Nightingale College BSN 206 Exam 1 (pdf) | 2026/2027 | Foundations
Q&A | Nursing
1. A nurse is reviewing the nursing process with a student. Which statement
by the student indicates an understanding of the "Assessment" phase?
A) "Assessment involves setting measurable goals for the patient's recovery."
B) "Assessment is the systematic collection of subjective and objective data."
C) "Assessment is the final step where we see if the interventions worked."
D) "Assessment is the process of delegating tasks to unlicensed personnel."
Correct Answer: "Assessment is the systematic collection of subjective and
objective data."
Rationale: The assessment phase is the first step of the nursing process and
focuses on data collection. It requires the nurse to gather both subjective
reports from the patient and objective findings from physical examinations.
This information serves as the foundation for the entire care plan and
subsequent nursing diagnoses.
2. According to Maslow's Hierarchy of Needs, which patient should the nurse
prioritize first?
A) A patient who expresses feelings of loneliness and isolation
B) A patient experiencing difficulty breathing and low oxygen saturation
C) A patient who is concerned about their safety in a new environment
D) A patient who is seeking information about self-care after discharge
Correct Answer: A patient experiencing difficulty breathing and low oxygen
saturation
Rationale: Physiological needs, such as oxygenation and circulation, are the
most basic and critical according to Maslow's hierarchy. Without meeting
,these survival needs, higher-level needs like safety or self-esteem cannot be
addressed. Respiratory distress represents a life-threatening physiological
priority that must be resolved immediately.
3. A nurse is caring for a patient who refuses a scheduled blood transfusion
for religious reasons. Which ethical principle is the nurse upholding by
supporting this decision?
A) Justice
B) Beneficence
C) Non-maleficence
D) Autonomy
Correct Answer: Autonomy
Rationale: Autonomy refers to the right of the patient to make their own
decisions regarding their healthcare. The nurse's role is to ensure the patient
is informed but to respect their ultimate choice, even if it conflicts with
medical advice. Upholding autonomy is a fundamental aspect of professional
nursing ethics and patient-centered care.
4. The nurse is using the SBAR tool to communicate with a physician. What
does the "R" in SBAR stand for?
A) Recommendation
B) Response
C) Review
D) Requirement
Correct Answer: Recommendation
,Rationale: SBAR stands for Situation, Background, Assessment, and
Recommendation. The Recommendation phase is where the nurse suggests
a specific action or asks what the provider wants to be done. This structured
communication tool improves patient safety by ensuring that all critical
information is conveyed clearly and concisely.
5. Which of the following patients would require follow-up based on
respiratory rate?
A) An adolescent with a respiratory rate of 16 breaths per minute
B) A child with a respiratory rate of 20 breaths per minute
C) A newborn with a respiratory rate of 40 breaths per minute
D) An adult with a respiratory rate of 10 breaths per minute
Correct Answer: An adult with a respiratory rate of 10 breaths per minute
Rationale: An adult with a respiratory rate of 10 breaths per minute is
bradypneic and would require follow-up. Normal adult respiratory rate is 12-
20 breaths per minute. Adolescents, children, and newborns have different
normal ranges. A rate of 10 indicates respiratory depression or compromise.
6. Which of the following vital signs recorded for an older adult would be
considered acceptable (within normal limits)?
A) Temp 98.6°F, P-56, R-20, BP 120/80, O2 sat 91%
B) Temp 97.0°F, P-60, R-16, BP 116/78, O2 sat 95%
C) Temp 96.8°F, P-60, R-18, BP 160/90, O2 sat 93%
D) Temp 98.0°F, P-76, R-22, BP 110/70, O2 sat 88%
Correct Answer: Temp 97.0°F, P-60, R-16, BP 116/78, O2 sat 95%
, Rationale: This set of vital signs is within normal limits for an older adult.
Normal oxygen saturation should be 95% or higher. BP 160/90 is elevated
(hypertension), R-22 is tachypneic, and O2 sat 88% indicates hypoxia
requiring intervention.
7. When performing catheter care, how many inches of the catheter should
be cleansed after it exits the urinary meatus?
A) 1 inch (2.5 cm)
B) 2 inches (5 cm)
C) 3 inches (7.5 cm)
D) 4 inches (10 cm)
Correct Answer: 4 inches (10 cm)
Rationale: The optimum distance to cleanse is 4 inches (10 cm) to reduce the
presence of secretions or drainage on the exterior catheter surface. This
helps prevent catheter-associated urinary tract infections (CAUTIs) by
removing bacteria that could migrate into the urethra.
8. The nurse is assessing a patient's radial pulse and notes that it is irregular.
What should be the nurse's next action?
A) Document the finding as a normal variation and recheck in 4 hours
B) Use a Doppler ultrasound device to find the pulse
C) Auscultate the apical pulse for one full minute
D) Immediately notify the healthcare provider
Correct Answer: Auscultate the apical pulse for one full minute
Rationale: When a radial pulse is irregular, the nurse should auscultate the
apical pulse for one full minute to accurately assess the heart rate and
Q&A | Nursing
1. A nurse is reviewing the nursing process with a student. Which statement
by the student indicates an understanding of the "Assessment" phase?
