NURS 100 FUNDAMENTALS QUIZ 2
WITH 100% DETAILED CORRECT
ANSWERS 2025/2026 STUDY
Section 1: Nursing Process & Critical Thinking (Questions 1–15)
1. A nurse uses critical thinking to prioritize care for four clients. Which client
should the nurse assess first?
A. A client with a newly elevated blood pressure of 180/100 mmHg
B. A client who is requesting pain medication
C. A client who needs assistance with ambulation
D. A client who has questions about discharge instructions
Answer: A – A client with a newly elevated blood pressure of 180/100 mmHg
*Rationale: Critical thinking requires prioritization based on urgency. A newly
elevated blood pressure of 180/100 mmHg indicates a potential hypertensive
crisis, which is a life-threatening condition requiring immediate assessment and
intervention. The ABCs (Airway, Breathing, Circulation) are the foundation of
prioritization, with blood pressure affecting circulation.*
2. A nurse is following the steps of the nursing process. Place the following steps
in the correct order:
A. Diagnosis, Implementation, Assessment, Planning, Evaluation
B. Assessment, Diagnosis, Planning, Implementation, Evaluation
C. Planning, Assessment, Diagnosis, Implementation, Evaluation
D. Assessment, Planning, Diagnosis, Implementation, Evaluation
Answer: B – Assessment, Diagnosis, Planning, Implementation, Evaluation
Rationale: The nursing process is a five-step systematic method: Assessment
(collect data), Diagnosis (identify problems), Planning (set goals and
interventions), Implementation (perform interventions), Evaluation (assess
,outcomes). This order ensures logical progression from data collection to outcome
measurement.
3. Which statement by a newly licensed nurse correctly describes the purpose of
the nursing process?
A. "The nursing process provides a framework for the staff nurse to make
decisions about client care."
B. "The nursing process allows the healthcare team to focus on disease
processes."
C. "The nursing process is used primarily for documentation purposes."
D. "The nursing process replaces the need for physician orders."
Answer: A – "The nursing process provides a framework for the staff nurse to
make decisions about client care."
Rationale: The nursing process is a systematic, evidence-based framework that
guides nurses in clinical decision-making, problem-solving, and delivering
individualized, patient-centered care. It is not limited to documentation nor does it
replace physician orders.
4. A nurse is collecting data on a client admitted with pneumonia. Which finding
is an example of subjective data?
A. Respiratory rate of 24 breaths per minute
B. Oxygen saturation of 89% on room air
C. Client states, "I have a sharp pain in my chest when I cough."
D. Crackles auscultated in the lower lung bases
Answer: C – Client states, "I have a sharp pain in my chest when I cough."
Rationale: Subjective data are information provided directly by the client (verbal
statements, feelings, perceptions). Objective data are measurable and observable
(vital signs, physical assessment findings, lab results). The client's statement about
pain is subjective; vital signs and auscultation findings are objective.
5. A nurse is planning care for a client with impaired mobility. Which
intervention is appropriate to include in the plan of care?
A. Keep the client supine at all times
B. Reposition the client every 2 hours
C. Restrict fluid intake to prevent falls
D. Encourage the client to remain in bed
,Answer: B – Reposition the client every 2 hours
Rationale: Repositioning every 2 hours prevents pressure injuries, improves
circulation, and reduces the risk of complications from immobility (atelectasis,
constipation, DVT). Keeping the client supine or in bed increases these risks. Fluid
restriction is not indicated and may cause dehydration.
6. A nurse is evaluating a client's response to pain medication. Which action
demonstrates the evaluation phase of the nursing process?
A. Administering morphine 2 mg IV as ordered
B. Asking the client to rate pain on a 0–10 scale 30 minutes after medication
administration
C. Documenting the client's allergy to codeine
D. Setting a goal for pain to be ≤ 3 out of 10
Answer: B – Asking the client to rate pain on a 0–10 scale 30 minutes after
medication administration
Rationale: Evaluation involves reassessing the client after interventions to
determine whether goals have been met. Comparing the post-intervention pain
score to the goal is evaluation. Administration is implementation, documentation
is part of assessment/implementation, and goal setting is planning.
7. A nurse is using the SMART framework to write a client goal. Which goal
meets the SMART criteria?
A. "Client will ambulate with a walker by discharge."
B. "Client will ambulate 50 feet with a walker without shortness of breath within 3
days."
