1
NUR 221 Test 1 Exam 2026/2027 | 200
Advanced Clinic Questions with Complete
Answers | Scored A+ | Detailed Rationales
Included
SECTION 1: ADVANCED ASSESSMENT AND CLINICAL DECISION-MAKING (Questions 1–30)
1. A nurse is caring for a client with a new onset of confusion. Which assessment should the
nurse perform FIRST?
A. Review the medication administration record
B. Assess the client's oxygen saturation and vital signs
C. Perform a focused neurological assessment
D. Ask the family about the client's baseline mental status
Correct Answer: B
Rationale: Using the ABCs framework, the nurse should first assess oxygenation and vital signs,
as hypoxia and hemodynamic instability are common reversible causes of acute confusion. This
takes priority over medication review, neurological assessment, and family history.
2. A nurse receives handoff report on four clients. Which client should the nurse assess FIRST?
A. A client with COPD who has an oxygen saturation of 88% on room air
B. A client with diabetes who has a blood glucose of 142 mg/dL
C. A client with a fractured femur reporting pain of 5/10
D. A client with heart failure who has 1+ pitting edema
Correct Answer: A
Rationale: Using ABC prioritization, hypoxia (SpO₂ 88%) is an immediate life threat requiring
assessment and intervention. The glucose (B) and pain (C) are second-level priorities;
dependent edema (D) can be assessed later.
,2
3. A nurse is using the SBAR communication tool. Which component includes the nurse's
assessment of the situation?
A. Situation
B. Background
C. Assessment
D. Recommendation
Correct Answer: C
Rationale: The SBAR tool stands for Situation, Background, Assessment, and Recommendation.
The Assessment component includes the nurse's clinical impression and analysis of the data.
4. A nurse is delegating tasks to an unlicensed assistive personnel (UAP). Which task is
appropriate to delegate?
A. Administering oral medications
B. Performing a sterile dressing change
C. Assisting a stable client with ambulation
D. Assessing a client's lung sounds
Correct Answer: C
Rationale: UAPs can assist with activities of daily living, including ambulation of stable clients.
Medication administration, sterile procedures, and assessments require RN or LPN scope of
practice.
5. A nurse is assessing a client with suspected fluid volume deficit. Which finding is most
indicative?
A. Bounding pulses
B. Crackles in the lungs
C. Decreased urine output
D. Weight gain
Correct Answer: C
Rationale: Decreased urine output is a key indicator of fluid volume deficit. Bounding pulses,
crackles, and weight gain indicate fluid overload.
,3
6. A nurse is performing a comprehensive health history. Which component includes the
client's perception of their health?
A. Past medical history
B. Review of systems
C. Health perception-health management pattern
D. Functional assessment
Correct Answer: C
Rationale: The health perception-health management pattern focuses on how the client
perceives their health and manages health-related activities.
7. A nurse is assessing a client for orthostatic hypotension. Which action is correct?
A. Measure blood pressure while supine, sitting, and standing
B. Measure blood pressure only while sitting
C. Measure blood pressure only while standing
D. Measure blood pressure only while supine
Correct Answer: A
Rationale: Orthostatic hypotension is assessed by measuring blood pressure in supine, sitting,
and standing positions. A drop of ≥20 mmHg systolic or ≥10 mmHg diastolic within 3 minutes of
standing is significant.
8. A nurse is prioritizing care for multiple clients. Which client should the nurse see FIRST?
A. A client requesting pain medication for a headache
B. A client with new-onset chest pain
C. A client needing discharge teaching
D. A client requesting assistance with ambulation
Correct Answer: B
Rationale: New-onset chest pain requires immediate assessment to rule out acute coronary
syndrome, a life-threatening condition. The other requests are important but less urgent.
9. A nurse is using critical thinking in clinical decision-making. Which action demonstrates
critical thinking?
, 4
A. Following the provider's orders without question
B. Questioning an order that appears unsafe
C. Relying on memory for medication calculations
D. Avoiding collaboration with the interdisciplinary team
Correct Answer: B
Rationale: Critical thinking requires the nurse to question orders that appear unsafe and
advocate for client safety.
10. A nurse is assessing a client's level of consciousness. Which finding indicates the highest
level of consciousness?
A. Responds to painful stimuli only
B. Alert and oriented to person, place, and time
C. Drowsy but easily aroused
D. Unresponsive to all stimuli
Correct Answer: B
Rationale: Alert and oriented to person, place, and time indicates the highest level of
consciousness. The other options indicate decreasing levels of consciousness.
11. A nurse is assessing a client with increased intracranial pressure. Which finding is a late
sign?
A. Headache
B. Vomiting
C. Papilledema
D. Cushing's triad (hypertension, bradycardia, irregular respirations)
Correct Answer: D
Rationale: Cushing's triad is a late sign of increased ICP indicating brainstem herniation and
requires immediate intervention.
12. A nurse is caring for a client with a new tracheostomy. Which assessment is most
important?
