NUR 2356: MULTIDIMENSIONAL CARE I
EXAM 1 COMPREHENSIVE
ASSESSMENT QUESTIONS AND
VERIFIED ANSWERS |GRADE A+| JUST
RELEASED
1. A nurse is assessing a patient who is experiencing acute pain following surgery. According
to the nursing process, which action should the nurse take first?
A. Administer the prescribed analgesic medication.
B. Assess the intensity, location, and quality of the pain.
C. Document the patient’s report of pain in the medical record.
D. Re-evaluate the patient’s pain level 30 minutes after intervention.
Answer: B
Conceptual Explanation: Assessment is the first step of the nursing process. The nurse
must collect comprehensive data about the pain before implementing interventions or
evaluating them.
,2. Using Maslow’s Hierarchy of Needs, which patient should the nurse prioritize for
immediate intervention?
A. A patient expressing feelings of loneliness and isolation.
B. A patient who is concerned about their ability to pay for their hospital stay.
C. A patient with a respiratory rate of 28 breaths per minute and audible wheezing.
D. A patient asking for information regarding their new diagnosis.
Answer: C
Conceptual Explanation: Physiological needs, specifically airway and breathing, are at the
base of Maslow’s hierarchy and take precedence over safety, love/belonging, and self-
esteem needs.
3. A nurse is caring for a patient who has been immobile for several days. Which clinical
manifestation should the nurse identify as a potential complication of immobility?
A. Increased bowel sounds and diarrhea.
B. Redness and edema in the left calf.
C. Decreased heart rate during activity.
D. Improved lung expansion and increased oxygen saturation.
Answer: B
Conceptual Explanation: Immobility increases the risk of Deep Vein Thrombosis (DVT),
often manifested by unilateral redness, warmth, and edema in the lower extremities.
, 4. When assessing a pressure injury, the nurse notes full-thickness skin loss with visible
subcutaneous fat, but no bone or muscle is exposed. How should this be staged?
A. Stage 1
B. Stage 2
C. Stage 3
D. Stage 4
Answer: C
Conceptual Explanation: Stage 3 pressure injuries involve full-thickness skin loss where
adipose (fat) is visible, but fascia, muscle, tendons, or bone are not exposed.
5. A nurse is preparing to perform a sterile dressing change. Which action would violate the
principles of surgical asepsis?
A. Reaching over the sterile field to pick up a discarded wrapper.
B. Dropping a sterile gauze pad onto the center of the sterile field.
C. Keeping the sterile field within the direct line of vision.
D. Holding sterile forceps above the level of the waist.
Answer: A
Conceptual Explanation: Reaching over a sterile field contaminates it because
microorganisms can fall from the nurse’s clothing or arms onto the field.
EXAM 1 COMPREHENSIVE
ASSESSMENT QUESTIONS AND
VERIFIED ANSWERS |GRADE A+| JUST
RELEASED
1. A nurse is assessing a patient who is experiencing acute pain following surgery. According
to the nursing process, which action should the nurse take first?
A. Administer the prescribed analgesic medication.
B. Assess the intensity, location, and quality of the pain.
C. Document the patient’s report of pain in the medical record.
D. Re-evaluate the patient’s pain level 30 minutes after intervention.
Answer: B
Conceptual Explanation: Assessment is the first step of the nursing process. The nurse
must collect comprehensive data about the pain before implementing interventions or
evaluating them.
,2. Using Maslow’s Hierarchy of Needs, which patient should the nurse prioritize for
immediate intervention?
A. A patient expressing feelings of loneliness and isolation.
B. A patient who is concerned about their ability to pay for their hospital stay.
C. A patient with a respiratory rate of 28 breaths per minute and audible wheezing.
D. A patient asking for information regarding their new diagnosis.
Answer: C
Conceptual Explanation: Physiological needs, specifically airway and breathing, are at the
base of Maslow’s hierarchy and take precedence over safety, love/belonging, and self-
esteem needs.
3. A nurse is caring for a patient who has been immobile for several days. Which clinical
manifestation should the nurse identify as a potential complication of immobility?
A. Increased bowel sounds and diarrhea.
B. Redness and edema in the left calf.
C. Decreased heart rate during activity.
D. Improved lung expansion and increased oxygen saturation.
Answer: B
Conceptual Explanation: Immobility increases the risk of Deep Vein Thrombosis (DVT),
often manifested by unilateral redness, warmth, and edema in the lower extremities.
, 4. When assessing a pressure injury, the nurse notes full-thickness skin loss with visible
subcutaneous fat, but no bone or muscle is exposed. How should this be staged?
A. Stage 1
B. Stage 2
C. Stage 3
D. Stage 4
Answer: C
Conceptual Explanation: Stage 3 pressure injuries involve full-thickness skin loss where
adipose (fat) is visible, but fascia, muscle, tendons, or bone are not exposed.
5. A nurse is preparing to perform a sterile dressing change. Which action would violate the
principles of surgical asepsis?
A. Reaching over the sterile field to pick up a discarded wrapper.
B. Dropping a sterile gauze pad onto the center of the sterile field.
C. Keeping the sterile field within the direct line of vision.
D. Holding sterile forceps above the level of the waist.
Answer: A
Conceptual Explanation: Reaching over a sterile field contaminates it because
microorganisms can fall from the nurse’s clothing or arms onto the field.
