NSG 100 Exams 1–4 + Final
,TABLE OF CONTENTS
• Exam 1 — Nursing Foundations: Nursing Process • Clinical Judgment • Prioritization •
Infection Control • Cultural Care
• Exam 2 — Safety & Oxygenation: Patient Safety • Falls • ADLs/IADLs • Mobility • Body
Mechanics • Perfusion • Gas Exchange • Respiratory Care
• Exam 3 — Pharmacology & Physical Function: Medication Safety •
Pharmacokinetics/Pharmacodynamics • Lifespan Pharmacology • Musculoskeletal Health • Skin
Integrity • Pressure Injuries
• Exam 4 — Nutrition, Elimination & Pain: Nutrition • Urinary Elimination • Bowel Elimination •
BPH • Pain Physiology • Pain Assessment & Management
• Final Exam — Comprehensive Review: Integrated review of Nursing Process • Safety •
Infection • Mobility • Oxygenation • Pharmacology • Skin • Nutrition • Elimination • Pain •
Lifespan Concepts
,EXAM 1 — Nursing Process, Prioritization, Clinical Judgment & Infection
Control
Question 1
Change-of-shift report identifies four clients. Which client should the nurse assess first?
A. Client requesting assistance to ambulate to the bathroom
B. Client reporting incisional pain rated 6/10
C. Client waiting for discharge-teaching clarification
D. Client with new inspiratory stridor and increasing restlessness
Correct Answer: D. Client with new inspiratory stridor and increasing restlessness
Rationale: Inspiratory stridor suggests significant upper-airway narrowing and can rapidly progress to
complete obstruction. Restlessness may also indicate worsening hypoxemia. Airway problems take
priority over pain, mobility, and teaching needs because failure to maintain an airway immediately
threatens life.
Concept Pearl: ABC priorities place airway before breathing, circulation, comfort, and education.
Exam Strategy: When one option contains an acute airway threat, evaluate it before less immediate
problems.
Question 2
Reviewing a newly admitted client's report of weakness and excessive thirst, which nursing action
belongs to the assessment phase?
A. Establishing a goal for improved hydration
B. Asking when the symptoms began and what makes them worse
C. Selecting interventions to improve fluid intake
D. Determining whether the interventions were effective
Correct Answer: B. Asking when the symptoms began and what makes them worse
Rationale: Assessment involves systematically collecting subjective and objective information about the
client's health status. Asking about onset, duration, severity, and associated symptoms expands the
database. Goals and interventions occur after data have been collected and analyzed.
Concept Pearl: Assessment comes before diagnosis, planning, implementation, and evaluation.
Exam Strategy: If the nurse is gathering information, the nursing-process step is assessment.
Question 3
Which information should the nurse classify as subjective data?
A. Respiratory rate of 26/min
B. Temperature of 38.2°C
C. “I feel dizzy whenever I stand up.”
D. Yellow drainage observed on the dressing
Correct Answer: C. “I feel dizzy whenever I stand up.”
,Rationale: Subjective data consist of sensations, symptoms, beliefs, perceptions, and experiences
reported by the client. Dizziness cannot be directly measured by the nurse. Respiratory rate,
temperature, and visible drainage are objective findings because they can be observed or measured.
Concept Pearl: Subjective = what the client says; objective = what the nurse observes or measures.
Exam Strategy: Look for quotation marks or personal symptoms when identifying subjective data.
Question 4
An alert, oriented client arrives with sudden abdominal pain. Which source should provide the nurse's
primary data?
A. The client
B. The client's spouse
C. The emergency medical technician
D. The electronic medical record
Correct Answer: A. The client
Rationale: Whenever the client can communicate reliably, the client is the primary source of health
information. Family members, health professionals, and records provide secondary data. Secondary
sources become especially important when the client cannot provide accurate information.
Concept Pearl: The client is normally the best primary source.
Exam Strategy: Unless cognition or communication is impaired, select the client as the primary source.
Question 5
Following collection and clustering of assessment findings, which statement best describes a nursing
diagnosis?
