NUR 155 FOUNDATIONS OF NURSING –
EXAM 2: 100 PRACTICE QUESTIONS
WITH VERIFIED ANSWERS & CLINICAL
RATIONALES ACADEMIC YEAR
2026/2027 – EXAMINATION 2
GRADED A+ || NEWEST
1. A nurse is using the nursing process to plan care for a newly admitted
patient. After collecting vital signs and the patient's health history, what is the
next step the nurse should take?
A) Implement a nursing intervention
B) Formulate a nursing diagnosis
C) Evaluate the patient's response
D) Set measurable goals for the patient
Correct answer: B) Formulate a nursing diagnosis
Rationale: The nursing process follows a specific, sequential order: Assessment
(collecting data), Diagnosis (identifying patient problems), Planning (setting goals),
Implementation (performing interventions), and Evaluation (assessing outcomes).
Therefore, after completing the assessment, the nurse must formulate a nursing
diagnosis before moving on to planning or implementation .
2. A nurse is caring for a patient who has recently been diagnosed with
diabetes. The nurse provides education on self-administration of insulin. This
nursing action falls under which phase of the nursing process?
A) Assessment
B) Planning
,C) Implementation
D) Evaluation
Correct answer: C) Implementation
Rationale: Implementation is the phase of the nursing process where the nurse
carries out the interventions identified during the planning phase. This includes
actions like patient education, medication administration, and direct patient care .
3. A nurse notices that a patient's blood pressure is significantly higher than the
previous reading. According to Tanner's Clinical Judgment Model, which step
involves the nurse recognizing this change as a potential problem?
A) Reflecting
B) Interpreting
C) Responding
D) Noticing
Correct answer: D) Noticing
Rationale: Tanner's Clinical Judgment Model consists of four steps: Noticing,
Interpreting, Responding, and Reflecting. Noticing is the initial step where the nurse
identifies a change in a patient's condition or recognizes a significant clinical cue,
such as an unexpected change in vital signs .
4. Which of the following represents objective data?
A) The patient states, "I feel nauseous."
B) The patient reports a headache that started an hour ago.
C) The patient rates their pain as a 7 on a 0-10 scale.
D) The patient's blood pressure is 160/90 mm Hg.
Correct answer: D) The patient's blood pressure is 160/90 mm Hg.
Rationale: Objective data are measurable, observable, and verifiable facts that the
nurse obtains through physical assessment, vital signs, and laboratory results. In
contrast, subjective data are what the patient tells the nurse .
5. The nurse is documenting a client's vital signs. Which documentation is most
appropriate?
,A) "Vital signs stable"
B) "BP 118/76, HR 72, RR 16, Temp 98.6°F, SpO2 98%"
C) "Client looks good"
D) "Vital signs are normal"
Correct answer: B) "BP 118/76, HR 72, RR 16, Temp 98.6°F, SpO2 98%"
Rationale: Documentation should include specific, objective data. "Vital signs stable"
and "normal" are vague and subjective. "Client looks good" is not an objective
assessment. The nurse should document exact measurements .
6. The nurse is prioritizing care for multiple clients. Which client should the
nurse see first?
A. A client requesting pain medication
B. A client with an SpO2 of 88% on room air
C. A client needing assistance with toileting
D. A client with a dietary question
Correct answer: B. A client with an SpO2 of 88% on room air
Rationale: Using the ABCs (Airway, Breathing, Circulation), the client with an SpO2 of
88% has a potential breathing problem that requires immediate intervention. This
takes priority over pain medication, toileting assistance, and dietary questions .
7. The nurse is communicating with a client who is anxious about surgery.
Which statement by the nurse is most therapeutic?
A. "Don't worry, everything will be fine."
B. "I can see that you are anxious. Can you tell me what concerns you have about the
surgery?"
C. "You should not be anxious; this is a routine procedure."
D. "I will come back when you are calmer."
Correct answer: B. "I can see that you are anxious. Can you tell me what concerns
you have about the surgery?"
Rationale: The nurse should acknowledge the client's feelings and encourage them
to express their concerns. This response validates the client's feelings, is empathetic,
and opens the door for communication .
, 8. The nurse is using the SBAR communication tool to report a client's change
in status to the healthcare provider. What does SBAR stand for?
A. Situation, Background, Action, Response
B. Situation, Background, Assessment, Recommendation
C. Summary, Baseline, Assessment, Referral
D. Situation, Behavior, Assessment, Recommendation
Correct answer: B. Situation, Background, Assessment, Recommendation
Rationale: SBAR stands for Situation (what is happening now), Background (relevant
history), Assessment (what the nurse thinks is happening), and Recommendation
(what the nurse recommends). SBAR is a standardized communication tool that
improves handoff communication and reduces errors .
9. The nurse is caring for a client with a new diagnosis of diabetes. Which
nursing diagnosis is most appropriate?
A. Risk for Infection related to diabetes
B. Deficient Knowledge related to new diagnosis as evidenced by client asking
questions about diet and medication
C. Imbalanced Nutrition: Less Than Body Requirements
D. Activity Intolerance
Correct answer: B. Deficient Knowledge related to new diagnosis as evidenced by
client asking questions about diet and medication
Rationale: Deficient Knowledge is an appropriate nursing diagnosis for a client with
a new diagnosis who is asking questions. This diagnosis includes all three
components: problem (Deficient Knowledge), etiology (related to new diagnosis),
and defining characteristics (as evidenced by client asking questions) .
10. Which of the following is considered subjective data?
A) Blood pressure 130/80 mmHg
B) Patient states, "I have a severe headache."
