NURS_101: Potter and Perry Fundamentals of Nursing
(11th Ed.) Comprehensive NCLEX-Style Exam Bank
Course Code: NURS_101
Course Name: Fundamentals of Nursing
Topic: Complete Nursing Process & Core Concepts
Academic Year: 2026/2027
Question 1
A nurse is conducting an admission interview for a client with a history of heart
failure. Which action by the nurse represents the collection of primary subjective
data?
A. Recording the client's statement: "I feel short of breath when climbing one
flight of stairs."
B. Reviewing the client's recent echocardiogram report from the electronic health
record.
C. Measuring the client's oxygen saturation level using a pulse oximeter.
D. Noting a family member's comment that the client has been sleeping in a chair.
CORRECT ANSWER: A
RATIONALE: Primary subjective data consist of information provided
directly by the client that reflects their personal perceptions or feelings. Option B
and C represent objective data because they are measurable, observable facts.
Option D represents secondary subjective data because it comes from a third-party
source rather than the patient directly.
,Question 2
A nurse is assessing an older adult client who has been immobile following hip
surgery. The nurse notes a localized, intact area of non-blanchable erythema over
the client's sacrum. How should the nurse accurately classify this finding according
to current guidelines?
A. Stage 1 Pressure Injury
B. Stage 2 Pressure Injury
C. Deep Tissue Pressure Injury
D. Unstageable Pressure Injury
CORRECT ANSWER: A
RATIONALE: A Stage 1 Pressure Injury is characterized by intact skin with a
localized area of non-blanchable erythema. Option B involves partial-thickness
skin loss with exposed dermis. Option C presents as persistent, non-blanchable
deep red, maroon, or purple discoloration. Option D features full-thickness skin
loss in which the extent of tissue damage within the ulcer cannot be confirmed
because it is obscured by slough or eschar.
Question 3
The nurse is reviewing a medication order that reads: "Digoxin 0.25 mg PO daily."
Before administering the medication, the nurse checks the patient's apical pulse
and finds it is 54 beats per minute. What is the priority nursing action?
A. Administer the medication as prescribed and recheck the pulse in 1 hour.
B. Withhold the medication and immediately document the pulse rate and
notification of the healthcare provider.
C. Administer half of the prescribed dose and note it in the medication
administration record.
D. Obtain a baseline blood pressure reading before deciding whether to give the
drug.
CORRECT ANSWER: B
RATIONALE: Digoxin is a cardiac glycoside that slows down the heart rate.
Standard safety guidelines dictate that digoxin must be withheld if the adult apical
pulse drops below 60 beats per minute, as administering it could trigger severe
,bradycardia or toxicity. Modifying the dose autonomously is a violation of the
nurse's legal scope of practice.
Question 4
A nurse is formulating a nursing diagnosis for a client experiencing clinical
manifestations of severe dehydration. Which statement is formatted correctly as a
three-part NANDA-I diagnostic statement?
A. Fluid Volume Deficit related to decreased oral intake as evidenced by poor skin
turgor and dark urine.
B. Deficient Fluid Volume related to active fluid volume loss as evidenced by
dry mucous membranes, concentrated urine, and tachycardia.
C. Dehydration related to gastroenteritis as evidenced by fluid loss and nausea.
D. Altered Nutrition related to inability to absorb fluids and loss of total body
weight.
CORRECT ANSWER: B
RATIONALE: A proper three-part diagnosis uses the PES format: Problem
(NANDA-I label), Etiology (related to factor), and Signs/Symptoms (as evidenced
by). Option B accurately follows this format using approved terms. Option A uses
"Fluid Volume Deficit" instead of the approved NANDA-I term "Deficient Fluid
Volume." Option C incorporates a medical diagnosis ("gastroenteritis"), which is
contraindicated in nursing diagnostic statements.
Question 5
During the planning phase of the nursing process, the nurse writes a patient-
centered outcome. Which option reflects a correctly formatted SMART outcome
goal?