NUR 221 Test 1 Exam 2026/2027 | 200
Advanced Clinic Questions with Complete
Answers | Scored A+ | Detailed Rationales
Included
SECTION 1: ADVANCED ASSESSMENT AND CLINICAL DECISION-MAKING (Questions 1–30)
1. A nurse is caring for a client with a new onset of confusion. Which assessment should the
nurse perform FIRST?
A. Review the medication administration record
B. Assess the client's oxygen saturation and vital signs
C. Perform a focused neurological assessment
D. Ask the family about the client's baseline mental status
Correct Answer: B
Rationale: Using the ABCs framework, the nurse should first assess oxygenation and vital signs,
as hypoxia and hemodynamic instability are common reversible causes of acute confusion. This
takes priority over medication review, neurological assessment, and family history.
2. A nurse receives handoff report on four clients. Which client should the nurse assess FIRST?
A. A client with COPD who has an oxygen saturation of 88% on room air
B. A client with diabetes who has a blood glucose of 142 mg/dL
C. A client with a fractured femur reporting pain of 5/10
D. A client with heart failure who has 1+ pitting edema
Correct Answer: A
Rationale: Using ABC prioritization, hypoxia (SpO₂ 88%) is an immediate life threat requiring
assessment and intervention. The glucose (B) and pain (C) are second-level priorities;
dependent edema (D) can be assessed later.
,2
3. A nurse is using the SBAR communication tool. Which component includes the nurse's
assessment of the situation?
A. Situation
B. Background
C. Assessment
D. Recommendation
Correct Answer: C
Rationale: The SBAR tool stands for Situation, Background, Assessment, and Recommendation.
The Assessment component includes the nurse's clinical impression and analysis of the data.
4. A nurse is delegating tasks to an unlicensed assistive personnel (UAP). Which task is
appropriate to delegate?
A. Administering oral medications
B. Performing a sterile dressing change
C. Assisting a stable client with ambulation
D. Assessing a client's lung sounds
Correct Answer: C
Rationale: UAPs can assist with activities of daily living, including ambulation of stable clients.
Medication administration, sterile procedures, and assessments require RN or LPN scope of
practice.
5. A nurse is assessing a client with suspected fluid volume deficit. Which finding is most
indicative?
A. Bounding pulses
B. Crackles in the lungs
C. Decreased urine output
D. Weight gain
Correct Answer: C
Rationale: Decreased urine output is a key indicator of fluid volume deficit. Bounding pulses,
crackles, and weight gain indicate fluid overload.
,3
6. A nurse is performing a comprehensive health history. Which component includes the
client's perception of their health?
A. Past medical history
B. Review of systems
C. Health perception-health management pattern
D. Functional assessment
Correct Answer: C
Rationale: The health perception-health management pattern focuses on how the client
perceives their health and manages health-related activities.
7. A nurse is assessing a client for orthostatic hypotension. Which action is correct?
A. Measure blood pressure while supine, sitting, and standing
B. Measure blood pressure only while sitting
C. Measure blood pressure only while standing
D. Measure blood pressure only while supine
Correct Answer: A
Rationale: Orthostatic hypotension is assessed by measuring blood pressure in supine, sitting,
and standing positions. A drop of ≥20 mmHg systolic or ≥10 mmHg diastolic within 3 minutes of
standing is significant.
8. A nurse is prioritizing care for multiple clients. Which client should the nurse see FIRST?
A. A client requesting pain medication for a headache
B. A client with new-onset chest pain
C. A client needing discharge teaching
D. A client requesting assistance with ambulation
Correct Answer: B
Rationale: New-onset chest pain requires immediate assessment to rule out acute coronary
syndrome, a life-threatening condition. The other requests are important but less urgent.
9. A nurse is using critical thinking in clinical decision-making. Which action demonstrates
critical thinking?
, 4
A. Following the provider's orders without question
B. Questioning an order that appears unsafe
C. Relying on memory for medication calculations
D. Avoiding collaboration with the interdisciplinary team
Correct Answer: B
Rationale: Critical thinking requires the nurse to question orders that appear unsafe and
advocate for client safety.
10. A nurse is assessing a client's level of consciousness. Which finding indicates the highest
level of consciousness?
A. Responds to painful stimuli only
B. Alert and oriented to person, place, and time
C. Drowsy but easily aroused
D. Unresponsive to all stimuli
Correct Answer: B
Rationale: Alert and oriented to person, place, and time indicates the highest level of
consciousness. The other options indicate decreasing levels of consciousness.
11. A nurse is assessing a client with increased intracranial pressure. Which finding is a late
sign?
A. Headache
B. Vomiting
C. Papilledema
D. Cushing's triad (hypertension, bradycardia, irregular respirations)
Correct Answer: D
Rationale: Cushing's triad is a late sign of increased ICP indicating brainstem herniation and
requires immediate intervention.
12. A nurse is caring for a client with a new tracheostomy. Which assessment is most
important?