A. It identifies the disease responsible for the client's hospitalization
B. It represents a clinical judgment about human responses to health conditions
C. It lists all prescribed medical treatments
D. It predicts the client's final medical outcome
Correct Answer: B. It represents a clinical judgment about human responses to health
conditions
Rationale: Nursing diagnoses address actual or potential human responses that nurses can assess,
monitor, prevent, or treat within nursing practice. They are developed from assessment data and clinical
judgment. They are distinct from medical diagnoses, which identify diseases or pathological conditions.
Concept Pearl: Medical diagnosis identifies disease; nursing diagnosis identifies human response.
Exam Strategy: If the wording focuses on the client's response, think nursing diagnosis.
Question 6
Which nursing-diagnosis statement is written most appropriately?
A. Pneumonia related to bacterial infection
B. Risk for falls as evidenced by two falls yesterday
C. Impaired mobility related to physician diagnosis
D. Acute Pain related to tissue trauma as evidenced by pain rated 8/10
,Correct Answer: D. Acute Pain related to tissue trauma as evidenced by pain rated 8/10
Rationale: An actual nursing diagnosis commonly includes the problem, contributing etiology, and
defining evidence. Option D identifies a nursing problem, a related factor, and supporting evidence.
Medical diagnoses should not replace nursing diagnostic labels or etiologies.
Concept Pearl: Actual diagnosis = problem + related factor + defining characteristics.
Exam Strategy: Check whether each part describes something nursing assessment and intervention
can address.
Question 7
Immobility contributes to a client's impaired skin integrity. Within the nursing diagnosis, immobility
represents the:
A. Etiology
B. Diagnostic label
C. Outcome
D. Evaluation criterion
Correct Answer: A. Etiology
Rationale: Etiology describes the factor contributing to or maintaining the nursing problem. Recognizing
the etiology helps the nurse select interventions aimed at the cause rather than only the symptom. The
diagnostic label identifies the actual human response.
Concept Pearl: Etiology answers: What is contributing to the problem?
Exam Strategy: In a “related to” statement, the information after related to is generally the etiology.
Question 8
Complete the nursing-process pathway:
ASSESSMENT
↓
DIAGNOSIS
↓
PLANNING
↓
__________
↓
EVALUATION
Which term belongs in the blank?
A. Interpretation
B. Reflection
C. Implementation
D. Prognosis
Correct Answer: C. Implementation
Rationale: After assessment, diagnosis, and planning, the nurse carries out the selected nursing
interventions during implementation. Evaluation follows to determine whether the interventions moved
,the client toward the expected outcomes. The process remains dynamic and may cycle back to
reassessment.
Concept Pearl: ADPIE = Assessment, Diagnosis, Planning, Implementation, Evaluation.
Exam Strategy: Memorize the sequence, but also understand what the nurse does within each step.
Question 9
Assessment findings are grouped into patterns, compared with expected findings, and analyzed for
significance. Which component of Tanner's clinical-judgment process is occurring?
A. Noticing
B. Responding
C. Reflecting
D. Interpreting
Correct Answer: D. Interpreting
Rationale: Interpreting involves making sense of cues by comparing, clustering, analyzing, and
determining their importance. Noticing involves recognizing important information initially. Responding
involves acting, while reflecting involves reviewing the experience and learning from it.
Concept Pearl: Tanner: Notice → Interpret → Respond → Reflect.
Exam Strategy: Words such as analyze, cluster, compare, and make sense of indicate interpreting.
Question 10
After a difficult clinical situation, which question best demonstrates reflection?
A. “Which finding should I collect first?”
B. “What could I change next time to improve the outcome?”
C. “Which intervention should I perform now?”
D. “Which diagnosis is the provider considering?”
Correct Answer: B. “What could I change next time to improve the outcome?”
Rationale: Reflection involves looking back on decisions, actions, and outcomes to identify what worked
and what could be improved. It supports development of clinical judgment over time. Questions about
what is occurring now relate more closely to noticing or responding.
