NUR 230 Exam 1 questions with verified answers and rationales 2026/2027
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1. A nurse is caring for a newly admitted patient. Which action should the nurse
perform first according to the nursing process?
A. Develop a nursing care plan
B. Assess the patient's condition
C. Implement nursing interventions
D. Evaluate outcomes
Answer: B
Rationale: Assessment is the first step of the nursing process (ADPIE). The nurse must collect
data before identifying problems, planning care, or implementing interventions.
2. The nurse identifies that a patient has difficulty breathing. Which nursing
diagnosis is most appropriate?
A. Impaired gas exchange
B. Risk for infection
C. Activity intolerance only
D. Knowledge deficit
Answer: A
Rationale: A nursing diagnosis should describe the patient’s actual health problem. Difficulty
breathing may indicate impaired gas exchange related to oxygenation problems.
3. Which action demonstrates the evaluation phase of the nursing process?
A. Administering prescribed medication
B. Collecting admission history
C. Determining whether interventions improved patient outcomes
D. Identifying nursing diagnoses
Answer: C
Rationale: Evaluation involves determining whether nursing interventions achieved the desired
outcomes and modifying the care plan if needed.
,4. A nurse enters a patient’s room and performs hand hygiene. What is the
primary purpose?
A. Prevent transmission of microorganisms
B. Improve patient comfort
C. Reduce documentation errors
D. Maintain patient privacy
Answer: A
Rationale: Hand hygiene is the most effective method to prevent healthcare-associated infections
by reducing microorganism transmission.
5. Which patient should the nurse assess first?
A. A patient requesting a blanket
B. A patient reporting sudden chest pain and shortness of breath
C. A patient asking about discharge instructions
D. A patient requesting assistance with meals
Answer: B
Rationale: Using the ABC priority framework, airway and breathing problems are life-
threatening and require immediate assessment.
6. Which finding requires immediate nursing intervention?
A. Temperature of 37°C (98.6°F)
B. Oxygen saturation of 88%
C. Heart rate of 82 beats/min
D. Blood pressure of 120/80 mmHg
Answer: B
Rationale: Oxygen saturation below normal indicates impaired oxygenation and requires prompt
intervention.
,7. A nurse is communicating with a patient who is anxious. Which approach is
best?
A. Use simple language and allow time for questions
B. Speak quickly to provide all information
C. Avoid eye contact
D. Change the subject when emotions arise
Answer: A
Rationale: Therapeutic communication involves clear language, active listening, empathy, and
allowing patients time to process information.
8. Which statement by the nurse demonstrates therapeutic communication?
A. “Everything will be fine.”
B. “Why are you worried?”
C. “Tell me more about what concerns you.”
D. “You should not feel that way.”
Answer: C
Rationale: Open-ended questions encourage patients to express feelings and promote effective
communication.
9. Which action violates patient confidentiality?
A. Discussing care with the healthcare team privately
B. Sharing patient information with a friend who asks about the patient
C. Documenting care in the medical record
D. Providing information to authorized providers
Answer: B
Rationale: Patient information must only be shared with individuals involved in care or
authorized to receive information.
10. A nurse documents patient care in the electronic health record. Which
principle is correct?
, A. Documentation should be accurate, timely, and objective
B. Documentation may include personal opinions
C. Documentation can be completed days later
D. Documentation is optional if care was provided
Answer: A
Rationale: Accurate and timely documentation supports communication, legal protection, and
continuity of care.
11. Which intervention is appropriate for preventing falls in a hospitalized
patient?
A. Keep frequently used items within reach
B. Raise all four side rails
C. Encourage independent walking without assistance
D. Leave the patient alone during transfers
Answer: A
Rationale: Keeping needed items within reach reduces unnecessary movement and fall risk. Four
side rails may be considered a restraint.
12. A nurse is preparing to administer medication. Which action is most
important?
A. Verify patient identity using two identifiers
B. Ask another patient for the patient's name
C. Give medications before checking allergies
D. Skip documentation after administration
Answer: A
Rationale: Using two patient identifiers helps prevent medication errors and promotes patient
safety.
