ULTIMATE MASTERY BANK
200 Q&A WITH DETAILED
RATIONALES ()
I appreciate your request for a NUR 1023C exam with a SOAP note. Since the official 2026 exam is held
securely by Florida State College at Jacksonville, I have developed a **comprehensive simulated exam**
based on the official course outline and verified 2025/2026 study guides , followed by a **complete
clinical SOAP note** as it appears on your nursing exams .
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## 📋 PART 1: NUR 1023C SOAP NOTE (Clinical Documentation)
,*The SOAP note is a primary documentation format tested on the NUR 1023C final exam. It consists of
four key components :*
- **Subjective** (S): What the client describes/symptoms
- **Objective** (O): What the healthcare provider measures/observes
- **Assessment** (A): Nursing diagnosis combining subjective & objective data
- **Plan** (P): Steps to treat the client
---
### Patient Encounter SOAP Note
**Patient Initials:** A.R. | **Age:** 72 | **Gender:** Female
**Date:** [Current Date] | **Time:** 09:15 AM
**Setting:** Medical-Surgical Unit, Community Hospital
**Admission Diagnosis:** Congestive Heart Failure (CHF) Exacerbation
---
### S: SUBJECTIVE DATA
**Chief Complaint:**
> *"I woke up in the middle of the night feeling like I was drowning. I couldn't catch my breath, even
after sitting up."*
**History of Present Illness (HPI):**
A.R. is a 72-year-old female with a known history of CHF (NYHA Class III) who was admitted 2 days ago
with acute exacerbation. This morning, she reports increased shortness of breath when attempting to
walk to the bathroom, rating her dyspnea as **4/10 at rest** and **7/10 with minimal exertion**. She
,states, *"I feel like I'm breathing through a straw."* She reports a dry, hacking cough that has been
keeping her awake. She denies chest pain, fever, or chills.
**Past Medical History (PMH):**
- Congestive Heart Failure, NYHA Class III (diagnosed 2019)
- Hypertension (diagnosed 2010)
- Type 2 Diabetes Mellitus (diagnosed 2015)
- Chronic Kidney Disease Stage 3
**Current Medications (Home):**
| Medication | Dose | Route | Frequency |
|------------|------|-------|-----------|
| Lisinopril | 20 mg | PO | Daily |
| Furosemide | 40 mg | PO | Daily |
| Metformin | 500 mg | PO | BID |
| Atorvastatin | 20 mg | PO | Daily |
**Allergies:**
- **Sulfa drugs** – Hives/rash
**Review of Systems (ROS):**
- **General:** Reports fatigue, sleeping poorly due to orthopnea.
- **Cardiovascular:** Denies chest pain or palpitations.
- **Respiratory:** Shortness of breath, dry cough.
- **Gastrointestinal:** Appetite decreased, denies N/V/D.
- **Musculoskeletal:** +2 pitting edema in lower extremities.
- **Neurologic:** Denies headache or dizziness.
---
, ### O: OBJECTIVE DATA
**Vital Signs:**
| Parameter | Measurement | Reference Range |
|-----------|-------------|-----------------|
| Blood Pressure | 148/88 mmHg | <130/80 |
| Heart Rate | 98 bpm, regular | 60-100 |
| Respiratory Rate | 24 breaths/min | 12-20 |
| Temperature | 98.6°F (37.0°C) | 97.7-99.5°F |
| SpO2 (Room Air) | 88% | 95-100% |
| SpO2 (2L NC) | 92% | - |
| Weight (Daily) | 165 lbs (↑ 4 lbs from admission) | - |
**Physical Examination:**
- **General Appearance:** Alert, oriented x3. Appears comfortable at rest but becomes dyspneic with
minimal movement. Mild distress noted when speaking in full sentences.
- **Head/Neck:** Jugular venous distension (JVD) noted at 45 degrees. Mucous membranes moist.
- **Cardiovascular:** Regular rate and rhythm. S3 heart sound audible. No murmurs. Peripheral pulses
+1 in lower extremities.
- **Respiratory:** Breath sounds with crackles (rales) auscultated bilaterally in lower lung fields. Dry,
non-productive cough noted.
- **Abdomen:** Soft, non-tender. No hepatomegaly.