Nursing 120 Quiz 2 Tutoring Assessment West Coast
University Actual Exam 2026/2027 – Complete Exam-Style
Questions with Detailed Rationales | 100% Verified | Pass
Guaranteed – A+ Graded
Section A: Nursing Process & Clinical Judgment (Questions 1–8)
Q1: Which sequence represents the five steps of the nursing process in the correct
order?
A. Assessment, Planning, Diagnosis, Implementation, Evaluation
B. Assessment, Diagnosis, Planning, Implementation, Evaluation [CORRECT]
C. Diagnosis, Assessment, Planning, Evaluation, Implementation
D. Assessment, Diagnosis, Implementation, Planning, Evaluation
Correct Answer: B
Rationale: The nursing process follows ADPIE — Assessment, Diagnosis, Planning,
Implementation, Evaluation. The other options place diagnosis or planning out of
sequence.
Q2: A postoperative patient presses the call light and states, "My chest feels tight and
I'm having trouble breathing." According to the nursing process, what is the nurse's first
action?
A. Administer the PRN pain medication
B. Document the complaint in the chart
C. Complete a focused assessment of the patient's condition [CORRECT]
D. Notify the charge nurse to call the provider
Correct Answer: C
Rationale: Assessment is always the first step; data must be gathered before
intervening, notifying, or documenting fully. Acting or reporting on incomplete data risks
inaccurate decisions.
Q3: Which are the four phases of Tanner's Clinical Judgment Model?
A. Assessment, Diagnosis, Outcome, Response
B. Noticing, Interpreting, Responding, Reflecting [CORRECT]
C. Collecting, Clustering, Caring, Closing
D. Observe, Orient, Decide, Act
, Correct Answer: B
Rationale: Tanner's model consists of Noticing, Interpreting, Responding, and Reflecting.
The other options mix nursing process steps or unrelated frameworks.
Q4: A nurse entering a room sees a patient with labored breathing, use of accessory
muscles, and SpO2 of 88% on room air. In Tanner's model, the nurse's immediate
recognition that "something is wrong" represents which phase?
A. Noticing [CORRECT]
B. Interpreting
C. Responding
D. Reflecting
Correct Answer: A
Rationale: Noticing is the initial perception of significant cues and deviations from
expected findings. Interpreting analyzes meaning, Responding takes action, and
Reflecting reviews the outcome afterward.
Q5: A patient admitted with pneumonia reports feeling short of breath, has RR 24, SpO2
91% on room air, and fine crackles at both bases. Which is the correctly written nursing
diagnosis for this patient?
A. Ineffective breathing pattern related to pulmonary inflammation as evidenced by RR
24 and SpO2 91% [CORRECT]
B. Pneumonia related to bacterial infection
C. Impaired gas exchange as evidenced by pneumonia
D. Pneumonia as evidenced by crackles and dyspnea
Correct Answer: A
Rationale: A nursing diagnosis uses NANDA-I language, a treatable etiology, and
supporting data; pneumonia is a medical diagnosis nurses cannot treat independently.
Options B, C, and D incorporate the medical diagnosis or invert the PES format.
Q6: For the diagnosis "Acute pain related to surgical incision as evidenced by pain 7/10,"
which outcome should the nurse include in the planning step?
A. "Patient will have less pain."
B. "Patient will understand pain management."
C. "Patient will not complain of pain during the shift."
D. "Patient will report pain 3/10 or less within 30 minutes of receiving analgesia."
[CORRECT]
Correct Answer: D
Rationale: The goal is specific, measurable, attainable, relevant, and time-bound
(SMART). The other options are vague, unmeasurable, or equate absence of complaints
with absence of pain.
University Actual Exam 2026/2027 – Complete Exam-Style
Questions with Detailed Rationales | 100% Verified | Pass
Guaranteed – A+ Graded
Section A: Nursing Process & Clinical Judgment (Questions 1–8)
Q1: Which sequence represents the five steps of the nursing process in the correct
order?
A. Assessment, Planning, Diagnosis, Implementation, Evaluation
B. Assessment, Diagnosis, Planning, Implementation, Evaluation [CORRECT]
C. Diagnosis, Assessment, Planning, Evaluation, Implementation
D. Assessment, Diagnosis, Implementation, Planning, Evaluation
Correct Answer: B
Rationale: The nursing process follows ADPIE — Assessment, Diagnosis, Planning,
Implementation, Evaluation. The other options place diagnosis or planning out of
sequence.
Q2: A postoperative patient presses the call light and states, "My chest feels tight and
I'm having trouble breathing." According to the nursing process, what is the nurse's first
action?
A. Administer the PRN pain medication
B. Document the complaint in the chart
C. Complete a focused assessment of the patient's condition [CORRECT]
D. Notify the charge nurse to call the provider
Correct Answer: C
Rationale: Assessment is always the first step; data must be gathered before
intervening, notifying, or documenting fully. Acting or reporting on incomplete data risks
inaccurate decisions.
Q3: Which are the four phases of Tanner's Clinical Judgment Model?
A. Assessment, Diagnosis, Outcome, Response
B. Noticing, Interpreting, Responding, Reflecting [CORRECT]
C. Collecting, Clustering, Caring, Closing
D. Observe, Orient, Decide, Act
, Correct Answer: B
Rationale: Tanner's model consists of Noticing, Interpreting, Responding, and Reflecting.
The other options mix nursing process steps or unrelated frameworks.
Q4: A nurse entering a room sees a patient with labored breathing, use of accessory
muscles, and SpO2 of 88% on room air. In Tanner's model, the nurse's immediate
recognition that "something is wrong" represents which phase?
A. Noticing [CORRECT]
B. Interpreting
C. Responding
D. Reflecting
Correct Answer: A
Rationale: Noticing is the initial perception of significant cues and deviations from
expected findings. Interpreting analyzes meaning, Responding takes action, and
Reflecting reviews the outcome afterward.
Q5: A patient admitted with pneumonia reports feeling short of breath, has RR 24, SpO2
91% on room air, and fine crackles at both bases. Which is the correctly written nursing
diagnosis for this patient?
A. Ineffective breathing pattern related to pulmonary inflammation as evidenced by RR
24 and SpO2 91% [CORRECT]
B. Pneumonia related to bacterial infection
C. Impaired gas exchange as evidenced by pneumonia
D. Pneumonia as evidenced by crackles and dyspnea
Correct Answer: A
Rationale: A nursing diagnosis uses NANDA-I language, a treatable etiology, and
supporting data; pneumonia is a medical diagnosis nurses cannot treat independently.
Options B, C, and D incorporate the medical diagnosis or invert the PES format.
Q6: For the diagnosis "Acute pain related to surgical incision as evidenced by pain 7/10,"
which outcome should the nurse include in the planning step?
A. "Patient will have less pain."
B. "Patient will understand pain management."
C. "Patient will not complain of pain during the shift."
D. "Patient will report pain 3/10 or less within 30 minutes of receiving analgesia."
[CORRECT]
Correct Answer: D
Rationale: The goal is specific, measurable, attainable, relevant, and time-bound
(SMART). The other options are vague, unmeasurable, or equate absence of complaints
with absence of pain.