13. Which situation requires the nurse to use standard precautions?
A. Caring for every patient regardless of diagnosis
B. Caring only for patients with infections
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1. A nurse is caring for a newly admitted patient. Which action should the nurse
perform first according to the nursing process?
A. Develop a nursing care plan
B. Assess the patient's condition
C. Implement nursing interventions
D. Evaluate outcomes
Answer: B
Rationale: Assessment is the first step of the nursing process (ADPIE). The nurse must collect
data before identifying problems, planning care, or implementing interventions.
2. The nurse identifies that a patient has difficulty breathing. Which nursing
diagnosis is most appropriate?
A. Impaired gas exchange
B. Risk for infection
C. Activity intolerance only
D. Knowledge deficit
Answer: A
Rationale: A nursing diagnosis should describe the patient’s actual health problem. Difficulty
breathing may indicate impaired gas exchange related to oxygenation problems.
3. Which action demonstrates the evaluation phase of the nursing process?
A. Administering prescribed medication
B. Collecting admission history
C. Determining whether interventions improved patient outcomes
D. Identifying nursing diagnoses
Answer: C
Rationale: Evaluation involves determining whether nursing interventions achieved the desired
outcomes and modifying the care plan if needed.
,4. A nurse enters a patient’s room and performs hand hygiene. What is the
primary purpose?
A. Prevent transmission of microorganisms
B. Improve patient comfort
C. Reduce documentation errors
D. Maintain patient privacy
Answer: A
Rationale: Hand hygiene is the most effective method to prevent healthcare-associated infections
by reducing microorganism transmission.
5. Which patient should the nurse assess first?
A. A patient requesting a blanket
B. A patient reporting sudden chest pain and shortness of breath
C. A patient asking about discharge instructions
D. A patient requesting assistance with meals
Answer: B
Rationale: Using the ABC priority framework, airway and breathing problems are life-
threatening and require immediate assessment.
6. Which finding requires immediate nursing intervention?
A. Temperature of 37°C (98.6°F)
B. Oxygen saturation of 88%
C. Heart rate of 82 beats/min
D. Blood pressure of 120/80 mmHg
Answer: B
Rationale: Oxygen saturation below normal indicates impaired oxygenation and requires prompt
intervention.
,7. A nurse is communicating with a patient who is anxious. Which approach is
best?
A. Use simple language and allow time for questions
B. Speak quickly to provide all information
C. Avoid eye contact
D. Change the subject when emotions arise
Answer: A
Rationale: Therapeutic communication involves clear language, active listening, empathy, and
allowing patients time to process information.
8. Which statement by the nurse demonstrates therapeutic communication?
A. “Everything will be fine.”
B. “Why are you worried?”
C. “Tell me more about what concerns you.”
D. “You should not feel that way.”
Answer: C
Rationale: Open-ended questions encourage patients to express feelings and promote effective
communication.
9. Which action violates patient confidentiality?
A. Discussing care with the healthcare team privately
B. Sharing patient information with a friend who asks about the patient
C. Documenting care in the medical record
D. Providing information to authorized providers
Answer: B
Rationale: Patient information must only be shared with individuals involved in care or
authorized to receive information.
10. A nurse documents patient care in the electronic health record. Which
principle is correct?
, A. Documentation should be accurate, timely, and objective
B. Documentation may include personal opinions
C. Documentation can be completed days later
D. Documentation is optional if care was provided
Answer: A
Rationale: Accurate and timely documentation supports communication, legal protection, and
continuity of care.
11. Which intervention is appropriate for preventing falls in a hospitalized
patient?
A. Keep frequently used items within reach
B. Raise all four side rails
C. Encourage independent walking without assistance
D. Leave the patient alone during transfers
Answer: A
Rationale: Keeping needed items within reach reduces unnecessary movement and fall risk. Four
side rails may be considered a restraint.
12. A nurse is preparing to administer medication. Which action is most
important?
A. Verify patient identity using two identifiers
B. Ask another patient for the patient's name
C. Give medications before checking allergies
D. Skip documentation after administration
Answer: A
Rationale: Using two patient identifiers helps prevent medication errors and promotes patient
safety.
13. Which situation requires the nurse to use standard precautions?
A. Caring for every patient regardless of diagnosis
B. Caring only for patients with infections
