NUR 231
EXAM 1
(Adult Nursing II)
Actual Questions w/Correct Answers
(NCLEX (NGN) style Clinical Scenarios)
Illinois State University
What you Will Get:
• 65 verified questions
• MCQ, SATA, NGN, Dosage Calculation
• Correct Answers, and Rationales
• NURS 231 Exam 1 Study Guide & Review
• Ideal for exam preparation and concept reinforcement.
,Table of Contents
NURS 231 EXAM 1 ............................................................................................... 2
NURS 231 Exam 1 Study Guide & Review .............................................................. 28
NURS 231 EXAM 1
1. A nurse is caring for a group of patients on a medical-surgical unit. Which patient
situation requires the nurse's IMMEDIATE attention according to priority framework?
A. A patient requesting a sleeping medication
B. A patient with a blood pressure of 148/92 mmHg
C. A patient with an oxygen saturation of 88% on room air
D. A patient complaining of incisional pain rated 4/10
Correct Answer: C
Expert Rationale:
Using the ABCSINP priority framework (Airway, Breathing, Circulation, Safety, Infection, Nutrition,
Psychosocial), airway and breathing take precedence over all other needs. An oxygen saturation of
88% indicates significant hypoxemia and compromised breathing, requiring immediate intervention.
Pain control, sleep medication, and mildly elevated blood pressure are important but do not
supersede physiological stability.
2. A community health nurse is implementing a program to reduce the incidence of type 2
diabetes through exercise and nutrition education. This level of health care is BEST
described as:
A. Preventative
B. Primary
C. Secondary
D. Tertiary
Correct Answer: B
Expert Rationale:
Primary care emphasizes health promotion and disease prevention. While preventative care
includes specific actions like immunizations and sunscreen use, primary care focuses on broader
health promotion strategies such as exercise programs, nutrition education, and disease control
,initiatives. Secondary care involves diagnosis and treatment of acute illness, and tertiary care
involves specialized, highly technical interventions.
3. A nurse is preparing a patient for discharge after abdominal surgery. Which action
demonstrates the QSEN competency of Patient-Centered Care?
A. Ensuring the patient receives the standard discharge protocol
B. Collaborating with the physical therapist on mobility goals
C. Involving the patient and family in establishing discharge goals and home care needs
D. Documenting all discharge instructions in the electronic health record
Correct Answer: C
Expert Rationale:
The QSEN competency of Patient-Centered Care requires recognizing the patient as the source of
control and full partner in providing compassionate and coordinated care. Involving the patient and
family in goal-setting exemplifies this principle. While collaboration (B) reflects Teamwork and
Collaboration, and documentation (D) reflects Informatics, only option C places the patient at the
center of the care planning process.
4. A 68-year-old patient with chronic obstructive pulmonary disease (COPD) is being
transferred from the intensive care unit to the medical-surgical floor. To ensure continuity of
care and patient safety, the nurse should use which communication tool?
A. SOAP note
B. ISBARQ
C. NANDA-I diagnosis
D. Care map
Correct Answer: B
Expert Rationale:
ISBARQ (Introduction, Situation, Background, Assessment, Recommendation, Questions) is the
standardized communication tool designed specifically for handoff reports and transitions of care.
Report and transitions of care are recognized as dangerous times for clients due to the high risk for
miscommunication and errors. SOAP notes are for documentation, NANDA-I provides diagnostic
language, and care maps outline expected outcomes.
5. A nurse is preparing an ISBARQ handoff report. Which information belongs in the
standardized handoff? (Select all that apply.)
A. Introduction
B. Situation
C. Background
D. Assessment
E. Recommendation or nursing care priorities
F. Questions and read-back when orders are received
G. The nurse's personal opinion about the patient's family
, Correct Answers: A, B, C, D, E, F
Expert Rationale:
ISBARQ structures communication during high-risk transitions of care. It includes Introduction,
Situation, Background, Assessment, Recommendation, and Questions. Read-back is important
when orders are received. Personal opinions unrelated to clinical care do not belong in a structured
handoff.