C. "Client will feel better after physical therapy."
D. "Client will try to walk in the hallway when able."
Answer: B – "Client will ambulate 50 feet with a walker without shortness of
breath within 3 days."
*Rationale: SMART goals are Specific (50 feet, walker), Measurable (distance,
absence of shortness of breath), Acceptable (realistic for the client), Relevant (to
mobility), and Time-bound (within 3 days). Vague goals ("feel better," "try to
walk") are not measurable.*
8. A nurse identifies that a client has a nursing diagnosis of "Risk for Falls." What
is the most appropriate intervention?
, A. Keep the bed in the highest position
B. Place all four side rails up
C. Ensure the call light is within reach and the bed is in low position
D. Restrain the client to prevent movement
Answer: C – Ensure the call light is within reach and the bed is in low position
Rationale: Fall prevention includes keeping the bed in the lowest position,
ensuring the call light is accessible, using non-slip mats, and providing adequate
lighting. Four side rails up is considered a restraint and increases fall risk.
Restraints are a last resort.
9. A nurse is prioritizing care using Maslow's hierarchy of needs. Which client
need should be addressed first?
A. A client who reports feeling lonely
B. A client with an oxygen saturation of 88% on room air
C. A client who requests help with bathing
D. A client who asks about support groups
Answer: B – A client with an oxygen saturation of 88% on room air
Rationale: Maslow's hierarchy prioritizes physiological needs (oxygen, food, water,
shelter, sleep) before safety, love/belonging, esteem, and self-actualization.
Hypoxemia (low oxygen) is a physiological need and is potentially life-threatening,
requiring immediate attention.
10. A nurse is documenting client care. Which entry follows proper
documentation guidelines?
A. "Client seems anxious about surgery tomorrow."
B. "Client is in a bad mood today."
C. "Client states, 'I'm nervous about my surgery tomorrow.'"
D. "Client is being difficult with staff."
Answer: C – "Client states, 'I'm nervous about my surgery tomorrow.'"
Rationale: Proper documentation is objective, factual, and uses direct quotes
when documenting client statements. Subjective opinions ("seems anxious," "bad
mood," "being difficult") are not appropriate. Documentation should avoid labels
and judgments.
WITH 100% DETAILED CORRECT
ANSWERS 2025/2026 STUDY
Section 1: Nursing Process & Critical Thinking (Questions 1–15)
1. A nurse uses critical thinking to prioritize care for four clients. Which client
should the nurse assess first?
A. A client with a newly elevated blood pressure of 180/100 mmHg
B. A client who is requesting pain medication
C. A client who needs assistance with ambulation
D. A client who has questions about discharge instructions
Answer: A – A client with a newly elevated blood pressure of 180/100 mmHg
*Rationale: Critical thinking requires prioritization based on urgency. A newly
elevated blood pressure of 180/100 mmHg indicates a potential hypertensive
crisis, which is a life-threatening condition requiring immediate assessment and
intervention. The ABCs (Airway, Breathing, Circulation) are the foundation of
prioritization, with blood pressure affecting circulation.*
2. A nurse is following the steps of the nursing process. Place the following steps
in the correct order:
A. Diagnosis, Implementation, Assessment, Planning, Evaluation
B. Assessment, Diagnosis, Planning, Implementation, Evaluation
C. Planning, Assessment, Diagnosis, Implementation, Evaluation
D. Assessment, Planning, Diagnosis, Implementation, Evaluation
Answer: B – Assessment, Diagnosis, Planning, Implementation, Evaluation
Rationale: The nursing process is a five-step systematic method: Assessment
(collect data), Diagnosis (identify problems), Planning (set goals and
interventions), Implementation (perform interventions), Evaluation (assess
,outcomes). This order ensures logical progression from data collection to outcome
measurement.
3. Which statement by a newly licensed nurse correctly describes the purpose of
the nursing process?
A. "The nursing process provides a framework for the staff nurse to make
decisions about client care."
B. "The nursing process allows the healthcare team to focus on disease
processes."
C. "The nursing process is used primarily for documentation purposes."
D. "The nursing process replaces the need for physician orders."
Answer: A – "The nursing process provides a framework for the staff nurse to
make decisions about client care."
Rationale: The nursing process is a systematic, evidence-based framework that
guides nurses in clinical decision-making, problem-solving, and delivering
individualized, patient-centered care. It is not limited to documentation nor does it
replace physician orders.
