8. Which client should the nurse assess first?
A. A client requesting a blanket
B. A client with sudden difficulty breathing
C. A client reporting mild chronic pain
D. A client waiting for discharge instructions
Answer: B. A client with sudden difficulty breathing
Rationale: Airway and breathing problems are immediate threats to life and take priority over
nonurgent needs.
9. Which action demonstrates appropriate use of standard precautions?
A. Performing hand hygiene before and after client contact
B. Wearing an N95 respirator for every client
C. Using sterile gloves for every procedure
D. Placing every client in isolation
Answer: A. Performing hand hygiene before and after client contact
Rationale: Standard precautions apply to all clients and include hand hygiene and appropriate
use of personal protective equipment based on anticipated exposure.
10. When should the nurse perform hand hygiene?
A. Only when hands appear visibly dirty
B. Before and after client contact
C. Only after removing gloves
D. Only at the beginning of the shift
, Answer: B. Before and after client contact
Rationale: Hand hygiene should be performed before and after client contact and at other
appropriate times to prevent transmission of microorganisms.
11. A nurse removes gloves after providing wound care. What should the nurse do next?
A. Perform hand hygiene
B. Put on another pair of gloves immediately
C. Touch the computer
D. Leave the room without cleaning the hands
Answer: A. Perform hand hygiene
Rationale: Gloves do not replace hand hygiene. Hands should be cleaned after glove removal
because contamination may occur during removal.
12. Which microorganism requires contact precautions when the infection is transmitted
primarily through direct or indirect contact?
A. A pathogen spread through contaminated surfaces
B. A pathogen spread only through airborne particles
C. A pathogen transmitted exclusively through mosquito bites
D. A pathogen transmitted only through food
Answer: A. A pathogen spread through contaminated surfaces
Rationale: Contact precautions are used when pathogens are transmitted through direct contact
with the client or indirect contact with contaminated objects or surfaces.
13. Which personal protective equipment is generally appropriate when caring for a client
on droplet precautions?
A. Surgical mask according to exposure risk
B. Shoe covers only
C. Sterile gown only
D. No PPE
Answer: A. Surgical mask according to exposure risk
version
1. The nurse is assessing a newly admitted client. Which action should the nurse perform
first?
A. Establish a nursing diagnosis
B. Collect assessment data
C. Develop a nursing care plan
D. Evaluate the client's response to treatment
Answer: B. Collect assessment data
Rationale: Assessment is the first step of the nursing process. The nurse must collect relevant
subjective and objective data before identifying problems or planning interventions.
2. Which statement best describes the purpose of the nursing process?
A. To replace the healthcare provider's treatment plan
B. To provide a systematic approach to individualized nursing care
C. To ensure that every client receives identical care
D. To eliminate the need for clinical judgment
Answer: B. To provide a systematic approach to individualized nursing care
Rationale: The nursing process provides a systematic framework for assessment, diagnosis,
planning, implementation, and evaluation of individualized care.
3. A client states, "I have severe pain in my abdomen." This information is classified as:
A. Objective data
B. Subjective data
C. Laboratory data
D. Secondary data
Answer: B. Subjective data
Rationale: Subjective data are symptoms or information reported by the client that cannot be
directly measured by the nurse.
,4. Which finding is an example of objective data?
A. "I feel dizzy."
B. "My pain is 8 out of 10."
C. Blood pressure of 150/90 mmHg
D. "I feel nauseated."
Answer: C. Blood pressure of 150/90 mmHg
Rationale: Objective data are observable or measurable findings obtained through physical
assessment, vital signs, laboratory tests, and other measurements.
5. Which nursing diagnosis is written correctly?
A. Pneumonia related to infection
B. Impaired physical mobility related to pain as evidenced by difficulty walking
C. Antibiotics related to infection
D. Fever related to pneumonia
Answer: B. Impaired physical mobility related to pain as evidenced by difficulty walking
Rationale: A nursing diagnosis identifies a client response or problem and may include related
factors and defining characteristics.
6. Which phase of the nursing process determines whether the client's goals have been
achieved?
A. Assessment
B. Diagnosis
C. Implementation
D. Evaluation
Answer: D. Evaluation
Rationale: During evaluation, the nurse determines whether expected outcomes were achieved
and whether the plan of care needs modification.
7. A nurse identifies that a client has an increased risk for falls. Which intervention is most
appropriate?
,A. Keep the bed in the lowest position
B. Keep all four side rails raised at all times
C. Encourage the client to walk without assistance
D. Place frequently used items out of reach
Answer: A. Keep the bed in the lowest position
Rationale: A low bed reduces injury risk if the client attempts to get out of bed and is an
important fall-prevention measure.
8. Which client should the nurse assess first?
A. A client requesting a blanket
B. A client with sudden difficulty breathing
C. A client reporting mild chronic pain
D. A client waiting for discharge instructions
Answer: B. A client with sudden difficulty breathing
Rationale: Airway and breathing problems are immediate threats to life and take priority over
nonurgent needs.
9. Which action demonstrates appropriate use of standard precautions?
A. Performing hand hygiene before and after client contact
B. Wearing an N95 respirator for every client
C. Using sterile gloves for every procedure
D. Placing every client in isolation
Answer: A. Performing hand hygiene before and after client contact
Rationale: Standard precautions apply to all clients and include hand hygiene and appropriate
use of personal protective equipment based on anticipated exposure.
10. When should the nurse perform hand hygiene?
A. Only when hands appear visibly dirty
B. Before and after client contact
C. Only after removing gloves
D. Only at the beginning of the shift
, Answer: B. Before and after client contact
Rationale: Hand hygiene should be performed before and after client contact and at other
appropriate times to prevent transmission of microorganisms.
11. A nurse removes gloves after providing wound care. What should the nurse do next?
A. Perform hand hygiene
B. Put on another pair of gloves immediately
C. Touch the computer
D. Leave the room without cleaning the hands
Answer: A. Perform hand hygiene
Rationale: Gloves do not replace hand hygiene. Hands should be cleaned after glove removal
because contamination may occur during removal.
12. Which microorganism requires contact precautions when the infection is transmitted
primarily through direct or indirect contact?
A. A pathogen spread through contaminated surfaces
B. A pathogen spread only through airborne particles
C. A pathogen transmitted exclusively through mosquito bites
D. A pathogen transmitted only through food
Answer: A. A pathogen spread through contaminated surfaces
Rationale: Contact precautions are used when pathogens are transmitted through direct contact
with the client or indirect contact with contaminated objects or surfaces.
13. Which personal protective equipment is generally appropriate when caring for a client
on droplet precautions?
A. Surgical mask according to exposure risk
B. Shoe covers only
C. Sterile gown only
D. No PPE
Answer: A. Surgical mask according to exposure risk
