1
NUR 100 Exam 2 – Foundations of Nursing
(2026 Latest Edition)
Q1: A nurse is reviewing the care plan for a patient admitted with impaired skin
integrity. Which nursing diagnosis statement is written correctly using the PES
format?
A. Impaired skin integrity related to immobility as evidenced by a Stage 2
pressure injury on the coccyx [CORRECT]
B. Impaired skin integrity
C. Risk for impaired skin integrity related to immobility
D. Impaired skin integrity related to pressure injury on the coccyx
Correct Answer: A
Rationale: The PES (Problem, Etiology, Signs/Symptoms) format requires a
diagnostic label, the related factor (etiology), and defining characteristics
(evidence). Option A includes all three required components, while the others are
missing essential elements of a properly formatted nursing diagnosis.
Q2: During the evaluation phase of the nursing process, which action
demonstrates that the nurse is determining whether patient outcomes have been
met?
A. Collecting vital signs every 4 hours
B. Documenting a decrease in wound size from 4 cm to 2 cm after 5 days of
treatment [CORRECT]
C. Establishing a goal for the patient to ambulate 100 feet by discharge
D. Consulting physical therapy for gait training
Correct Answer: B
Rationale: Evaluation involves comparing actual patient outcomes against
expected outcomes to determine goal achievement. Measuring and documenting
wound improvement directly assesses whether the planned interventions
produced the desired outcome, which is the core function of the evaluation
phase.
Q3: Which statement best describes the difference between a medical diagnosis
and a nursing diagnosis?
, 2
A. A medical diagnosis identifies disease pathology, while a nursing diagnosis
identifies patient responses to actual or potential health problems [CORRECT]
B. A medical diagnosis remains constant throughout hospitalization, while a
nursing diagnosis changes every shift
C. A medical diagnosis requires physician approval, while a nursing diagnosis
requires only nursing judgment
D. A medical diagnosis focuses on prevention, while a nursing diagnosis focuses
on cure
Correct Answer: A
Rationale: Medical diagnoses identify disease states or pathological conditions,
whereas nursing diagnoses describe human responses to health conditions or
life processes that nurses can independently treat. This distinction forms the
foundation of nursing's unique scope of practice and autonomous decision-
making.
Q4: A nurse is developing a care plan for a patient at risk for falls. Which goal
statement follows SMART criteria?
A. The patient will not fall during the hospital stay
B. The patient will use the call light before getting out of bed by the end of the
shift, as demonstrated on 3 consecutive occasions [CORRECT]
C. The patient will be careful when ambulating
D. The nurse will keep the bed in the lowest position at all times
Correct Answer: B
Rationale: SMART goals are Specific, Measurable, Achievable, Relevant, and
Time-bound. Option B specifies the exact behavior (call light use), measurement
method (3 consecutive demonstrations), and timeframe (end of shift), making it
evaluable and patient-centered.
Q5: Select all that apply. Which actions demonstrate critical thinking in nursing
practice? (Select all that apply.)
A. Following the unit's standardized postoperative protocol without modification
B. Recognizing that a postoperative patient's tachycardia and restlessness may
indicate hemorrhage despite stable blood pressure [CORRECT]
, 3
C. Clustering assessment data to identify that a patient's fever, elevated WBC,
and purulent wound drainage indicate infection [CORRECT]
D. Questioning a physician's order for a medication that exceeds the safe dose
range [CORRECT]
E. Applying the same pain management approach to all patients with similar
diagnoses
Correct Answers: B, C, D
Rationale: Critical thinking involves analysis, synthesis, evaluation of
information, and willingness to question assumptions or orders when patient
safety is concerned. Options B, C, and D demonstrate pattern recognition, data
clustering, and advocacy—hallmarks of clinical reasoning. Following protocols
rigidly (A) or applying one-size-fits-all approaches (E) reflect rote task completion
rather than critical thinking.
Q6: A nurse is creating a concept map for a patient with diabetes mellitus,
peripheral neuropathy, and impaired wound healing. Which relationship should
the nurse identify as the primary link between the diagnoses?
A. Diabetes mellitus causes peripheral neuropathy, which increases risk for
impaired wound healing due to decreased sensation and circulation [CORRECT]
B. Impaired wound healing causes diabetes mellitus
C. Peripheral neuropathy is unrelated to impaired wound healing
D. Diabetes mellitus and peripheral neuropathy are independent medical
diagnoses with no nursing relationship
Correct Answer: A
Rationale: Concept mapping requires identifying meaningful relationships among
patient problems. Diabetes causes microvascular and neurological changes that
lead to reduced sensation and impaired perfusion, which directly increases
wound healing risk. Understanding these pathophysiological connections
enables holistic, prioritized nursing care.
Q7: According to The Joint Commission's National Patient Safety Goals, which
action is required when administering medications?