Concept Pearl: Reflection converts clinical experience into future learning.
Exam Strategy: If the question looks backward at completed care, think reflection.
Question 11
Which outcome is written according to SMART principles?
A. Client will feel much better soon.
B. Nurse will encourage ambulation frequently.
C. Client will ambulate 50 feet with a walker by 1600 today without dizziness.
D. Client will improve mobility before discharge.
Correct Answer: C. Client will ambulate 50 feet with a walker by 1600 today without dizziness.
,Rationale: This outcome is specific, measurable, attainable, relevant, and time limited. It describes
exactly what the client will accomplish and provides a measurable distance and deadline. The other
options are vague or describe a nursing action instead of a client outcome.
Concept Pearl: SMART outcomes must be measurable enough for later evaluation.
Exam Strategy: Look for client-centered action + measurable criterion + time frame.
Question 12
Which statement is an expected outcome rather than a nursing intervention?
A. Client will demonstrate correct incentive-spirometer use before the end of teaching.
B. Nurse will assist the client to sit upright.
C. Oxygen will be applied as prescribed.
D. Respiratory therapy will evaluate the client.
Correct Answer: A. Client will demonstrate correct incentive-spirometer use before the end of
teaching.
Rationale: Outcomes describe a measurable change or behavior expected from the client. Positioning,
oxygen administration, and consultation are actions performed by health professionals and therefore
are interventions. Evaluation later determines whether the outcome was achieved.
Concept Pearl: Outcome = what the client will achieve; intervention = what the nurse will do.
Exam Strategy: A well-written outcome usually begins with “The client will…”
Question 13
Which intervention may the nurse initiate independently?
A. Beginning an IV antibiotic
B. Changing the prescribed oxygen flow rate without an order
C. Requesting a new prescription for physical therapy
D. Repositioning an immobile client every 2 hours
Correct Answer: D. Repositioning an immobile client every 2 hours
Rationale: Independent nursing interventions fall within nursing scope and do not require a provider
prescription. Repositioning prevents pressure injury and is a routine nursing intervention. Medication
administration and changes to prescribed therapy require appropriate orders or collaboration.
Concept Pearl: Education, positioning, comfort measures, and many preventive actions are
independent interventions.
Exam Strategy: Ask whether the nurse can legally perform the action without first obtaining another
professional's order.
Question 14
Which action is best classified as a collaborative intervention?
A. Teaching a client to cough and deep-breathe
B. Reinforcing transfer techniques recommended by physical therapy
C. Repositioning a client with limited mobility
D. Providing emotional support before surgery
,Correct Answer: B. Reinforcing transfer techniques recommended by physical therapy
Rationale: Collaborative interventions involve coordinated care with another healthcare discipline.
Reinforcing a physical therapist's mobility plan is part of interdisciplinary collaboration. Teaching,
positioning, and emotional support can generally be independently initiated by nursing.
Concept Pearl: Collaborative care combines the expertise of multiple disciplines.
Exam Strategy: If the intervention depends on another healthcare team's specialty plan, think
collaborative.
Question 15
Which action is an example of an indirect-care intervention?
A. Participating in an interdisciplinary care conference about the client's discharge needs
B. Assisting the client with bathing
C. Teaching insulin self-administration
D. Applying a warm compress for comfort
Correct Answer: A. Participating in an interdisciplinary care conference about the client's
discharge needs
Rationale: Indirect care occurs away from direct interaction with the client but is performed on the
client's behalf. Communication, coordination, consultation, and documentation may all be indirect-care
activities. Bathing, teaching, and comfort measures involve direct client interaction.
Concept Pearl: Indirect care still benefits the client even when the client is not physically present.
Exam Strategy: Ask whether the intervention occurs with the client or on behalf of the client.
Question 16
Thirty minutes after administering an analgesic, the nurse reassesses the client's pain level. Which
nursing-process phase is being demonstrated?
A. Diagnosis
B. Planning
C. Evaluation
D. Implementation only
Correct Answer: C. Evaluation
Rationale: Evaluation determines the client's response to interventions and whether expected
outcomes are being achieved. Reassessing pain after treatment allows the nurse to determine
effectiveness. Depending on findings, the plan may be continued, modified, or stopped.