A. The nurse will turn the patient every 2 hours to prevent skin breakdown.
B. The patient will understand how to use an incentive spirometer before the end of
the shift.
C. The patient will ambulate 30 feet down the hallway with assistance by day 2
of hospitalization.
D. The patient's pain level will be well-managed throughout the post-operative
period.
, CORRECT ANSWER: C
RATIONALE: A SMART goal must be Specific, Measurable, Attainable,
Realistic, and Time-bound. Option C fulfills all criteria by outlining a specific
distance, a clear method of measurement, and a strict timeline. Option A focuses
on the nurse's actions rather than the patient's behavior. Option B contains an
unmeasurable verb ("understand"). Option D lacks a clear metric for what
constitutes "well-managed" pain.
Question 6
A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen
therapy via a simple face mask. The nurse checks the arterial blood gas (ABG)
results and notes: pH 7.32, PaCO2 52 mmHg, and HCO3 24 mEq/L. How should
the nurse interpret this acid-base imbalance?
A. Uncompensated Metabolic Acidosis
B. Uncompensated Respiratory Acidosis
C. Partially Compensated Respiratory Alkalosis
D. Fully Compensated Metabolic Alkalosis
CORRECT ANSWER: B
RATIONALE: The pH is below 7.35, indicating acidosis. The PaCO2 is
elevated above 45 mmHg, matching the acidotic state, which establishes a
respiratory origin. Because the HCO3 is within the normal reference range (22–26
mEq/L), the metabolic system has not yet begun to compensate for the retained
carbon dioxide. This points directly to uncompensated respiratory acidosis.
Question 7
A nurse is preparing to perform a sterile dressing change for a central venous
access catheter. Which action constitutes a critical breach of sterile technique?
A. Opening the innermost flap of the sterile kit wrapper away from the nurse's
body.
B. Maintaining a 1-inch (2.5 cm) non-sterile border around the edges of the sterile
field drape.
C. Placing a bottle of sterile saline solution cap-side down on a clean bedside
table.
(11th Ed.) Comprehensive NCLEX-Style Exam Bank
Course Code: NURS_101
Course Name: Fundamentals of Nursing
Topic: Complete Nursing Process & Core Concepts
Academic Year: 2026/2027
Question 1
A nurse is conducting an admission interview for a client with a history of heart
failure. Which action by the nurse represents the collection of primary subjective
data?
A. Recording the client's statement: "I feel short of breath when climbing one
flight of stairs."
B. Reviewing the client's recent echocardiogram report from the electronic health
record.
C. Measuring the client's oxygen saturation level using a pulse oximeter.
D. Noting a family member's comment that the client has been sleeping in a chair.
CORRECT ANSWER: A
RATIONALE: Primary subjective data consist of information provided
directly by the client that reflects their personal perceptions or feelings. Option B
and C represent objective data because they are measurable, observable facts.
Option D represents secondary subjective data because it comes from a third-party
source rather than the patient directly.
,Question 2
A nurse is assessing an older adult client who has been immobile following hip
surgery. The nurse notes a localized, intact area of non-blanchable erythema over
the client's sacrum. How should the nurse accurately classify this finding according
to current guidelines?
A. Stage 1 Pressure Injury
B. Stage 2 Pressure Injury
C. Deep Tissue Pressure Injury
D. Unstageable Pressure Injury
CORRECT ANSWER: A
RATIONALE: A Stage 1 Pressure Injury is characterized by intact skin with a
localized area of non-blanchable erythema. Option B involves partial-thickness
skin loss with exposed dermis. Option C presents as persistent, non-blanchable
deep red, maroon, or purple discoloration. Option D features full-thickness skin
loss in which the extent of tissue damage within the ulcer cannot be confirmed
because it is obscured by slough or eschar.
Question 3
The nurse is reviewing a medication order that reads: "Digoxin 0.25 mg PO daily."
Before administering the medication, the nurse checks the patient's apical pulse
and finds it is 54 beats per minute. What is the priority nursing action?
