Page 1 of 78
NUR 210 EXAM WITH VERIFIED ANSWERS DETAILED
RATIONALES GRADED A+
Section 1: Nursing Process & Critical Thinking (Questions 1-25)
1. A nurse is caring for a patient who reports new onset of chest pain. Which action should
the nurse take first in the nursing process?
A. Administer nitroglycerin as ordered.
B. Assess the patient's pain characteristics and vital signs.
C. Document the patient's complaint in the chart.
D. Notify the healthcare provider immediately.
Rationale: The first step of the nursing process is assessment. The nurse must gather data about
the pain (location, quality, intensity, duration) and vital signs before implementing any
interventions.
2. A nurse is developing a care plan for a patient with impaired mobility. Which of the
following is an example of a correctly written patient-centered goal?
A. "The nurse will turn the patient every two hours."
B. "The patient will walk to the bathroom without assistance by discharge."
C. "The patient will not develop a pressure ulcer."
D. "The nurse will apply sequential compression devices."
Rationale: A patient-centered goal is specific, measurable, achievable, relevant, and time-bound
(SMART). "The patient will walk to the bathroom without assistance by discharge" is patient-
centered and measurable.
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3. During the evaluation phase of the nursing process, the nurse determines that a patient's
goal of "maintaining a clear airway" was not met. What is the nurse's priority action?
A. Document the goal as unmet and move on.
B. Reassess the patient and revise the care plan.
C. Notify the healthcare provider that the goal failed.
D. Blame the previous shift for inadequate care.
Rationale: If a goal is not met, the nurse must reassess the patient, identify barriers to goal
achievement, and revise the care plan accordingly. This is the evaluation phase of the nursing
process.
4. A nurse is using clinical judgment to prioritize care for multiple patients. Which patient
should the nurse assess first?
A. A patient requesting pain medication for a headache.
B. A patient with a new onset of shortness of breath and oxygen saturation of 88%.
C. A patient who needs assistance with ambulation to the bathroom.
D. A patient who is due for a scheduled blood pressure check.
Rationale: Using the ABC (Airway, Breathing, Circulation) priority framework, the patient with
new shortness of breath and low oxygen saturation is the highest priority and should be
assessed first.
5. A nurse is collecting subjective data from a patient. Which of the following is an example of
subjective data?
A. Blood pressure of 140/90 mm Hg.
B. Heart rate of 88 beats per minute.
C. Patient reports feeling "nauseous and dizzy."
D. Temperature of 101.2°F.
Rationale: Subjective data is information that the patient reports, such as feelings, perceptions,
and symptoms. "Nauseous and dizzy" are symptoms the patient is experiencing.
6. A nurse is reviewing a patient's medical record and notes a nursing diagnosis of "Acute Pain
related to surgical incision." Which component of the nursing diagnosis is "surgical incision"?
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A. The problem
B. The etiology (related to)
C. The defining characteristics
D. The outcome
Rationale: In a nursing diagnosis, the "related to" (etiology) component identifies the
underlying cause or contributing factors of the problem. "Surgical incision" is the cause of the
acute pain.
7. A nurse is implementing a nursing intervention for a patient with impaired gas exchange.
Which action demonstrates the implementation phase?
A. Auscultating the patient's lung sounds.
B. Positioning the patient in a high-Fowler's position.
C. Identifying that the patient has decreased breath sounds.
D. Evaluating the patient's oxygen saturation.
Rationale: Implementation is the "doing" phase of the nursing process. Positioning the patient
to improve breathing is an active intervention.
8. A nurse is evaluating the effectiveness of a patient's pain management plan. Which finding
indicates that the plan is effective?
A. The patient reports pain at a level of 8/10.
B. The patient is grimacing and guarding the abdomen.
C. The patient reports pain at a level of 2/10 and is able to ambulate.
D. The patient refuses to take pain medication.
Rationale: An effective pain management plan results in reduced pain and improved function. A
pain level of 2/10 and the ability to ambulate indicate that the plan is working.
9. A nurse is using the SBAR communication tool to report a patient's condition to the
healthcare provider. What does the "A" in SBAR stand for?
A. Action
B. Assessment
C. Allergies
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D. Admitting diagnosis
Rationale: SBAR stands for Situation, Background, Assessment, and Recommendation. The "A"
stands for Assessment, which is the nurse's clinical impression of the patient's condition.
10. A nurse is caring for a patient who is scheduled for surgery. Which of the following is a
priority nursing assessment before surgery?
A. Assessing the patient's financial status.
B. Verifying the patient's allergy history and NPO status.
C. Asking the patient about their living arrangements.
D. Assessing the patient's educational level.
Rationale: Verifying allergies and NPO (nothing by mouth) status is critical for patient safety
before surgery to prevent allergic reactions and aspiration during anesthesia.
11. A nurse is documenting a patient's care. Which of the following is an example of objective
data?
A. The patient states, "I feel sad today."
B. The patient reports a headache.
C. The patient's skin is pale and cool to the touch.
D. The patient complains of nausea.
Rationale: Objective data is measurable and observable. "Skin is pale and cool to the touch" is
an objective finding that the nurse can see and feel.
12. A nurse is developing a care plan for a patient at risk for falls. Which intervention should
the nurse include?
A. Keep the bed in the highest position.
B. Keep the call light within reach and instruct the patient to call for assistance.
C. Leave the side rails down at all times.
D. Place the patient in a room far from the nurses' station.
Rationale: Keeping the call light within reach and instructing the patient to call for assistance is
a key fall prevention intervention. The bed should be in the lowest position, and side rails
should be used appropriately.