Concept Pearl: Evaluation always compares the client's current status with an expected outcome.
Exam Strategy: Watch for wording such as after an intervention, response, or goal met.
Question 17
The expected wound-healing outcome has not been achieved by the planned date. Which action
should occur first?
,A. Discontinue the care plan
B. Automatically extend the goal date
C. Add several new interventions immediately
D. Reassess the client and wound before revising the plan
Correct Answer: D. Reassess the client and wound before revising the plan
Rationale: Unmet outcomes require the nurse to determine why progress did not occur. Reassessment
provides updated data about the wound, contributing factors, and client response. Revising goals or
interventions without reassessment may result in inappropriate care.
Concept Pearl: When outcomes are unmet, return to assessment.
Exam Strategy: Nursing process is cyclical; a failed outcome often sends you back to collect new data.
Question 18
A client requests that meals exclude certain foods because of religious practices. Which nursing
response best demonstrates culturally competent care?
A. Ask the client which foods are acceptable and incorporate the preferences when possible.
B. Explain that hospital menus cannot accommodate individual beliefs.
C. Ask the family to bring every meal from home.
D. Choose foods based on what is commonly associated with the client's religion.
Correct Answer: A. Ask the client which foods are acceptable and incorporate the preferences
when possible.
Rationale: Culturally competent care begins with individualized assessment rather than assumptions
based on group membership. Asking the client directly respects autonomy and identifies actual
preferences. The nurse can then collaborate with dietary services to provide appropriate choices.
Concept Pearl: Cultural assessment should be individualized, respectful, and free of stereotyping.
Exam Strategy: Choose the option that asks rather than assumes.
Question 19
Which cluster of findings is most consistent with a systemic infection?
A. Localized redness, warmth, and tenderness only
B. Fever, malaise, and tachycardia
C. Mild bruising around an IV site
D. Dry skin and decreased turgor
Correct Answer: B. Fever, malaise, and tachycardia
Rationale: Systemic infection affects the body more broadly and commonly produces fever, chills,
malaise, fatigue, and increased heart rate. Redness, warmth, swelling, and tenderness are more typical
of a localized inflammatory or infectious process.
Concept Pearl: Systemic infection produces whole-body manifestations.
Exam Strategy: Fever plus generalized symptoms should make you think systemic rather than local
infection.
,Question 20
Which stage of infection is commonly associated with vague symptoms such as fatigue and malaise
while organisms continue multiplying and transmission risk may be high?
A. Incubation
B. Full stage of illness
C. Prodromal stage
D. Convalescent stage
Correct Answer: C. Prodromal stage
Rationale: The prodromal stage occurs after incubation and is characterized by early, often nonspecific
symptoms. Because the individual may not yet recognize the illness, opportunities for transmission can
be substantial. Specific disease manifestations become more apparent during the full stage.
Concept Pearl: Prodromal = early vague symptoms before the disease is fully expressed.
Exam Strategy: “Vague early symptoms” is the key clue for the prodromal stage.
Question 21
Study the chain of infection:
INFECTIOUS AGENT
↓
RESERVOIR
↓
PORTAL OF EXIT
↓
MODE OF TRANSMISSION
↓
PORTAL OF ENTRY
↓
SUSCEPTIBLE HOST
Respiratory droplets leaving an infected client's mouth during coughing represent the:
A. Portal of exit
B. Reservoir
C. Susceptible host
D. Portal of entry
Correct Answer: A. Portal of exit
Rationale: A portal of exit is the route through which a microorganism leaves its reservoir or infected
host. Respiratory secretions, blood, urine, stool, and wound drainage can all serve as exit routes.
Transmission cannot continue unless organisms leave the reservoir.
Concept Pearl: Breaking any link in the infection chain can reduce transmission.
Exam Strategy: Ask, “How is the organism leaving the infected person?”
Question 22
What is an important protective function of normal microbial flora?