A. Administer the medication as prescribed and recheck the pulse in 1 hour.
B. Withhold the medication and immediately document the pulse rate and
notification of the healthcare provider.
C. Administer half of the prescribed dose and note it in the medication
administration record.
D. Obtain a baseline blood pressure reading before deciding whether to give the
drug.
CORRECT ANSWER: B
RATIONALE: Digoxin is a cardiac glycoside that slows down the heart rate.
Standard safety guidelines dictate that digoxin must be withheld if the adult apical
pulse drops below 60 beats per minute, as administering it could trigger severe
,bradycardia or toxicity. Modifying the dose autonomously is a violation of the
nurse's legal scope of practice.
Question 4
A nurse is formulating a nursing diagnosis for a client experiencing clinical
manifestations of severe dehydration. Which statement is formatted correctly as a
three-part NANDA-I diagnostic statement?
A. Fluid Volume Deficit related to decreased oral intake as evidenced by poor skin
turgor and dark urine.
B. Deficient Fluid Volume related to active fluid volume loss as evidenced by
dry mucous membranes, concentrated urine, and tachycardia.
C. Dehydration related to gastroenteritis as evidenced by fluid loss and nausea.
D. Altered Nutrition related to inability to absorb fluids and loss of total body
weight.
CORRECT ANSWER: B
RATIONALE: A proper three-part diagnosis uses the PES format: Problem
(NANDA-I label), Etiology (related to factor), and Signs/Symptoms (as evidenced
by). Option B accurately follows this format using approved terms. Option A uses
"Fluid Volume Deficit" instead of the approved NANDA-I term "Deficient Fluid
Volume." Option C incorporates a medical diagnosis ("gastroenteritis"), which is
contraindicated in nursing diagnostic statements.
Question 5
During the planning phase of the nursing process, the nurse writes a patient-
centered outcome. Which option reflects a correctly formatted SMART outcome
goal?
A. The nurse will turn the patient every 2 hours to prevent skin breakdown.
B. The patient will understand how to use an incentive spirometer before the end of
the shift.
C. The patient will ambulate 30 feet down the hallway with assistance by day 2
of hospitalization.
D. The patient's pain level will be well-managed throughout the post-operative
period.
, CORRECT ANSWER: C
RATIONALE: A SMART goal must be Specific, Measurable, Attainable,
Realistic, and Time-bound. Option C fulfills all criteria by outlining a specific
distance, a clear method of measurement, and a strict timeline. Option A focuses
on the nurse's actions rather than the patient's behavior. Option B contains an
unmeasurable verb ("understand"). Option D lacks a clear metric for what
constitutes "well-managed" pain.
Question 6
A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen
therapy via a simple face mask. The nurse checks the arterial blood gas (ABG)
results and notes: pH 7.32, PaCO2 52 mmHg, and HCO3 24 mEq/L. How should
the nurse interpret this acid-base imbalance?
A. Uncompensated Metabolic Acidosis
B. Uncompensated Respiratory Acidosis
C. Partially Compensated Respiratory Alkalosis
D. Fully Compensated Metabolic Alkalosis
CORRECT ANSWER: B
RATIONALE: The pH is below 7.35, indicating acidosis. The PaCO2 is
elevated above 45 mmHg, matching the acidotic state, which establishes a
respiratory origin. Because the HCO3 is within the normal reference range (22–26
mEq/L), the metabolic system has not yet begun to compensate for the retained
carbon dioxide. This points directly to uncompensated respiratory acidosis.
Question 7
A nurse is preparing to perform a sterile dressing change for a central venous
access catheter. Which action constitutes a critical breach of sterile technique?
A. Opening the innermost flap of the sterile kit wrapper away from the nurse's
body.
B. Maintaining a 1-inch (2.5 cm) non-sterile border around the edges of the sterile
field drape.
C. Placing a bottle of sterile saline solution cap-side down on a clean bedside
table.
