Complete 200-Question Review Bank foR the
kaplan pRaCtiCal nuRsing foundations of
nuRsing B integRated assessment –
2025/2026 edition: featuRing CliniCal
Judgment, pRioRity setting, safety,
delegation, and mediCation administRation
with detailed Rationales
Clinical Judgment and Priority Setting
1. A nurse is caring for a client with heart
failure. Which finding should be reported
immediately?
A. Weight gain of 0.5 kg (1 lb) in 24 hours
B. Crackles in the lung bases
C. Blood pressure 130/80 mm Hg
D. Heart rate 72/min
Correct ☑VERIFIED ANSWER: B. Crackles in the
lung bases
Rationale: Crackles indicate fluid accumulation
in the lungs, which is a sign of worsening heart
,failure and potential pulmonary edema. This
finding requires prompt intervention to prevent
respiratory compromise .
2. Which action should the nurse take first
when a client reports chest pain?
A. Obtain vital signs
B. Notify the provider
C. Assess the pain characteristics
D. Administer oxygen
Correct ☑VERIFIED ANSWER: C. Assess the
pain characteristics
Rationale: Assessment is the first step of the
nursing process. The nurse must gather data
about the pain's quality, location, severity, and
duration to determine the appropriate
intervention and identify the underlying cause .
3. Which client should the nurse assess first?
A. Client with a headache rated 3/10
,B. Client requesting a blanket
C. Client with oxygen saturation of 88%
D. Client with a scheduled medication due in 30
minutes
Correct ☑VERIFIED ANSWER: C. Client with
oxygen saturation of 88%
Rationale: A low oxygen saturation (88%)
indicates hypoxia, which is a life-threatening
condition. This client is unstable and requires
immediate attention to ensure adequate
oxygenation .
4. What are the steps of clinical judgment in
order?
Correct ☑VERIFIED ANSWER: Recognize cues
→ Analyze cues → Prioritize hypotheses →
Generate solutions → Take action → Evaluate
outcomes
Rationale: This process outlines the systematic
, approach nurses use to make clinical decisions,
starting with observation and ending with
evaluating the effectiveness of interventions .
5. What is the priority framework for
establishing priorities in client care?
Correct ☑VERIFIED ANSWER: Airway,
Breathing, and Circulation (ABCs)
Rationale: Airway, breathing, and circulation
are the most critical physiological needs.
Ensuring a patent airway and adequate
breathing and circulation takes precedence over
all other interventions .
6. According to Maslow's hierarchy of needs,
which client need is the priority?
A. Love and belonging
B. Safety and security
C. Physiological needs
D. Self-esteem
kaplan pRaCtiCal nuRsing foundations of
nuRsing B integRated assessment –
2025/2026 edition: featuRing CliniCal
Judgment, pRioRity setting, safety,
delegation, and mediCation administRation
with detailed Rationales
Clinical Judgment and Priority Setting
1. A nurse is caring for a client with heart
failure. Which finding should be reported
immediately?
A. Weight gain of 0.5 kg (1 lb) in 24 hours
B. Crackles in the lung bases
C. Blood pressure 130/80 mm Hg
D. Heart rate 72/min
Correct ☑VERIFIED ANSWER: B. Crackles in the
lung bases
Rationale: Crackles indicate fluid accumulation
in the lungs, which is a sign of worsening heart
,failure and potential pulmonary edema. This
finding requires prompt intervention to prevent
respiratory compromise .
2. Which action should the nurse take first
when a client reports chest pain?
A. Obtain vital signs
B. Notify the provider
C. Assess the pain characteristics
D. Administer oxygen
Correct ☑VERIFIED ANSWER: C. Assess the
pain characteristics
Rationale: Assessment is the first step of the
nursing process. The nurse must gather data
about the pain's quality, location, severity, and
duration to determine the appropriate
intervention and identify the underlying cause .
3. Which client should the nurse assess first?
A. Client with a headache rated 3/10
,B. Client requesting a blanket
C. Client with oxygen saturation of 88%
D. Client with a scheduled medication due in 30
minutes
Correct ☑VERIFIED ANSWER: C. Client with
oxygen saturation of 88%
Rationale: A low oxygen saturation (88%)
indicates hypoxia, which is a life-threatening
condition. This client is unstable and requires
immediate attention to ensure adequate
oxygenation .
4. What are the steps of clinical judgment in
order?
Correct ☑VERIFIED ANSWER: Recognize cues
→ Analyze cues → Prioritize hypotheses →
Generate solutions → Take action → Evaluate
outcomes
Rationale: This process outlines the systematic
, approach nurses use to make clinical decisions,
starting with observation and ending with
evaluating the effectiveness of interventions .
5. What is the priority framework for
establishing priorities in client care?
Correct ☑VERIFIED ANSWER: Airway,
Breathing, and Circulation (ABCs)
Rationale: Airway, breathing, and circulation
are the most critical physiological needs.
Ensuring a patent airway and adequate
breathing and circulation takes precedence over
all other interventions .
6. According to Maslow's hierarchy of needs,
which client need is the priority?
A. Love and belonging
B. Safety and security
C. Physiological needs
D. Self-esteem