6. Which patient population is MOST vulnerable to health care disparities and requires
targeted nursing interventions?
A. A 45-year-old accountant with health insurance
B. A 28-year-old pregnant woman with gestational diabetes
C. A 62-year-old homeless veteran with chronic mental illness and substance use disorder
D. A 35-year-old teacher with a broken ankle
Correct Answer: C
Expert Rationale:
Vulnerable populations include individuals with disabilities, chronic conditions, mental illness,
substance abuse disorders, poverty, and those experiencing homelessness. The homeless veteran
with comorbid mental illness and substance use disorder faces multiple barriers to care including
difficulty communicating needs, lack of resources, and stigma. Nurses must work with
interdisciplinary teams to help such patients access care and engage in care planning WITH the
patient rather than simply providing care TO the patient.
7. A nurse is reviewing the National Patient Safety Goals established by The Joint
Commission. Which action is a REQUIRED element for identifying clients correctly?
A. Verifying the patient's name and date of birth at the bedside
B. Checking the patient's insurance card against the chart
C. Asking the patient to state their Social Security number
D. Confirming the patient's address with the admission paperwork
Correct Answer: A
Expert Rationale:
The Joint Commission's National Patient Safety Goals require using at least two patient identifiers
when providing care, treatment, and services. Acceptable identifiers include the patient's name,
date of birth, assigned identification number, or other person-specific identifiers. Verifying name and
date of birth directly with the patient at the bedside is the standard of practice. Relying on
paperwork, insurance cards, or Social Security numbers is not the recommended practice for
bedside identification.
8. Dosage Calculation - Fill in the Blank. A patient is prescribed heparin 25,000 units in 500
mL of D5W to infuse at 1,200 units per hour. How many mL per hour should the IV pump be
programmed?
ANSWER: __________ mL/hr
EXAM 1
(Adult Nursing II)
Actual Questions w/Correct Answers
(NCLEX (NGN) style Clinical Scenarios)
Illinois State University
What you Will Get:
• 65 verified questions
• MCQ, SATA, NGN, Dosage Calculation
• Correct Answers, and Rationales
• NURS 231 Exam 1 Study Guide & Review
• Ideal for exam preparation and concept reinforcement.
,Table of Contents
NURS 231 EXAM 1 ............................................................................................... 2
NURS 231 Exam 1 Study Guide & Review .............................................................. 28
NURS 231 EXAM 1
1. A nurse is caring for a group of patients on a medical-surgical unit. Which patient
situation requires the nurse's IMMEDIATE attention according to priority framework?
A. A patient requesting a sleeping medication
B. A patient with a blood pressure of 148/92 mmHg
C. A patient with an oxygen saturation of 88% on room air
D. A patient complaining of incisional pain rated 4/10
Correct Answer: C
Expert Rationale:
Using the ABCSINP priority framework (Airway, Breathing, Circulation, Safety, Infection, Nutrition,
Psychosocial), airway and breathing take precedence over all other needs. An oxygen saturation of
88% indicates significant hypoxemia and compromised breathing, requiring immediate intervention.
Pain control, sleep medication, and mildly elevated blood pressure are important but do not
supersede physiological stability.
2. A community health nurse is implementing a program to reduce the incidence of type 2
diabetes through exercise and nutrition education. This level of health care is BEST
described as:
A. Preventative
B. Primary
C. Secondary
D. Tertiary
Correct Answer: B
Expert Rationale:
Primary care emphasizes health promotion and disease prevention. While preventative care
includes specific actions like immunizations and sunscreen use, primary care focuses on broader
health promotion strategies such as exercise programs, nutrition education, and disease control
,initiatives. Secondary care involves diagnosis and treatment of acute illness, and tertiary care
involves specialized, highly technical interventions.