,TABLE OF CONTENTS
• Exam 1 — Nursing Foundations: Nursing Process • Clinical Judgment • Prioritization •
Infection Control • Cultural Care
• Exam 2 — Safety & Oxygenation: Patient Safety • Falls • ADLs/IADLs • Mobility • Body
Mechanics • Perfusion • Gas Exchange • Respiratory Care
• Exam 3 — Pharmacology & Physical Function: Medication Safety •
Pharmacokinetics/Pharmacodynamics • Lifespan Pharmacology • Musculoskeletal Health • Skin
Integrity • Pressure Injuries
• Exam 4 — Nutrition, Elimination & Pain: Nutrition • Urinary Elimination • Bowel Elimination •
BPH • Pain Physiology • Pain Assessment & Management
• Final Exam — Comprehensive Review: Integrated review of Nursing Process • Safety •
Infection • Mobility • Oxygenation • Pharmacology • Skin • Nutrition • Elimination • Pain •
Lifespan Concepts
,EXAM 1 — Nursing Process, Prioritization, Clinical Judgment & Infection
Control
Question 1
Change-of-shift report identifies four clients. Which client should the nurse assess first?
A. Client requesting assistance to ambulate to the bathroom
B. Client reporting incisional pain rated 6/10
C. Client waiting for discharge-teaching clarification
D. Client with new inspiratory stridor and increasing restlessness
Correct Answer: D. Client with new inspiratory stridor and increasing restlessness
Rationale: Inspiratory stridor suggests significant upper-airway narrowing and can rapidly progress to
complete obstruction. Restlessness may also indicate worsening hypoxemia. Airway problems take
priority over pain, mobility, and teaching needs because failure to maintain an airway immediately
threatens life.
Concept Pearl: ABC priorities place airway before breathing, circulation, comfort, and education.
Exam Strategy: When one option contains an acute airway threat, evaluate it before less immediate
problems.
Question 2
Reviewing a newly admitted client's report of weakness and excessive thirst, which nursing action
belongs to the assessment phase?
A. Establishing a goal for improved hydration
B. Asking when the symptoms began and what makes them worse
C. Selecting interventions to improve fluid intake
D. Determining whether the interventions were effective
Correct Answer: B. Asking when the symptoms began and what makes them worse
Rationale: Assessment involves systematically collecting subjective and objective information about the
client's health status. Asking about onset, duration, severity, and associated symptoms expands the
database. Goals and interventions occur after data have been collected and analyzed.
Concept Pearl: Assessment comes before diagnosis, planning, implementation, and evaluation.
Exam Strategy: If the nurse is gathering information, the nursing-process step is assessment.
Question 3
Which information should the nurse classify as subjective data?
A. Respiratory rate of 26/min
B. Temperature of 38.2°C
C. “I feel dizzy whenever I stand up.”
D. Yellow drainage observed on the dressing
Correct Answer: C. “I feel dizzy whenever I stand up.”
,Rationale: Subjective data consist of sensations, symptoms, beliefs, perceptions, and experiences
reported by the client. Dizziness cannot be directly measured by the nurse. Respiratory rate,
temperature, and visible drainage are objective findings because they can be observed or measured.
Concept Pearl: Subjective = what the client says; objective = what the nurse observes or measures.
Exam Strategy: Look for quotation marks or personal symptoms when identifying subjective data.
Question 4
An alert, oriented client arrives with sudden abdominal pain. Which source should provide the nurse's
primary data?
A. The client
B. The client's spouse
C. The emergency medical technician
D. The electronic medical record
Correct Answer: A. The client
Rationale: Whenever the client can communicate reliably, the client is the primary source of health
information. Family members, health professionals, and records provide secondary data. Secondary
sources become especially important when the client cannot provide accurate information.
Concept Pearl: The client is normally the best primary source.
Exam Strategy: Unless cognition or communication is impaired, select the client as the primary source.
Question 5
Following collection and clustering of assessment findings, which statement best describes a nursing
diagnosis?
