NSG 100 EXAM 2 | NEWEST VERSION | UPDATED ACTUAL
QUESTIONS AND VERIFIED ANSWERS
• A patient comes to the emergency department complaining of nausea and
vomiting. What should the nurse ask the patient about first?
a. Family history of diabetes
b. Medications the patient is taking
c. Operations the patient has had in the past
d. Severity and duration of the nausea and vomiting -✓✓ANSWER: d. Severity and
duration of the nausea and vomiting
• An alert, oriented patient is admitted to the hospital with chest pain. From
whom should the nurse collect primary data on this patient?
a. Family member
b. Physician
c. Another nurse
d. Patient -✓✓ANSWER: d. Patient
• What is the primary purpose of the nursing diagnosis?
a. Resolving patient confusion
b. Communicating patient needs
c. Meeting accreditation requirements
d. Articulating the nursing scope of practice -✓✓ANSWER: b. Communicating
patient needs
,• On what premise is a nursing diagnosis identified for a patient?
a. First impressions
b. Nursing intuition
c. Clustered data
d. Medical diagnoses -✓✓ANSWER: c. Clustered data
• Which statement is an appropriately written short-term goal?
a. Patient will walk to the bathroom independently without falling within 2 days
after surgery.
b. Nurse will watch patient demonstrate proper insulin injection technique each
morning.
c. Patient's spouse will express satisfaction with patient's progress before
discharge.
d. Patient's incision will be well approximated each time it is assessed by the
nurse. -✓✓ANSWER: Patient will walk to the bathroom independently without
falling within 2 days after surgery.
• What should be the primary focus for nursing interventions?
a. Patient needs
b. Nurse concerns
c. Physician priorities
d. Patient's family requests -✓✓ANSWER: a. Patient needs
• Which nursing action is critical before delegating interventions to another
member of the health care team?
a. Locate all members of the health care team.
, b. Notify the physician of potential complications.
c. Know the scope of practice and competency of the other team member.
d. Call a meeting of the health care team to determine the needs of the patient. -
✓✓ANSWER: c. Know the scope of practice and competency of the other team
member.
• A patient reports feeling tired and complains of not sleeping at night. What
action should the nurse perform first?
a. Identify reasons the patient is unable to sleep.
b. Request medication to help the patient sleep.
c. Tell the patient that sleep will come with relaxation.
d. Notify the physician that the patient is restless and anxious. -✓✓ANSWER: a.
Identify reasons the patient is unable to sleep.
• What action should the nurse take regarding a patient's plan of care if the
patient appears to have met the short-term goal of urinating within 1 hour after
surgery?
a. Consult the surgeon to see if the clinical pathway is being followed.
b. Discontinue the plan of care, because the patient has met the established goal.
c. Monitor patient urine output to evaluate the need for the current plan of care.
d. Notify the patient that the goal has been attained and no further intervention is
needed. -✓✓ANSWER: c. Monitor patient urine output to evaluate the need for
the current plan of care.
• Which action by a patient marks the beginning of the physical assessment
process?
a. Redressing after a physical examination
QUESTIONS AND VERIFIED ANSWERS
• A patient comes to the emergency department complaining of nausea and
vomiting. What should the nurse ask the patient about first?
a. Family history of diabetes
b. Medications the patient is taking
c. Operations the patient has had in the past
d. Severity and duration of the nausea and vomiting -✓✓ANSWER: d. Severity and
duration of the nausea and vomiting
• An alert, oriented patient is admitted to the hospital with chest pain. From
whom should the nurse collect primary data on this patient?
a. Family member
b. Physician
c. Another nurse
d. Patient -✓✓ANSWER: d. Patient
• What is the primary purpose of the nursing diagnosis?
a. Resolving patient confusion
b. Communicating patient needs
c. Meeting accreditation requirements
d. Articulating the nursing scope of practice -✓✓ANSWER: b. Communicating
patient needs
,• On what premise is a nursing diagnosis identified for a patient?
a. First impressions
b. Nursing intuition
c. Clustered data
d. Medical diagnoses -✓✓ANSWER: c. Clustered data
• Which statement is an appropriately written short-term goal?
a. Patient will walk to the bathroom independently without falling within 2 days
after surgery.
b. Nurse will watch patient demonstrate proper insulin injection technique each
morning.
c. Patient's spouse will express satisfaction with patient's progress before
discharge.
d. Patient's incision will be well approximated each time it is assessed by the
nurse. -✓✓ANSWER: Patient will walk to the bathroom independently without
falling within 2 days after surgery.
• What should be the primary focus for nursing interventions?
a. Patient needs
b. Nurse concerns
c. Physician priorities
d. Patient's family requests -✓✓ANSWER: a. Patient needs
• Which nursing action is critical before delegating interventions to another
member of the health care team?
a. Locate all members of the health care team.
, b. Notify the physician of potential complications.
c. Know the scope of practice and competency of the other team member.
d. Call a meeting of the health care team to determine the needs of the patient. -
✓✓ANSWER: c. Know the scope of practice and competency of the other team
member.
• A patient reports feeling tired and complains of not sleeping at night. What
action should the nurse perform first?
a. Identify reasons the patient is unable to sleep.
b. Request medication to help the patient sleep.
c. Tell the patient that sleep will come with relaxation.
d. Notify the physician that the patient is restless and anxious. -✓✓ANSWER: a.
Identify reasons the patient is unable to sleep.
• What action should the nurse take regarding a patient's plan of care if the
patient appears to have met the short-term goal of urinating within 1 hour after
surgery?
a. Consult the surgeon to see if the clinical pathway is being followed.
b. Discontinue the plan of care, because the patient has met the established goal.
c. Monitor patient urine output to evaluate the need for the current plan of care.
d. Notify the patient that the goal has been attained and no further intervention is
needed. -✓✓ANSWER: c. Monitor patient urine output to evaluate the need for
the current plan of care.
• Which action by a patient marks the beginning of the physical assessment
process?
a. Redressing after a physical examination
