And Answers 2026/2027 Jersey College
Q1. Four patients require assessment. Which patient should be seen
first?
A) A patient requesting teaching about a low-sodium diet
B) A patient with new stridor and increasing difficulty breathing
C) A patient reporting constipation for two days
D) A patient requesting assistance with morning hygiene
Correct Answer: B) A patient with new stridor and increasing difficulty
breathing
Rationale: Stridor may indicate critical upper-airway obstruction and
requires immediate assessment and intervention.
Q2. Which finding is subjective data?
A) “My pain becomes sharp when I take a deep breath.”
B) Respiratory rate of 28/min
C) Temperature of 38.4°C
D) Oxygen saturation of 91%
Correct Answer: A) “My pain becomes sharp when I take a deep breath.”
Rationale: Subjective data consist of symptoms and perceptions reported
by the patient.
Q3. A patient's oxygen saturation falls from 97% to 88% while the
respiratory rate increases to 30/min. Identifying these changes as
clinically important represents which clinical-judgment function?
A) Generate Solutions
B) Evaluate Outcomes
C) Recognize Cues
D) Take Action
Correct Answer: C) Recognize Cues
Rationale: Recognizing cues involves identifying relevant findings and
changes that may signal a patient problem.
Q4. After reviewing low oxygen saturation, rapid respirations,
crackles, and increasing confusion, the nurse connects the findings
as evidence of impaired oxygenation. Which function is occurring?
,A) Take Action
B) Generate Solutions
C) Evaluate Outcomes
D) Analyze Cues
Correct Answer: D) Analyze Cues
Rationale: Analyzing cues involves interpreting and connecting related
assessment findings to identify possible problems.
Q5. Several problems are identified for a patient. Which problem
should generally receive the highest priority?
A) Disturbed sleep pattern
B) Knowledge deficit about diet
C) Chronic constipation
D) Acute respiratory compromise
Correct Answer: D) Acute respiratory compromise
Rationale: Acute threats to airway and breathing take priority over stable or
non-life-threatening problems.
Q6. Which outcome is written most appropriately?
A) Patient will feel better soon
B) Staff will encourage ambulation
C) Patient will ambulate 50 feet with a walker and one-person assistance by
1500
D) Patient will improve mobility
Correct Answer: C) Patient will ambulate 50 feet with a walker and one-
person assistance by 1500
Rationale: Effective outcomes are patient-centered, measurable, specific,
realistic, and time limited.
Q7. A planned intervention is due, but the patient's condition has
changed substantially since the care plan was written. What should
occur first?
A) Complete the intervention because it is already documented
B) Reassess the patient before proceeding
C) Ask assistive personnel to decide whether it is safe
D) Wait until the next shift
, Correct Answer: B) Reassess the patient before proceeding
Rationale: Current assessment findings should be considered before
implementing previously planned care.
Q8. A patient's automated blood-pressure reading is 70/38 mm Hg,
but the patient is alert, asymptomatic, and has strong peripheral
pulses. What is the best next action?
A) Diagnose shock immediately
B) Validate the unexpected blood-pressure measurement
C) Document the value without further assessment
D) Ignore blood pressure for the rest of the shift
Correct Answer: B) Validate the unexpected blood-pressure measurement
Rationale: Unexpected data that do not match the clinical presentation
should be verified before conclusions are drawn.
Q9. Which finding is objective data?
A) Heart rate of 118/min
B) “I feel dizzy.”
C) “My stomach hurts.”
D) “I have been tired all day.”
Correct Answer: A) Heart rate of 118/min
Rationale: Objective data are observable or measurable findings.
Q10. An intervention was implemented for acute pain. Which action
best evaluates effectiveness?
A) Confirm that the intervention was charted
B) Reassess pain intensity and the patient's ability to function afterward
C) Ask another patient whether the intervention usually works
D) Assume effectiveness because the intervention was completed
Correct Answer: B) Reassess pain intensity and the patient's ability to
function afterward
Rationale: Evaluation compares the patient's response with the expected
outcome.
CHAPTER 2 — SAFETY, INFECTION CONTROL, AND EMERGENCY CARE
Q11. Which action is part of Standard Precautions?