4. A nurse is collecting data on a client admitted with pneumonia. Which finding
is an example of subjective data?
A. Respiratory rate of 24 breaths per minute
B. Oxygen saturation of 89% on room air
C. Client states, "I have a sharp pain in my chest when I cough."
D. Crackles auscultated in the lower lung bases
Answer: C – Client states, "I have a sharp pain in my chest when I cough."
Rationale: Subjective data are information provided directly by the client (verbal
statements, feelings, perceptions). Objective data are measurable and observable
(vital signs, physical assessment findings, lab results). The client's statement about
pain is subjective; vital signs and auscultation findings are objective.
5. A nurse is planning care for a client with impaired mobility. Which
intervention is appropriate to include in the plan of care?
A. Keep the client supine at all times
B. Reposition the client every 2 hours
C. Restrict fluid intake to prevent falls
D. Encourage the client to remain in bed
,Answer: B – Reposition the client every 2 hours
Rationale: Repositioning every 2 hours prevents pressure injuries, improves
circulation, and reduces the risk of complications from immobility (atelectasis,
constipation, DVT). Keeping the client supine or in bed increases these risks. Fluid
restriction is not indicated and may cause dehydration.
6. A nurse is evaluating a client's response to pain medication. Which action
demonstrates the evaluation phase of the nursing process?
A. Administering morphine 2 mg IV as ordered
B. Asking the client to rate pain on a 0–10 scale 30 minutes after medication
administration
C. Documenting the client's allergy to codeine
D. Setting a goal for pain to be ≤ 3 out of 10
Answer: B – Asking the client to rate pain on a 0–10 scale 30 minutes after
medication administration
Rationale: Evaluation involves reassessing the client after interventions to
determine whether goals have been met. Comparing the post-intervention pain
score to the goal is evaluation. Administration is implementation, documentation
is part of assessment/implementation, and goal setting is planning.
7. A nurse is using the SMART framework to write a client goal. Which goal
meets the SMART criteria?
A. "Client will ambulate with a walker by discharge."
B. "Client will ambulate 50 feet with a walker without shortness of breath within 3
days."
C. "Client will feel better after physical therapy."
D. "Client will try to walk in the hallway when able."
Answer: B – "Client will ambulate 50 feet with a walker without shortness of
breath within 3 days."
*Rationale: SMART goals are Specific (50 feet, walker), Measurable (distance,
absence of shortness of breath), Acceptable (realistic for the client), Relevant (to
mobility), and Time-bound (within 3 days). Vague goals ("feel better," "try to
walk") are not measurable.*
8. A nurse identifies that a client has a nursing diagnosis of "Risk for Falls." What
is the most appropriate intervention?
, A. Keep the bed in the highest position
B. Place all four side rails up
C. Ensure the call light is within reach and the bed is in low position
D. Restrain the client to prevent movement
Answer: C – Ensure the call light is within reach and the bed is in low position
Rationale: Fall prevention includes keeping the bed in the lowest position,
ensuring the call light is accessible, using non-slip mats, and providing adequate
lighting. Four side rails up is considered a restraint and increases fall risk.
Restraints are a last resort.
9. A nurse is prioritizing care using Maslow's hierarchy of needs. Which client
need should be addressed first?
A. A client who reports feeling lonely
B. A client with an oxygen saturation of 88% on room air
C. A client who requests help with bathing
D. A client who asks about support groups
Answer: B – A client with an oxygen saturation of 88% on room air
Rationale: Maslow's hierarchy prioritizes physiological needs (oxygen, food, water,
shelter, sleep) before safety, love/belonging, esteem, and self-actualization.
Hypoxemia (low oxygen) is a physiological need and is potentially life-threatening,
requiring immediate attention.
10. A nurse is documenting client care. Which entry follows proper
documentation guidelines?
A. "Client seems anxious about surgery tomorrow."
B. "Client is in a bad mood today."
C. "Client states, 'I'm nervous about my surgery tomorrow.'"
D. "Client is being difficult with staff."
Answer: C – "Client states, 'I'm nervous about my surgery tomorrow.'"
Rationale: Proper documentation is objective, factual, and uses direct quotes
when documenting client statements. Subjective opinions ("seems anxious," "bad
mood," "being difficult") are not appropriate. Documentation should avoid labels
and judgments.