A. It identifies the disease responsible for the client's hospitalization
B. It represents a clinical judgment about human responses to health conditions
C. It lists all prescribed medical treatments
D. It predicts the client's final medical outcome
Correct Answer: B. It represents a clinical judgment about human responses to health
conditions
Rationale: Nursing diagnoses address actual or potential human responses that nurses can assess,
monitor, prevent, or treat within nursing practice. They are developed from assessment data and clinical
judgment. They are distinct from medical diagnoses, which identify diseases or pathological conditions.
Concept Pearl: Medical diagnosis identifies disease; nursing diagnosis identifies human response.
Exam Strategy: If the wording focuses on the client's response, think nursing diagnosis.
Question 6
Which nursing-diagnosis statement is written most appropriately?
A. Pneumonia related to bacterial infection
B. Risk for falls as evidenced by two falls yesterday
C. Impaired mobility related to physician diagnosis
D. Acute Pain related to tissue trauma as evidenced by pain rated 8/10
,Correct Answer: D. Acute Pain related to tissue trauma as evidenced by pain rated 8/10
Rationale: An actual nursing diagnosis commonly includes the problem, contributing etiology, and
defining evidence. Option D identifies a nursing problem, a related factor, and supporting evidence.
Medical diagnoses should not replace nursing diagnostic labels or etiologies.
Concept Pearl: Actual diagnosis = problem + related factor + defining characteristics.
Exam Strategy: Check whether each part describes something nursing assessment and intervention
can address.
Question 7
Immobility contributes to a client's impaired skin integrity. Within the nursing diagnosis, immobility
represents the:
A. Etiology
B. Diagnostic label
C. Outcome
D. Evaluation criterion
Correct Answer: A. Etiology
Rationale: Etiology describes the factor contributing to or maintaining the nursing problem. Recognizing
the etiology helps the nurse select interventions aimed at the cause rather than only the symptom. The
diagnostic label identifies the actual human response.
Concept Pearl: Etiology answers: What is contributing to the problem?
Exam Strategy: In a “related to” statement, the information after related to is generally the etiology.
Question 8
Complete the nursing-process pathway:
ASSESSMENT
↓
DIAGNOSIS
↓
PLANNING
↓
__________
↓
EVALUATION
Which term belongs in the blank?
A. Interpretation
B. Reflection
C. Implementation
D. Prognosis
Correct Answer: C. Implementation
Rationale: After assessment, diagnosis, and planning, the nurse carries out the selected nursing
interventions during implementation. Evaluation follows to determine whether the interventions moved
,the client toward the expected outcomes. The process remains dynamic and may cycle back to
reassessment.
Concept Pearl: ADPIE = Assessment, Diagnosis, Planning, Implementation, Evaluation.
Exam Strategy: Memorize the sequence, but also understand what the nurse does within each step.
Question 9
Assessment findings are grouped into patterns, compared with expected findings, and analyzed for
significance. Which component of Tanner's clinical-judgment process is occurring?
A. Noticing
B. Responding
C. Reflecting
D. Interpreting
Correct Answer: D. Interpreting
Rationale: Interpreting involves making sense of cues by comparing, clustering, analyzing, and
determining their importance. Noticing involves recognizing important information initially. Responding
involves acting, while reflecting involves reviewing the experience and learning from it.
Concept Pearl: Tanner: Notice → Interpret → Respond → Reflect.
Exam Strategy: Words such as analyze, cluster, compare, and make sense of indicate interpreting.
Question 10
After a difficult clinical situation, which question best demonstrates reflection?
A. “Which finding should I collect first?”
B. “What could I change next time to improve the outcome?”
C. “Which intervention should I perform now?”
D. “Which diagnosis is the provider considering?”
Correct Answer: B. “What could I change next time to improve the outcome?”
Rationale: Reflection involves looking back on decisions, actions, and outcomes to identify what worked
and what could be improved. It supports development of clinical judgment over time. Questions about
what is occurring now relate more closely to noticing or responding.
Concept Pearl: Reflection converts clinical experience into future learning.
