NRSG 100 Exam 1 V1 | NRSG 100 Fundamentals of
Nursing | Actual Q&A with Rationale (NRSG100
Exam 1) | Ivy Tech
1. A nurse is performing a physical assessment on a client. Which of the following findings
should the nurse document as objective data?
A. The client reports feeling nauseated.
B. The client’s skin is cool and clammy to the touch.
C. The client describes a burning sensation in the chest.
D. The client states that their pain is a 7 on a scale of 0 to 10.
Correct Answer: B
Explanation: Objective data are observable and measurable signs that can be seen, heard,
felt, or smelled by the nurse. In this case, skin temperature and texture are physical
findings that the nurse can verify through palpation. Subjective data, such as pain or
nausea, are based on the client’s self-report and cannot be independently measured.
2. Which phase of the nursing process involves the nurse prioritizing nursing diagnoses and
identifying client-centered goals?
A. Assessment
B. Diagnosis
C. Planning
,D. Implementation
Correct Answer: C
Explanation: The planning phase of the nursing process is where the nurse sets priorities
and establishes expected outcomes for the client. During this step, the nurse and client
work together to develop specific, measurable goals to address the nursing diagnoses. This
phase provides the framework for the interventions that will be carried out in the
implementation stage.
3. A nurse is measuring a client’s blood pressure and finds it to be 160/90 mmHg. How should
the nurse proceed to ensure accuracy?
A. Document the reading immediately in the chart.
B. Use a smaller cuff to verify the high reading.
C. Wait 1 to 2 minutes and re-measure the blood pressure in the same arm.
D. Assume the client is anxious and ignore the result.
Correct Answer: C
Explanation: When an abnormal blood pressure reading is obtained, it is essential to verify
the result to rule out measurement error. The nurse should allow the client to rest and re-
measure after a short interval to ensure the reading is consistent. Consistent high readings
must be reported to the healthcare provider for further evaluation.
, 4. Which ethical principle is the nurse upholding when they support a client’s decision to
refuse a life-saving blood transfusion due to religious beliefs?
A. Beneficence
B. Justice
C. Autonomy
D. Nonmaleficence
Correct Answer: C
Explanation: Autonomy refers to the right of a competent individual to make their own
decisions regarding their healthcare. The nurse’s role is to respect these choices, even if
they conflict with the nurse’s personal or professional opinions. By supporting the client’s
refusal of treatment, the nurse acknowledges the client’s self-determination and legal
rights.
5. A nurse is preparing to perform hand hygiene. According to the CDC, what is the minimum
duration for scrubbing hands with soap and water?
A. 10 seconds
B. 45 seconds
C. 20 seconds
D. 60 seconds
Correct Answer: C
Nursing | Actual Q&A with Rationale (NRSG100
Exam 1) | Ivy Tech
1. A nurse is performing a physical assessment on a client. Which of the following findings
should the nurse document as objective data?
A. The client reports feeling nauseated.
B. The client’s skin is cool and clammy to the touch.
C. The client describes a burning sensation in the chest.
D. The client states that their pain is a 7 on a scale of 0 to 10.
Correct Answer: B
Explanation: Objective data are observable and measurable signs that can be seen, heard,
felt, or smelled by the nurse. In this case, skin temperature and texture are physical
findings that the nurse can verify through palpation. Subjective data, such as pain or
nausea, are based on the client’s self-report and cannot be independently measured.
2. Which phase of the nursing process involves the nurse prioritizing nursing diagnoses and
identifying client-centered goals?
A. Assessment
B. Diagnosis
C. Planning
,D. Implementation
Correct Answer: C
Explanation: The planning phase of the nursing process is where the nurse sets priorities
and establishes expected outcomes for the client. During this step, the nurse and client
work together to develop specific, measurable goals to address the nursing diagnoses. This
phase provides the framework for the interventions that will be carried out in the
implementation stage.
3. A nurse is measuring a client’s blood pressure and finds it to be 160/90 mmHg. How should
the nurse proceed to ensure accuracy?
A. Document the reading immediately in the chart.
B. Use a smaller cuff to verify the high reading.
C. Wait 1 to 2 minutes and re-measure the blood pressure in the same arm.
D. Assume the client is anxious and ignore the result.
Correct Answer: C
Explanation: When an abnormal blood pressure reading is obtained, it is essential to verify
the result to rule out measurement error. The nurse should allow the client to rest and re-
measure after a short interval to ensure the reading is consistent. Consistent high readings
must be reported to the healthcare provider for further evaluation.
, 4. Which ethical principle is the nurse upholding when they support a client’s decision to
refuse a life-saving blood transfusion due to religious beliefs?
A. Beneficence
B. Justice
C. Autonomy
D. Nonmaleficence
Correct Answer: C
Explanation: Autonomy refers to the right of a competent individual to make their own
decisions regarding their healthcare. The nurse’s role is to respect these choices, even if
they conflict with the nurse’s personal or professional opinions. By supporting the client’s
refusal of treatment, the nurse acknowledges the client’s self-determination and legal
rights.
5. A nurse is preparing to perform hand hygiene. According to the CDC, what is the minimum
duration for scrubbing hands with soap and water?
A. 10 seconds
B. 45 seconds
C. 20 seconds
D. 60 seconds
Correct Answer: C