C) Wound drainage is green and foul-smelling
D) The patient is coughing and wheezing
EXAM 2: 100 PRACTICE QUESTIONS
WITH VERIFIED ANSWERS & CLINICAL
RATIONALES ACADEMIC YEAR
2026/2027 – EXAMINATION 2
GRADED A+ || NEWEST
1. A nurse is using the nursing process to plan care for a newly admitted
patient. After collecting vital signs and the patient's health history, what is the
next step the nurse should take?
A) Implement a nursing intervention
B) Formulate a nursing diagnosis
C) Evaluate the patient's response
D) Set measurable goals for the patient
Correct answer: B) Formulate a nursing diagnosis
Rationale: The nursing process follows a specific, sequential order: Assessment
(collecting data), Diagnosis (identifying patient problems), Planning (setting goals),
Implementation (performing interventions), and Evaluation (assessing outcomes).
Therefore, after completing the assessment, the nurse must formulate a nursing
diagnosis before moving on to planning or implementation .
2. A nurse is caring for a patient who has recently been diagnosed with
diabetes. The nurse provides education on self-administration of insulin. This
nursing action falls under which phase of the nursing process?
A) Assessment
B) Planning
,C) Implementation
D) Evaluation
Correct answer: C) Implementation
Rationale: Implementation is the phase of the nursing process where the nurse
carries out the interventions identified during the planning phase. This includes
actions like patient education, medication administration, and direct patient care .
3. A nurse notices that a patient's blood pressure is significantly higher than the
previous reading. According to Tanner's Clinical Judgment Model, which step
involves the nurse recognizing this change as a potential problem?
A) Reflecting
B) Interpreting
C) Responding
D) Noticing
Correct answer: D) Noticing
Rationale: Tanner's Clinical Judgment Model consists of four steps: Noticing,
Interpreting, Responding, and Reflecting. Noticing is the initial step where the nurse
identifies a change in a patient's condition or recognizes a significant clinical cue,
such as an unexpected change in vital signs .
4. Which of the following represents objective data?
A) The patient states, "I feel nauseous."
B) The patient reports a headache that started an hour ago.
C) The patient rates their pain as a 7 on a 0-10 scale.
D) The patient's blood pressure is 160/90 mm Hg.
Correct answer: D) The patient's blood pressure is 160/90 mm Hg.
Rationale: Objective data are measurable, observable, and verifiable facts that the
nurse obtains through physical assessment, vital signs, and laboratory results. In
contrast, subjective data are what the patient tells the nurse .
5. The nurse is documenting a client's vital signs. Which documentation is most
appropriate?
,A) "Vital signs stable"
B) "BP 118/76, HR 72, RR 16, Temp 98.6°F, SpO2 98%"
C) "Client looks good"
D) "Vital signs are normal"
Correct answer: B) "BP 118/76, HR 72, RR 16, Temp 98.6°F, SpO2 98%"
Rationale: Documentation should include specific, objective data. "Vital signs stable"
and "normal" are vague and subjective. "Client looks good" is not an objective
assessment. The nurse should document exact measurements .
6. The nurse is prioritizing care for multiple clients. Which client should the
nurse see first?
A. A client requesting pain medication
B. A client with an SpO2 of 88% on room air
C. A client needing assistance with toileting
D. A client with a dietary question
Correct answer: B. A client with an SpO2 of 88% on room air
Rationale: Using the ABCs (Airway, Breathing, Circulation), the client with an SpO2 of
88% has a potential breathing problem that requires immediate intervention. This
takes priority over pain medication, toileting assistance, and dietary questions .
7. The nurse is communicating with a client who is anxious about surgery.
Which statement by the nurse is most therapeutic?
A. "Don't worry, everything will be fine."
B. "I can see that you are anxious. Can you tell me what concerns you have about the
surgery?"
C. "You should not be anxious; this is a routine procedure."
D. "I will come back when you are calmer."
Correct answer: B. "I can see that you are anxious. Can you tell me what concerns
you have about the surgery?"
Rationale: The nurse should acknowledge the client's feelings and encourage them
to express their concerns. This response validates the client's feelings, is empathetic,
and opens the door for communication .
, 8. The nurse is using the SBAR communication tool to report a client's change
in status to the healthcare provider. What does SBAR stand for?
A. Situation, Background, Action, Response
B. Situation, Background, Assessment, Recommendation
C. Summary, Baseline, Assessment, Referral
D. Situation, Behavior, Assessment, Recommendation
Correct answer: B. Situation, Background, Assessment, Recommendation
Rationale: SBAR stands for Situation (what is happening now), Background (relevant
history), Assessment (what the nurse thinks is happening), and Recommendation
(what the nurse recommends). SBAR is a standardized communication tool that
improves handoff communication and reduces errors .
9. The nurse is caring for a client with a new diagnosis of diabetes. Which
nursing diagnosis is most appropriate?
A. Risk for Infection related to diabetes
B. Deficient Knowledge related to new diagnosis as evidenced by client asking
questions about diet and medication
C. Imbalanced Nutrition: Less Than Body Requirements
D. Activity Intolerance
Correct answer: B. Deficient Knowledge related to new diagnosis as evidenced by
client asking questions about diet and medication
Rationale: Deficient Knowledge is an appropriate nursing diagnosis for a client with
a new diagnosis who is asking questions. This diagnosis includes all three
components: problem (Deficient Knowledge), etiology (related to new diagnosis),
and defining characteristics (as evidenced by client asking questions) .
10. Which of the following is considered subjective data?
A) Blood pressure 130/80 mmHg
B) Patient states, "I have a severe headache."
C) Wound drainage is green and foul-smelling
D) The patient is coughing and wheezing
