,NSG 122 Exam 1 | Nursing Fundamental
Concepts | Herzing University | High-Yield 150
Questions & Answers Exam Prep + MCQs +
Rationales | 2026/2027
1. A nurse is collecting data from a client who reports abdominal pain. Which action represents
the assessment phase of the nursing process?
A. Administering prescribed pain medication
B. Setting a goal for pain relief within 1 hour
C. Measuring vital signs and asking the client to describe the pain
D. Re-evaluating the client's pain level 30 minutes after intervention
Correct Answer: C. Measuring vital signs and asking the client to describe the pain
Rationale: The assessment phase involves systematic data collection. Measuring vital signs and
obtaining the client's description of pain are assessment activities. Administering medication is
implementation, setting goals is planning, and re-evaluation is evaluation. The assessment
phase is the first step of the nursing process and involves collecting both subjective and
objective data.
2. During the planning phase, the nurse establishes a client goal. Which statement is an example
of a correctly written client goal?
,A. "The nurse will assist the client to ambulate."
B. "The client will ambulate 50 feet with a walker by the end of the shift."
C. "The client should walk more every day."
D. "The nurse will encourage fluid intake."
Correct Answer: B. "The client will ambulate 50 feet with a walker by the end of the shift."
Rationale: A correctly written goal must be client-centered, measurable, and time-limited.
Option B specifies the client, the behavior, the distance, the method, and the timeframe. Goals
should be client-focused, not nurse-focused.
3. A nurse is evaluating whether a client has met the goal to "void within 8 hours after catheter
removal." The client voided 200 mL 6 hours after catheter removal. What should the nurse
document?
A. Goal not met; client did not void
B. Goal met; client voided within the specified time frame
C. Goal partially met; the volume was insufficient
D. Goal cannot be evaluated
Correct Answer: B. Goal met; client voided within the specified time frame
Rationale: The goal was met because the client voided within the 8-hour timeframe. The goal
did not specify a minimum volume. The evaluative statement should document the outcome
and supporting data.
, 4. Which action demonstrates the use of clinical judgment?
A. Following a standard procedure without deviation
B. Recognizing that a client's blood pressure drop is significant and notifying the provider with a
recommendation
C. Documenting vital signs exactly as measured
D. Delegating all tasks to unlicensed assistive personnel
Correct Answer: B. Recognizing that a client's blood pressure drop is significant and notifying
the provider with a recommendation
Rationale: Clinical judgment involves analyzing data, recognizing significant changes, and taking
appropriate action. Recognizing a BP drop and communicating with the provider demonstrates
interpretation and decision-making.
5. The nurse has just received report on four clients. Which client should the nurse assess first?
A. A client with COPD and SpO₂ of 89% on 2L nasal cannula
B. A client post-appendectomy day 2 with temperature of 38.3°C (101°F)
C. A client with heart failure and 3+ pitting edema
D. A client with new-onset confusion and a bounding pulse
Correct Answer: D. A client with new-onset confusion and a bounding pulse
Concepts | Herzing University | High-Yield 150
Questions & Answers Exam Prep + MCQs +
Rationales | 2026/2027
1. A nurse is collecting data from a client who reports abdominal pain. Which action represents
the assessment phase of the nursing process?
A. Administering prescribed pain medication
B. Setting a goal for pain relief within 1 hour
C. Measuring vital signs and asking the client to describe the pain
D. Re-evaluating the client's pain level 30 minutes after intervention
Correct Answer: C. Measuring vital signs and asking the client to describe the pain
Rationale: The assessment phase involves systematic data collection. Measuring vital signs and
obtaining the client's description of pain are assessment activities. Administering medication is
implementation, setting goals is planning, and re-evaluation is evaluation. The assessment
phase is the first step of the nursing process and involves collecting both subjective and
objective data.
2. During the planning phase, the nurse establishes a client goal. Which statement is an example
of a correctly written client goal?
,A. "The nurse will assist the client to ambulate."
B. "The client will ambulate 50 feet with a walker by the end of the shift."
C. "The client should walk more every day."
D. "The nurse will encourage fluid intake."
Correct Answer: B. "The client will ambulate 50 feet with a walker by the end of the shift."
Rationale: A correctly written goal must be client-centered, measurable, and time-limited.
Option B specifies the client, the behavior, the distance, the method, and the timeframe. Goals
should be client-focused, not nurse-focused.
3. A nurse is evaluating whether a client has met the goal to "void within 8 hours after catheter
removal." The client voided 200 mL 6 hours after catheter removal. What should the nurse
document?
A. Goal not met; client did not void
B. Goal met; client voided within the specified time frame
C. Goal partially met; the volume was insufficient
D. Goal cannot be evaluated
Correct Answer: B. Goal met; client voided within the specified time frame
Rationale: The goal was met because the client voided within the 8-hour timeframe. The goal
did not specify a minimum volume. The evaluative statement should document the outcome
and supporting data.
, 4. Which action demonstrates the use of clinical judgment?
A. Following a standard procedure without deviation
B. Recognizing that a client's blood pressure drop is significant and notifying the provider with a
recommendation
C. Documenting vital signs exactly as measured
D. Delegating all tasks to unlicensed assistive personnel
Correct Answer: B. Recognizing that a client's blood pressure drop is significant and notifying
the provider with a recommendation
Rationale: Clinical judgment involves analyzing data, recognizing significant changes, and taking
appropriate action. Recognizing a BP drop and communicating with the provider demonstrates
interpretation and decision-making.
5. The nurse has just received report on four clients. Which client should the nurse assess first?
A. A client with COPD and SpO₂ of 89% on 2L nasal cannula
B. A client post-appendectomy day 2 with temperature of 38.3°C (101°F)
C. A client with heart failure and 3+ pitting edema
D. A client with new-onset confusion and a bounding pulse
Correct Answer: D. A client with new-onset confusion and a bounding pulse
