NRSG 100 Exam 1 V2 | NRSG 100 Fundamentals of
Nursing | Actual Q&A with Rationale (NRSG100
Exam 1) | Ivy Tech
1. A nurse is conducting a health history for a newly admitted patient. Which of the following
is considered subjective data?
A. Blood pressure reading of 140/90 mmHg
B. A visible skin rash on the forearm
C. The patient reporting a sharp pain in their shoulder
D. A heart rate of 88 beats per minute
Correct Answer: C
Explanation: Subjective data refers to information provided by the patient that cannot be
directly observed or measured by the nurse. In this scenario, the patient’s report of pain is
a personal perception and is therefore subjective. Objective data, such as blood pressure
and heart rate, are measurable findings obtained through observation or examination.
2. When using the nursing process, which step involves the nurse setting prioritized goals and
expected outcomes for patient care?
A. Assessment
B. Planning
C. Diagnosis
,D. Implementation
Correct Answer: B
Explanation: The planning phase is the third step of the nursing process where the nurse
develops a care plan based on the identified nursing diagnoses. This step requires the
establishment of SMART goals, which are specific, measurable, attainable, relevant, and
timed. Effective planning ensures that nursing interventions are directed toward achieving
specific patient outcomes.
3. A nurse is preparing to perform hand hygiene. According to the CDC, what is the minimum
amount of time one should rub their hands with soap and water?
A. 10 seconds
B. 20 seconds
C. 1 minute
D. 5 seconds
Correct Answer: B
Explanation: The Centers for Disease Control and Prevention (CDC) recommends
scrubbing hands with soap for at least 20 seconds to effectively remove pathogens. This
duration ensures that all surfaces of the hands, including between fingers and under nails,
are thoroughly cleaned. Proper hand hygiene is the single most important intervention in
preventing the spread of healthcare-associated infections.
, 4. Which of the following describes the ‘Evaluation’ phase of the nursing process?
A. Collecting data and performing a physical exam
B. Performing a prescribed nursing intervention
C. Identifying the patient’s response to an actual health problem
D. Determining if the patient’s goals and outcomes were met
Correct Answer: D
Explanation: Evaluation is the final step of the nursing process where the nurse assesses
the patient’s progress toward goal achievement. During this phase, the nurse determines if
the interventions were successful or if the plan of care needs modification. It is a
continuous process that ensures the patient is receiving effective and appropriate care.
5. A patient has a large abdominal wound that is healing by secondary intention. The nurse
understands that this type of healing involves:
A. Suturing the wound edges together immediately
B. A low risk of infection due to rapid closure
C. The wound edges being left open to fill with granulation tissue
D. Minimal scarring compared to primary intention
Correct Answer: C
Explanation: Secondary intention occurs when a wound has edges that cannot be
approximated, such as a pressure injury or large burn. The wound heals from the bottom
Nursing | Actual Q&A with Rationale (NRSG100
Exam 1) | Ivy Tech
1. A nurse is conducting a health history for a newly admitted patient. Which of the following
is considered subjective data?
A. Blood pressure reading of 140/90 mmHg
B. A visible skin rash on the forearm
C. The patient reporting a sharp pain in their shoulder
D. A heart rate of 88 beats per minute
Correct Answer: C
Explanation: Subjective data refers to information provided by the patient that cannot be
directly observed or measured by the nurse. In this scenario, the patient’s report of pain is
a personal perception and is therefore subjective. Objective data, such as blood pressure
and heart rate, are measurable findings obtained through observation or examination.
2. When using the nursing process, which step involves the nurse setting prioritized goals and
expected outcomes for patient care?
A. Assessment
B. Planning
C. Diagnosis
,D. Implementation
Correct Answer: B
Explanation: The planning phase is the third step of the nursing process where the nurse
develops a care plan based on the identified nursing diagnoses. This step requires the
establishment of SMART goals, which are specific, measurable, attainable, relevant, and
timed. Effective planning ensures that nursing interventions are directed toward achieving
specific patient outcomes.
3. A nurse is preparing to perform hand hygiene. According to the CDC, what is the minimum
amount of time one should rub their hands with soap and water?
A. 10 seconds
B. 20 seconds
C. 1 minute
D. 5 seconds
Correct Answer: B
Explanation: The Centers for Disease Control and Prevention (CDC) recommends
scrubbing hands with soap for at least 20 seconds to effectively remove pathogens. This
duration ensures that all surfaces of the hands, including between fingers and under nails,
are thoroughly cleaned. Proper hand hygiene is the single most important intervention in
preventing the spread of healthcare-associated infections.
, 4. Which of the following describes the ‘Evaluation’ phase of the nursing process?
A. Collecting data and performing a physical exam
B. Performing a prescribed nursing intervention
C. Identifying the patient’s response to an actual health problem
D. Determining if the patient’s goals and outcomes were met
Correct Answer: D
Explanation: Evaluation is the final step of the nursing process where the nurse assesses
the patient’s progress toward goal achievement. During this phase, the nurse determines if
the interventions were successful or if the plan of care needs modification. It is a
continuous process that ensures the patient is receiving effective and appropriate care.
5. A patient has a large abdominal wound that is healing by secondary intention. The nurse
understands that this type of healing involves:
A. Suturing the wound edges together immediately
B. A low risk of infection due to rapid closure
C. The wound edges being left open to fill with granulation tissue
D. Minimal scarring compared to primary intention
Correct Answer: C
Explanation: Secondary intention occurs when a wound has edges that cannot be
approximated, such as a pressure injury or large burn. The wound heals from the bottom
