AND A WITH DEPTH RATIONALES AND
HIGHLIGHTED ANSWERS COMPLETE
COMPREHENSIVE GUIDE
Question 1 (Topic: Prioritization — ABC Framework)
A nurse receives change-of-shift report for four clients. Using the
Airway, Breathing, Circulation (ABC) prioritization framework,
which client should the nurse assess first?
• A. A client with type 2 diabetes mellitus requesting a snack
for a mild morning headache.
• B. A client with chronic obstructive pulmonary disease
(COPD) reporting acute dyspnea with an oxygen saturation
of 85% on room air.
• C. A postoperative client requesting pain medication
reporting an incisional pain score of 6 out of 10.
• D. A client scheduled for discharge in 2 hours who is asking
about discharge instructions.
CorreCt Answer: B
rAtionAle: Airway and breathing take absolute
priority in clinical prioritization. An oxygen saturation
of 85% represents an immediate, life-threatening
respiratory compromise requiring rapid intervention
before addressing stable or non-urgent client needs.
,Question 2 (Topic: Prioritization — Maslow's Hierarchy)
Applying Maslow’s Hierarchy of Needs, which of the following
nursing interventions addresses a fundamental physiological need
and must be prioritized first?
• A. Administering supplemental oxygen to a client with an
oxygen saturation of 88%.
• B. Providing educational brochures regarding smoking
cessation to an anxious client.
• C. Assisting a client to express feelings of grief over the loss
of a spouse.
• D. Encouraging a client to participate in a unit social support
group.
CorreCt Answer: A
rAtionAle: Physiological needs (such as oxygenation,
water, and food) form the base of Maslow's pyramid and
must be met to ensure survival before addressing safety,
belonging, or higher-level cognitive needs.
Question 3 (Topic: Nursing Process — Assessment)
A nurse is admitting an older adult client who reports abdominal
discomfort. Which of the following data collected by the nurse is
classified as objective data?
• A. The client stating, "My stomach feels sharp and
cramping."
, • B. The client reporting nausea for the past 3 days.
• C. The client describing a history of chronic constipation.
• D. A bowel sound assessment revealing hypoactive bowel
sounds in all four quadrants.
CorreCt Answer: D
rAtionAle: Objective data consist of observable and
measurable physical findings gathered directly by the
clinician during an examination (signs). Client-reported
statements, feelings, and histories represent subjective
data (symptoms).
Question 4 (Topic: Nursing Process — Diagnosis)
A nurse is reviewing a newly formulated nursing diagnosis: "Risk
for Infection related to immunosuppression secondary to
chemotherapy." Which component of this statement represents
the etiology?
• A. Immunosuppression secondary to chemotherapy
• B. Risk for Infection
• C. Chemotherapy
• D. Risk statement
CorreCt Answer: A
rAtionAle: The etiology (linked by the phrase "related
to") identifies the specific causative or contributing
factor that drives the clinical problem. This allows the
, nurse to target interventions effectively to mitigate that
cause.
Question 5 (Topic: Nursing Process — Planning)
A nurse is developing a plan of care for a client newly diagnosed
with heart failure. Which of the following client-centered outcome
statements is correctly written according to SMART criteria?
• A. The nurse will teach the client how to record daily
morning weights accurately.
• B. The client will never experience shortness of breath for the
rest of their life.
• C. The client will verbalize three low-sodium dietary choices
before discharge on Friday.
• D. The client understands heart failure management by
tomorrow morning.
CorreCt Answer: C
rAtionAle: A valid outcome statement must be
Specific, Measurable, Attainable, Realistic, and Time-
bound (SMART). Verbalizing choices provides a
measurable behavior with a clear timeline. Option A is a
nursing action, option B is unrealistic, and option D is
unmeasurable.
Question 6 (Topic: Nursing Process — Implementation)