3. A nurse is preparing a patient for discharge after abdominal surgery. Which action
demonstrates the QSEN competency of Patient-Centered Care?
A. Ensuring the patient receives the standard discharge protocol
B. Collaborating with the physical therapist on mobility goals
C. Involving the patient and family in establishing discharge goals and home care needs
D. Documenting all discharge instructions in the electronic health record
Correct Answer: C
Expert Rationale:
The QSEN competency of Patient-Centered Care requires recognizing the patient as the source of
control and full partner in providing compassionate and coordinated care. Involving the patient and
family in goal-setting exemplifies this principle. While collaboration (B) reflects Teamwork and
Collaboration, and documentation (D) reflects Informatics, only option C places the patient at the
center of the care planning process.
4. A 68-year-old patient with chronic obstructive pulmonary disease (COPD) is being
transferred from the intensive care unit to the medical-surgical floor. To ensure continuity of
care and patient safety, the nurse should use which communication tool?
A. SOAP note
B. ISBARQ
C. NANDA-I diagnosis
D. Care map
Correct Answer: B
Expert Rationale:
ISBARQ (Introduction, Situation, Background, Assessment, Recommendation, Questions) is the
standardized communication tool designed specifically for handoff reports and transitions of care.
Report and transitions of care are recognized as dangerous times for clients due to the high risk for
miscommunication and errors. SOAP notes are for documentation, NANDA-I provides diagnostic
language, and care maps outline expected outcomes.
5. A nurse is preparing an ISBARQ handoff report. Which information belongs in the
standardized handoff? (Select all that apply.)
A. Introduction
B. Situation
C. Background
D. Assessment
E. Recommendation or nursing care priorities
F. Questions and read-back when orders are received
G. The nurse's personal opinion about the patient's family
, Correct Answers: A, B, C, D, E, F
Expert Rationale:
ISBARQ structures communication during high-risk transitions of care. It includes Introduction,
Situation, Background, Assessment, Recommendation, and Questions. Read-back is important
when orders are received. Personal opinions unrelated to clinical care do not belong in a structured
handoff.
6. Which patient population is MOST vulnerable to health care disparities and requires
targeted nursing interventions?
A. A 45-year-old accountant with health insurance
B. A 28-year-old pregnant woman with gestational diabetes
C. A 62-year-old homeless veteran with chronic mental illness and substance use disorder
D. A 35-year-old teacher with a broken ankle
Correct Answer: C
Expert Rationale:
Vulnerable populations include individuals with disabilities, chronic conditions, mental illness,
substance abuse disorders, poverty, and those experiencing homelessness. The homeless veteran
with comorbid mental illness and substance use disorder faces multiple barriers to care including
difficulty communicating needs, lack of resources, and stigma. Nurses must work with
interdisciplinary teams to help such patients access care and engage in care planning WITH the
patient rather than simply providing care TO the patient.
7. A nurse is reviewing the National Patient Safety Goals established by The Joint
Commission. Which action is a REQUIRED element for identifying clients correctly?
A. Verifying the patient's name and date of birth at the bedside
B. Checking the patient's insurance card against the chart
C. Asking the patient to state their Social Security number
D. Confirming the patient's address with the admission paperwork
Correct Answer: A
Expert Rationale:
The Joint Commission's National Patient Safety Goals require using at least two patient identifiers
when providing care, treatment, and services. Acceptable identifiers include the patient's name,
date of birth, assigned identification number, or other person-specific identifiers. Verifying name and
date of birth directly with the patient at the bedside is the standard of practice. Relying on
paperwork, insurance cards, or Social Security numbers is not the recommended practice for
bedside identification.
8. Dosage Calculation - Fill in the Blank. A patient is prescribed heparin 25,000 units in 500
mL of D5W to infuse at 1,200 units per hour. How many mL per hour should the IV pump be
programmed?
ANSWER: __________ mL/hr
