NURS 221 - Exam 1 Liberty University (Latest) || Most Recent
Exam 2026|2027 Actual Complete Real Exam Questions And
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A nurse is caring for a hospitalized patient who is at high risk for falls.
Which intervention should the nurse implement first?
A. Place the patient's personal items within reach.
B. Keep the patient's bed in the highest position.
C. Encourage the patient to ambulate independently.
D. Keep all four side rails raised.
Answer: A. Place the patient's personal items within reach.
Rationale: Keeping essential items within reach reduces unnecessary
attempts to get out of bed and promotes patient safety. The bed should
generally be kept in the lowest safe position. Four raised side rails can
constitute a restraint and should not routinely be used as a fall-
prevention measure.
A nurse is preparing to provide care using medical asepsis. Which
action is most appropriate?
A. Maintaining a sterile field throughout the procedure
B. Performing hand hygiene before and after patient contact
C. Touching sterile supplies with bare hands
D. Using only sterile gloves for routine patient care
,Answer: B. Performing hand hygiene before and after patient contact.
Rationale: Medical asepsis, or clean technique, focuses on reducing the
number and spread of microorganisms. Hand hygiene is one of the
most important measures for preventing transmission of infection.
Sterile technique is required when complete elimination of
microorganisms is necessary.
Which statement best describes the primary purpose of the nursing
process?
A. To establish the medical diagnosis
B. To provide a systematic framework for individualized nursing care
C. To determine which medications the provider should prescribe
D. To replace clinical judgment
Answer: B. To provide a systematic framework for individualized
nursing care.
Rationale: The nursing process provides a structured approach to
assessing patients, identifying nursing problems, planning care,
implementing interventions, and evaluating outcomes. It supports
individualized, evidence-informed nursing practice and does not
replace clinical judgment.
Which phase of the nursing process involves collecting subjective and
objective information?
A. Diagnosis
B. Planning
C. Assessment
,D. Evaluation
Answer: C. Assessment.
Rationale: Assessment is the first phase of the nursing process and
involves systematic collection of patient information. Subjective data
come from the patient's reports, while objective data are observable or
measurable findings.
Which finding is an example of subjective data?
A. Temperature of 38.2°C
B. Blood pressure of 148/88 mm Hg
C. Patient reports feeling nauseated
D. Respiratory rate of 24 breaths/min
Answer: C. Patient reports feeling nauseated.
Rationale: Subjective data are symptoms or experiences reported by
the patient. Nausea cannot be directly measured by the nurse and must
be described by the patient. Temperature, blood pressure, and
respiratory rate are objective findings.
A nurse is prioritizing care for four patients. Which patient should
receive attention first?
A. Patient requesting assistance with bathing
B. Patient reporting difficulty breathing
C. Patient requesting a change of television channel
D. Patient awaiting discharge instructions
Answer: B. Patient reporting difficulty breathing.
, Rationale: Airway and breathing are immediate physiological
priorities. A patient experiencing respiratory difficulty may have a
potentially life-threatening problem and requires prompt assessment
and intervention.
According to Maslow's hierarchy of needs, which need has the highest
priority?
A. Self-esteem
B. Love and belonging
C. Physiological needs
D. Self-actualization
Answer: C. Physiological needs.
Rationale: Physiological needs, including oxygenation, nutrition,
hydration, elimination, and temperature regulation, form the
foundation of Maslow's hierarchy.
Unmet physiological needs generally take priority over psychosocial
and higher-level needs.
A patient states, "I am frightened about my upcoming surgery."
Which response by the nurse is most therapeutic?
A. "There is nothing to worry about."
B. "You should try to think positively."
C. "Tell me more about what concerns you about the surgery."
D. "Everyone feels that way before surgery."
Answer: C. "Tell me more about what concerns you about the
surgery."
Exam 2026|2027 Actual Complete Real Exam Questions And
Correct Answer (Verified Answers) Already Graded A+ |
Guaranteed Success!! Newest Exam | Just Released!!
A nurse is caring for a hospitalized patient who is at high risk for falls.
Which intervention should the nurse implement first?
A. Place the patient's personal items within reach.
B. Keep the patient's bed in the highest position.
C. Encourage the patient to ambulate independently.
D. Keep all four side rails raised.
Answer: A. Place the patient's personal items within reach.
Rationale: Keeping essential items within reach reduces unnecessary
attempts to get out of bed and promotes patient safety. The bed should
generally be kept in the lowest safe position. Four raised side rails can
constitute a restraint and should not routinely be used as a fall-
prevention measure.
A nurse is preparing to provide care using medical asepsis. Which
action is most appropriate?
A. Maintaining a sterile field throughout the procedure
B. Performing hand hygiene before and after patient contact
C. Touching sterile supplies with bare hands
D. Using only sterile gloves for routine patient care
,Answer: B. Performing hand hygiene before and after patient contact.
Rationale: Medical asepsis, or clean technique, focuses on reducing the
number and spread of microorganisms. Hand hygiene is one of the
most important measures for preventing transmission of infection.
Sterile technique is required when complete elimination of
microorganisms is necessary.
Which statement best describes the primary purpose of the nursing
process?
A. To establish the medical diagnosis
B. To provide a systematic framework for individualized nursing care
C. To determine which medications the provider should prescribe
D. To replace clinical judgment
Answer: B. To provide a systematic framework for individualized
nursing care.
Rationale: The nursing process provides a structured approach to
assessing patients, identifying nursing problems, planning care,
implementing interventions, and evaluating outcomes. It supports
individualized, evidence-informed nursing practice and does not
replace clinical judgment.
Which phase of the nursing process involves collecting subjective and
objective information?
A. Diagnosis
B. Planning
C. Assessment
,D. Evaluation
Answer: C. Assessment.
Rationale: Assessment is the first phase of the nursing process and
involves systematic collection of patient information. Subjective data
come from the patient's reports, while objective data are observable or
measurable findings.
Which finding is an example of subjective data?
A. Temperature of 38.2°C
B. Blood pressure of 148/88 mm Hg
C. Patient reports feeling nauseated
D. Respiratory rate of 24 breaths/min
Answer: C. Patient reports feeling nauseated.
Rationale: Subjective data are symptoms or experiences reported by
the patient. Nausea cannot be directly measured by the nurse and must
be described by the patient. Temperature, blood pressure, and
respiratory rate are objective findings.
A nurse is prioritizing care for four patients. Which patient should
receive attention first?
A. Patient requesting assistance with bathing
B. Patient reporting difficulty breathing
C. Patient requesting a change of television channel
D. Patient awaiting discharge instructions
Answer: B. Patient reporting difficulty breathing.
, Rationale: Airway and breathing are immediate physiological
priorities. A patient experiencing respiratory difficulty may have a
potentially life-threatening problem and requires prompt assessment
and intervention.
According to Maslow's hierarchy of needs, which need has the highest
priority?
A. Self-esteem
B. Love and belonging
C. Physiological needs
D. Self-actualization
Answer: C. Physiological needs.
Rationale: Physiological needs, including oxygenation, nutrition,
hydration, elimination, and temperature regulation, form the
foundation of Maslow's hierarchy.
Unmet physiological needs generally take priority over psychosocial
and higher-level needs.
A patient states, "I am frightened about my upcoming surgery."
Which response by the nurse is most therapeutic?
A. "There is nothing to worry about."
B. "You should try to think positively."
C. "Tell me more about what concerns you about the surgery."
D. "Everyone feels that way before surgery."
Answer: C. "Tell me more about what concerns you about the
surgery."