A) "Assessment involves setting measurable goals for the patient's recovery."
B) "Assessment is the systematic collection of subjective and objective data."
C) "Assessment is the final step where we see if the interventions worked."
D) "Assessment is the process of delegating tasks to unlicensed personnel."
Correct Answer: "Assessment is the systematic collection of subjective and
objective data."
Rationale: The assessment phase is the first step of the nursing process and
focuses on data collection. It requires the nurse to gather both subjective
reports from the patient and objective findings from physical examinations.
This information serves as the foundation for the entire care plan and
subsequent nursing diagnoses.
2. According to Maslow's Hierarchy of Needs, which patient should the nurse
prioritize first?
A) A patient who expresses feelings of loneliness and isolation
B) A patient experiencing difficulty breathing and low oxygen saturation
C) A patient who is concerned about their safety in a new environment
D) A patient who is seeking information about self-care after discharge
Correct Answer: A patient experiencing difficulty breathing and low oxygen
saturation
Rationale: Physiological needs, such as oxygenation and circulation, are the
most basic and critical according to Maslow's hierarchy. Without meeting
,these survival needs, higher-level needs like safety or self-esteem cannot be
addressed. Respiratory distress represents a life-threatening physiological
priority that must be resolved immediately.
3. A nurse is caring for a patient who refuses a scheduled blood transfusion
for religious reasons. Which ethical principle is the nurse upholding by
supporting this decision?
A) Justice
B) Beneficence
C) Non-maleficence
D) Autonomy
Correct Answer: Autonomy
Rationale: Autonomy refers to the right of the patient to make their own
decisions regarding their healthcare. The nurse's role is to ensure the patient
is informed but to respect their ultimate choice, even if it conflicts with
medical advice. Upholding autonomy is a fundamental aspect of professional
nursing ethics and patient-centered care.
4. The nurse is using the SBAR tool to communicate with a physician. What
does the "R" in SBAR stand for?
A) Recommendation
B) Response
C) Review
D) Requirement
Correct Answer: Recommendation
,Rationale: SBAR stands for Situation, Background, Assessment, and
Recommendation. The Recommendation phase is where the nurse suggests
a specific action or asks what the provider wants to be done. This structured
communication tool improves patient safety by ensuring that all critical
information is conveyed clearly and concisely.
5. Which of the following patients would require follow-up based on
respiratory rate?
A) An adolescent with a respiratory rate of 16 breaths per minute
B) A child with a respiratory rate of 20 breaths per minute
C) A newborn with a respiratory rate of 40 breaths per minute
D) An adult with a respiratory rate of 10 breaths per minute
Correct Answer: An adult with a respiratory rate of 10 breaths per minute
Rationale: An adult with a respiratory rate of 10 breaths per minute is
bradypneic and would require follow-up. Normal adult respiratory rate is 12-
20 breaths per minute. Adolescents, children, and newborns have different
normal ranges. A rate of 10 indicates respiratory depression or compromise.
6. Which of the following vital signs recorded for an older adult would be
considered acceptable (within normal limits)?
A) Temp 98.6°F, P-56, R-20, BP 120/80, O2 sat 91%
B) Temp 97.0°F, P-60, R-16, BP 116/78, O2 sat 95%
C) Temp 96.8°F, P-60, R-18, BP 160/90, O2 sat 93%
D) Temp 98.0°F, P-76, R-22, BP 110/70, O2 sat 88%
Correct Answer: Temp 97.0°F, P-60, R-16, BP 116/78, O2 sat 95%
, Rationale: This set of vital signs is within normal limits for an older adult.
Normal oxygen saturation should be 95% or higher. BP 160/90 is elevated
(hypertension), R-22 is tachypneic, and O2 sat 88% indicates hypoxia
requiring intervention.
7. When performing catheter care, how many inches of the catheter should
be cleansed after it exits the urinary meatus?
A) 1 inch (2.5 cm)
B) 2 inches (5 cm)
C) 3 inches (7.5 cm)
D) 4 inches (10 cm)
Correct Answer: 4 inches (10 cm)
Rationale: The optimum distance to cleanse is 4 inches (10 cm) to reduce the
presence of secretions or drainage on the exterior catheter surface. This
helps prevent catheter-associated urinary tract infections (CAUTIs) by
removing bacteria that could migrate into the urethra.
8. The nurse is assessing a patient's radial pulse and notes that it is irregular.
What should be the nurse's next action?
A) Document the finding as a normal variation and recheck in 4 hours
B) Use a Doppler ultrasound device to find the pulse
C) Auscultate the apical pulse for one full minute
D) Immediately notify the healthcare provider
Correct Answer: Auscultate the apical pulse for one full minute
Rationale: When a radial pulse is irregular, the nurse should auscultate the
apical pulse for one full minute to accurately assess the heart rate and