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NUR 210 EXAM WITH VERIFIED ANSWERS DETAILED
RATIONALES GRADED A+
Section 1: Nursing Process & Critical Thinking (Questions 1-25)
1. A nurse is caring for a patient who reports new onset of chest pain. Which action should
the nurse take first in the nursing process?
A. Administer nitroglycerin as ordered.
B. Assess the patient's pain characteristics and vital signs.
C. Document the patient's complaint in the chart.
D. Notify the healthcare provider immediately.
Rationale: The first step of the nursing process is assessment. The nurse must gather data about
the pain (location, quality, intensity, duration) and vital signs before implementing any
interventions.
2. A nurse is developing a care plan for a patient with impaired mobility. Which of the
following is an example of a correctly written patient-centered goal?
A. "The nurse will turn the patient every two hours."
B. "The patient will walk to the bathroom without assistance by discharge."
C. "The patient will not develop a pressure ulcer."
D. "The nurse will apply sequential compression devices."
Rationale: A patient-centered goal is specific, measurable, achievable, relevant, and time-bound
(SMART). "The patient will walk to the bathroom without assistance by discharge" is patient-
centered and measurable.
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,Page 2 of 78
3. During the evaluation phase of the nursing process, the nurse determines that a patient's
goal of "maintaining a clear airway" was not met. What is the nurse's priority action?
A. Document the goal as unmet and move on.
B. Reassess the patient and revise the care plan.
C. Notify the healthcare provider that the goal failed.
D. Blame the previous shift for inadequate care.
Rationale: If a goal is not met, the nurse must reassess the patient, identify barriers to goal
achievement, and revise the care plan accordingly. This is the evaluation phase of the nursing
process.
4. A nurse is using clinical judgment to prioritize care for multiple patients. Which patient
should the nurse assess first?
A. A patient requesting pain medication for a headache.
B. A patient with a new onset of shortness of breath and oxygen saturation of 88%.
C. A patient who needs assistance with ambulation to the bathroom.
D. A patient who is due for a scheduled blood pressure check.
Rationale: Using the ABC (Airway, Breathing, Circulation) priority framework, the patient with
new shortness of breath and low oxygen saturation is the highest priority and should be
assessed first.
5. A nurse is collecting subjective data from a patient. Which of the following is an example of
subjective data?
A. Blood pressure of 140/90 mm Hg.
B. Heart rate of 88 beats per minute.
C. Patient reports feeling "nauseous and dizzy."
D. Temperature of 101.2°F.
Rationale: Subjective data is information that the patient reports, such as feelings, perceptions,
and symptoms. "Nauseous and dizzy" are symptoms the patient is experiencing.
6. A nurse is reviewing a patient's medical record and notes a nursing diagnosis of "Acute Pain
related to surgical incision." Which component of the nursing diagnosis is "surgical incision"?
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A. The problem
B. The etiology (related to)
C. The defining characteristics
D. The outcome
Rationale: In a nursing diagnosis, the "related to" (etiology) component identifies the
underlying cause or contributing factors of the problem. "Surgical incision" is the cause of the
acute pain.
7. A nurse is implementing a nursing intervention for a patient with impaired gas exchange.
Which action demonstrates the implementation phase?
A. Auscultating the patient's lung sounds.
B. Positioning the patient in a high-Fowler's position.
C. Identifying that the patient has decreased breath sounds.
D. Evaluating the patient's oxygen saturation.
Rationale: Implementation is the "doing" phase of the nursing process. Positioning the patient
to improve breathing is an active intervention.
8. A nurse is evaluating the effectiveness of a patient's pain management plan. Which finding
indicates that the plan is effective?
A. The patient reports pain at a level of 8/10.
B. The patient is grimacing and guarding the abdomen.
C. The patient reports pain at a level of 2/10 and is able to ambulate.
D. The patient refuses to take pain medication.
Rationale: An effective pain management plan results in reduced pain and improved function. A
pain level of 2/10 and the ability to ambulate indicate that the plan is working.
9. A nurse is using the SBAR communication tool to report a patient's condition to the
healthcare provider. What does the "A" in SBAR stand for?
A. Action
B. Assessment
C. Allergies
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D. Admitting diagnosis
Rationale: SBAR stands for Situation, Background, Assessment, and Recommendation. The "A"
stands for Assessment, which is the nurse's clinical impression of the patient's condition.
10. A nurse is caring for a patient who is scheduled for surgery. Which of the following is a
priority nursing assessment before surgery?
A. Assessing the patient's financial status.
B. Verifying the patient's allergy history and NPO status.
C. Asking the patient about their living arrangements.
D. Assessing the patient's educational level.
Rationale: Verifying allergies and NPO (nothing by mouth) status is critical for patient safety
before surgery to prevent allergic reactions and aspiration during anesthesia.
11. A nurse is documenting a patient's care. Which of the following is an example of objective
data?
A. The patient states, "I feel sad today."
B. The patient reports a headache.
C. The patient's skin is pale and cool to the touch.
D. The patient complains of nausea.
Rationale: Objective data is measurable and observable. "Skin is pale and cool to the touch" is
an objective finding that the nurse can see and feel.
12. A nurse is developing a care plan for a patient at risk for falls. Which intervention should
the nurse include?
A. Keep the bed in the highest position.
B. Keep the call light within reach and instruct the patient to call for assistance.
C. Leave the side rails down at all times.
D. Place the patient in a room far from the nurses' station.
Rationale: Keeping the call light within reach and instructing the patient to call for assistance is
a key fall prevention intervention. The bed should be in the lowest position, and side rails
should be used appropriately.
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