Exam Strategy: If the question looks backward at completed care, think reflection.
Question 11
Which outcome is written according to SMART principles?
A. Client will feel much better soon.
B. Nurse will encourage ambulation frequently.
C. Client will ambulate 50 feet with a walker by 1600 today without dizziness.
D. Client will improve mobility before discharge.
Correct Answer: C. Client will ambulate 50 feet with a walker by 1600 today without dizziness.
,Rationale: This outcome is specific, measurable, attainable, relevant, and time limited. It describes
exactly what the client will accomplish and provides a measurable distance and deadline. The other
options are vague or describe a nursing action instead of a client outcome.
Concept Pearl: SMART outcomes must be measurable enough for later evaluation.
Exam Strategy: Look for client-centered action + measurable criterion + time frame.
Question 12
Which statement is an expected outcome rather than a nursing intervention?
A. Client will demonstrate correct incentive-spirometer use before the end of teaching.
B. Nurse will assist the client to sit upright.
C. Oxygen will be applied as prescribed.
D. Respiratory therapy will evaluate the client.
Correct Answer: A. Client will demonstrate correct incentive-spirometer use before the end of
teaching.
Rationale: Outcomes describe a measurable change or behavior expected from the client. Positioning,
oxygen administration, and consultation are actions performed by health professionals and therefore
are interventions. Evaluation later determines whether the outcome was achieved.
Concept Pearl: Outcome = what the client will achieve; intervention = what the nurse will do.
Exam Strategy: A well-written outcome usually begins with “The client will…”
Question 13
Which intervention may the nurse initiate independently?
A. Beginning an IV antibiotic
B. Changing the prescribed oxygen flow rate without an order
C. Requesting a new prescription for physical therapy
D. Repositioning an immobile client every 2 hours
Correct Answer: D. Repositioning an immobile client every 2 hours
Rationale: Independent nursing interventions fall within nursing scope and do not require a provider
prescription. Repositioning prevents pressure injury and is a routine nursing intervention. Medication
administration and changes to prescribed therapy require appropriate orders or collaboration.
Concept Pearl: Education, positioning, comfort measures, and many preventive actions are
independent interventions.
Exam Strategy: Ask whether the nurse can legally perform the action without first obtaining another
professional's order.
Question 14
Which action is best classified as a collaborative intervention?
A. Teaching a client to cough and deep-breathe
B. Reinforcing transfer techniques recommended by physical therapy
C. Repositioning a client with limited mobility
D. Providing emotional support before surgery
,Correct Answer: B. Reinforcing transfer techniques recommended by physical therapy
Rationale: Collaborative interventions involve coordinated care with another healthcare discipline.
Reinforcing a physical therapist's mobility plan is part of interdisciplinary collaboration. Teaching,
positioning, and emotional support can generally be independently initiated by nursing.
Concept Pearl: Collaborative care combines the expertise of multiple disciplines.
Exam Strategy: If the intervention depends on another healthcare team's specialty plan, think
collaborative.
Question 15
Which action is an example of an indirect-care intervention?
A. Participating in an interdisciplinary care conference about the client's discharge needs
B. Assisting the client with bathing
C. Teaching insulin self-administration
D. Applying a warm compress for comfort
Correct Answer: A. Participating in an interdisciplinary care conference about the client's
discharge needs
Rationale: Indirect care occurs away from direct interaction with the client but is performed on the
client's behalf. Communication, coordination, consultation, and documentation may all be indirect-care
activities. Bathing, teaching, and comfort measures involve direct client interaction.
Concept Pearl: Indirect care still benefits the client even when the client is not physically present.
Exam Strategy: Ask whether the intervention occurs with the client or on behalf of the client.
Question 16
Thirty minutes after administering an analgesic, the nurse reassesses the client's pain level. Which
nursing-process phase is being demonstrated?
A. Diagnosis
B. Planning
C. Evaluation
D. Implementation only
Correct Answer: C. Evaluation
Rationale: Evaluation determines the client's response to interventions and whether expected
outcomes are being achieved. Reassessing pain after treatment allows the nurse to determine
effectiveness. Depending on findings, the plan may be continued, modified, or stopped.