A. Verify patient identity using room number and birth date
B. Verify patient identity using two patient identifiers, such as name and date of
birth, before administration [CORRECT]
NUR 100 Exam 2 – Foundations of Nursing
(2026 Latest Edition)
Q1: A nurse is reviewing the care plan for a patient admitted with impaired skin
integrity. Which nursing diagnosis statement is written correctly using the PES
format?
A. Impaired skin integrity related to immobility as evidenced by a Stage 2
pressure injury on the coccyx [CORRECT]
B. Impaired skin integrity
C. Risk for impaired skin integrity related to immobility
D. Impaired skin integrity related to pressure injury on the coccyx
Correct Answer: A
Rationale: The PES (Problem, Etiology, Signs/Symptoms) format requires a
diagnostic label, the related factor (etiology), and defining characteristics
(evidence). Option A includes all three required components, while the others are
missing essential elements of a properly formatted nursing diagnosis.
Q2: During the evaluation phase of the nursing process, which action
demonstrates that the nurse is determining whether patient outcomes have been
met?
A. Collecting vital signs every 4 hours
B. Documenting a decrease in wound size from 4 cm to 2 cm after 5 days of
treatment [CORRECT]
C. Establishing a goal for the patient to ambulate 100 feet by discharge
D. Consulting physical therapy for gait training
Correct Answer: B
Rationale: Evaluation involves comparing actual patient outcomes against
expected outcomes to determine goal achievement. Measuring and documenting
wound improvement directly assesses whether the planned interventions
produced the desired outcome, which is the core function of the evaluation
phase.
Q3: Which statement best describes the difference between a medical diagnosis
and a nursing diagnosis?
, 2
A. A medical diagnosis identifies disease pathology, while a nursing diagnosis
identifies patient responses to actual or potential health problems [CORRECT]
B. A medical diagnosis remains constant throughout hospitalization, while a
nursing diagnosis changes every shift
C. A medical diagnosis requires physician approval, while a nursing diagnosis
requires only nursing judgment
D. A medical diagnosis focuses on prevention, while a nursing diagnosis focuses
on cure
Correct Answer: A
Rationale: Medical diagnoses identify disease states or pathological conditions,
whereas nursing diagnoses describe human responses to health conditions or
life processes that nurses can independently treat. This distinction forms the
foundation of nursing's unique scope of practice and autonomous decision-
making.
Q4: A nurse is developing a care plan for a patient at risk for falls. Which goal
statement follows SMART criteria?
A. The patient will not fall during the hospital stay
B. The patient will use the call light before getting out of bed by the end of the
shift, as demonstrated on 3 consecutive occasions [CORRECT]
C. The patient will be careful when ambulating
D. The nurse will keep the bed in the lowest position at all times
Correct Answer: B
Rationale: SMART goals are Specific, Measurable, Achievable, Relevant, and
Time-bound. Option B specifies the exact behavior (call light use), measurement
method (3 consecutive demonstrations), and timeframe (end of shift), making it
evaluable and patient-centered.
Q5: Select all that apply. Which actions demonstrate critical thinking in nursing
practice? (Select all that apply.)
A. Following the unit's standardized postoperative protocol without modification
B. Recognizing that a postoperative patient's tachycardia and restlessness may
indicate hemorrhage despite stable blood pressure [CORRECT]
, 3
C. Clustering assessment data to identify that a patient's fever, elevated WBC,
and purulent wound drainage indicate infection [CORRECT]
D. Questioning a physician's order for a medication that exceeds the safe dose
range [CORRECT]
E. Applying the same pain management approach to all patients with similar
diagnoses
Correct Answers: B, C, D
Rationale: Critical thinking involves analysis, synthesis, evaluation of
information, and willingness to question assumptions or orders when patient
safety is concerned. Options B, C, and D demonstrate pattern recognition, data
clustering, and advocacy—hallmarks of clinical reasoning. Following protocols
rigidly (A) or applying one-size-fits-all approaches (E) reflect rote task completion
rather than critical thinking.
Q6: A nurse is creating a concept map for a patient with diabetes mellitus,
peripheral neuropathy, and impaired wound healing. Which relationship should
the nurse identify as the primary link between the diagnoses?
A. Diabetes mellitus causes peripheral neuropathy, which increases risk for
impaired wound healing due to decreased sensation and circulation [CORRECT]
B. Impaired wound healing causes diabetes mellitus
C. Peripheral neuropathy is unrelated to impaired wound healing
D. Diabetes mellitus and peripheral neuropathy are independent medical
diagnoses with no nursing relationship
Correct Answer: A
Rationale: Concept mapping requires identifying meaningful relationships among
patient problems. Diabetes causes microvascular and neurological changes that
lead to reduced sensation and impaired perfusion, which directly increases
wound healing risk. Understanding these pathophysiological connections
enables holistic, prioritized nursing care.
Q7: According to The Joint Commission's National Patient Safety Goals, which
action is required when administering medications?
A. Verify patient identity using room number and birth date
B. Verify patient identity using two patient identifiers, such as name and date of
birth, before administration [CORRECT]
