YIELD PRACTICE QUESTIONS AND STUDY GUIDE
ACCURATE EXAM COMPLETE ACTUAL QUESTIONS AND
CORRECT VERIFIED ANSWERS WITH DETAILED
RATIONALES (RELIABLE ANSWERS) CURRENTLY
UPDATED VERSION 2026 EDITION |GUARANTEED PASS A+ |
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Question 1. A nurse collects data during the initial patient encounter.
Which activity represents the Assessment phase of the nursing
process?
A. Administering prescribed medications
B. Documenting a nursing diagnosis of impaired skin integrity
C. Obtaining vital signs and reviewing the patient's health history —
Correct Answer
D. Evaluating the patient's response to interventions
Rationale: Assessment involves systematic collection of subjective
and objective data. Administering medications is Implementation;
documenting a diagnosis is the Diagnosis phase; evaluating
responses is Evaluation.
,Question 2. A patient states, "I am having severe chest pain that
radiates to my left arm." This statement is classified as:
A. Objective data
B. Subjective data — Correct Answer
C. A medical diagnosis
D. An evaluation finding
Rationale: Subjective data includes symptoms, feelings, and
perceptions that only the patient can describe. Objective data is
observable and measurable; medical diagnosis identifies disease;
evaluation assesses outcomes.
Question 3. A nurse identifies that a patient is at risk for falls due to
unsteady gait. This is an example of:
A. A medical diagnosis
B. An actual nursing diagnosis
C. A risk nursing diagnosis — Correct Answer
D. A collaborative problem
Rationale: A risk nursing diagnosis identifies a vulnerability to
develop a negative health condition when no problem currently
exists. Medical diagnoses identify pathology; actual nursing
diagnoses describe existing problems; collaborative problems require
interdisciplinary management.
,Question 4. Using Maslow's hierarchy of needs, which patient need
should the nurse address first?
A. Need for social support after discharge
B. Need for adequate oxygenation and airway patency — Correct
Answer
C. Need for self-esteem following body image changes
D. Need for pain management
Rationale: Maslow prioritizes physiological needs first, with airway
and oxygenation being the highest priority. Social support, self-
esteem, and even pain management follow after life-sustaining needs
are met.
Question 5. A postoperative patient reports pain of 8/10, has BP
88/52, HR 128, and RR 28 with shallow respirations. Which action
takes priority using the ABC framework?
A. Administering the ordered analgesic
B. Assessing the surgical incision for infection
C. Initiating fluid resuscitation and calling the provider for
hypotension — Correct Answer
D. Encouraging the patient to use the incentive spirometer
, Rationale: The ABC framework and clinical judgment prioritize
circulation (shock from hypotension and tachycardia) over pain,
incision assessment, or respiratory interventions. This patient shows
signs of hemorrhagic shock requiring immediate intervention.
Question 6. In the NCSBN Clinical Judgment Measurement Model,
a nurse notices a patient's oxygen saturation has dropped from 96%
to 88%. This step is:
A. Analyze cues
B. Prioritize hypotheses
C. Recognize cues — Correct Answer
D. Generate solutions
Rationale: Recognizing cues involves identifying relevant and
significant data from assessments. Analyzing cues involves
interpreting data; prioritizing hypotheses ranks concerns; generating
solutions develops interventions.
Question 7. A nurse is assessing a client who is 48 hours post-op
following abdominal surgery. Which of the following findings should
the nurse report to the provider?
A. Blood pressure 102/66 mm Hg
B. Straw-colored urine from an indwelling urinary catheter