Concept Pearl: Evaluation always compares the client's current status with an expected outcome.
Exam Strategy: Watch for wording such as after an intervention, response, or goal met.
Question 17
The expected wound-healing outcome has not been achieved by the planned date. Which action
should occur first?
,A. Discontinue the care plan
B. Automatically extend the goal date
C. Add several new interventions immediately
D. Reassess the client and wound before revising the plan
Correct Answer: D. Reassess the client and wound before revising the plan
Rationale: Unmet outcomes require the nurse to determine why progress did not occur. Reassessment
provides updated data about the wound, contributing factors, and client response. Revising goals or
interventions without reassessment may result in inappropriate care.
Concept Pearl: When outcomes are unmet, return to assessment.
Exam Strategy: Nursing process is cyclical; a failed outcome often sends you back to collect new data.
Question 18
A client requests that meals exclude certain foods because of religious practices. Which nursing
response best demonstrates culturally competent care?
A. Ask the client which foods are acceptable and incorporate the preferences when possible.
B. Explain that hospital menus cannot accommodate individual beliefs.
C. Ask the family to bring every meal from home.
D. Choose foods based on what is commonly associated with the client's religion.
Correct Answer: A. Ask the client which foods are acceptable and incorporate the preferences
when possible.
Rationale: Culturally competent care begins with individualized assessment rather than assumptions
based on group membership. Asking the client directly respects autonomy and identifies actual
preferences. The nurse can then collaborate with dietary services to provide appropriate choices.
Concept Pearl: Cultural assessment should be individualized, respectful, and free of stereotyping.
Exam Strategy: Choose the option that asks rather than assumes.
Question 19
Which cluster of findings is most consistent with a systemic infection?
A. Localized redness, warmth, and tenderness only
B. Fever, malaise, and tachycardia
C. Mild bruising around an IV site
D. Dry skin and decreased turgor
Correct Answer: B. Fever, malaise, and tachycardia
Rationale: Systemic infection affects the body more broadly and commonly produces fever, chills,
malaise, fatigue, and increased heart rate. Redness, warmth, swelling, and tenderness are more typical
of a localized inflammatory or infectious process.
Concept Pearl: Systemic infection produces whole-body manifestations.
Exam Strategy: Fever plus generalized symptoms should make you think systemic rather than local
infection.
,Question 20
Which stage of infection is commonly associated with vague symptoms such as fatigue and malaise
while organisms continue multiplying and transmission risk may be high?
A. Incubation
B. Full stage of illness
C. Prodromal stage
D. Convalescent stage
Correct Answer: C. Prodromal stage
Rationale: The prodromal stage occurs after incubation and is characterized by early, often nonspecific
symptoms. Because the individual may not yet recognize the illness, opportunities for transmission can
be substantial. Specific disease manifestations become more apparent during the full stage.
Concept Pearl: Prodromal = early vague symptoms before the disease is fully expressed.
Exam Strategy: “Vague early symptoms” is the key clue for the prodromal stage.
Question 21
Study the chain of infection:
INFECTIOUS AGENT
↓
RESERVOIR
↓
PORTAL OF EXIT
↓
MODE OF TRANSMISSION
↓
PORTAL OF ENTRY
↓
SUSCEPTIBLE HOST
Respiratory droplets leaving an infected client's mouth during coughing represent the:
A. Portal of exit
B. Reservoir
C. Susceptible host
D. Portal of entry
Correct Answer: A. Portal of exit
Rationale: A portal of exit is the route through which a microorganism leaves its reservoir or infected
host. Respiratory secretions, blood, urine, stool, and wound drainage can all serve as exit routes.
Transmission cannot continue unless organisms leave the reservoir.
Concept Pearl: Breaking any link in the infection chain can reduce transmission.
Exam Strategy: Ask, “How is the organism leaving the infected person?”
Question 22
What is an important protective function of normal microbial flora?
