NSG 122 Exam 1: Nursing Fundamental Concepts
— Herzing University with answers and
rationale graded A+
Unit 1: Nursing Process & Clinical Judgment
1. A nurse is collecting data from a client who reports abdominal pain. Which action represents
the assessment phase of the nursing process?
A) Administering prescribed pain medication
B) Setting a goal for pain relief within 1 hour
C) Measuring vital signs and asking the client to describe the pain
D) Re-evaluating the client's pain level 30 minutes after intervention
Answer: C — Rationale: The assessment phase involves systematic data collection. Measuring vital
signs and obtaining the client's description of pain are assessment activities. Administering
medication is implementation, setting goals is planning, and re-evaluation is evaluation.-11
2. Which phase of the nursing process involves the nurse collecting subjective and objective
data about a patient's health status?
A) Planning
B) Diagnosis
C) Assessment
D) Evaluation
Answer: C — Rationale: Assessment is the first step of the nursing process where the nurse
systematically gathers information. This includes both subjective data reported by the patient and
objective data observed by the nurse.-4
3. A nurse gathers data about a patient's heart rate, blood pressure, lung sounds, and patient-
reported nausea. Which step of the nursing process is this?
A) Planning
B) Assessment
C) Implementation
D) Evaluation
Answer: B — Rationale: Assessment involves collecting both subjective (patient-reported nausea)
and objective (vital signs, lung sounds) data to establish a baseline.-3
4. During the planning phase, the nurse establishes a client goal. Which statement is an
example of a correctly written client goal?
A) "The nurse will assist the client to ambulate."
B) "The client will ambulate 50 feet with a walker by the end of the shift."
C) "The client should walk more every day."
D) "The nurse will encourage fluid intake."
Answer: B — Rationale: A proper client goal is SMART: Specific, Measurable, Attainable, Relevant,
and Time-bound. Option B specifies the client, the behavior, the distance, the method, and the
timeframe. Goals should be client-focused, not nurse-focused.-11
, 5. The nurse writes the following in a care plan: "Patient will ambulate 50 feet with a walker by
the end of the shift." This is an example of:
A) Nursing diagnosis
B) Goal/Outcome statement
C) Nursing intervention
D) Subjective data
Answer: B — Rationale: This is a measurable, patient-centered goal created during the Planning
phase. It is time-bound and specific.-3
6. A nurse is caring for a patient who is 24 hours post-surgery. The patient reports incisional
pain at a level of 7/10. The nurse administers the prescribed PRN analgesic. Thirty minutes
later, the nurse reassesses the patient's pain as 3/10. This reassessment represents which
step of the nursing process?
A) Assessment
B) Diagnosis
C) Implementation
D) Evaluation
Answer: D — Rationale: Evaluation is the final step where the nurse determines if the interventions
were effective by comparing the patient's current status to the expected outcomes.-3
7. A nurse is evaluating whether a client has met the goal to "void within 8 hours after catheter
removal." The client voided 200 mL 6 hours after catheter removal. What should the nurse
document?
A) Goal not met; client did not void
B) Goal met; client voided within the specified time frame
C) Goal partially met; the volume was insufficient
D) Goal cannot be evaluated
Answer: B — Rationale: The goal was met because the client voided within the 8-hour timeframe.
The goal did not specify a minimum volume. The evaluative statement should document the
outcome and supporting data.-11
8. A nurse is evaluating a patient's response to pain medication. Which finding indicates the
goal has been met?
A) Patient reports pain is 8/10
B) Patient is sleeping
C) Patient reports pain is 2/10 and is able to take deep breaths
D) Patient requests more medication
Answer: C — Rationale: The goal of pain management is to reduce pain to a tolerable level (2/10)
and improve function (deep breathing). Sleeping can be a side effect, not necessarily an indicator of
adequate pain relief.-3
9. The nurse is using the NCSBN Clinical Judgment Model. After recognizing cues and analyzing
them, what is the next step?
A) Evaluate outcomes
B) Generate solutions
C) Prioritize hypotheses
D) Take action
, Answer: C — Rationale: The order is: Recognize Cues → Analyze Cues → Prioritize Hypotheses →
Generate Solutions → Take Action → Evaluate Outcomes.-3
10. Which action demonstrates the use of clinical judgment?
A) Following a standard procedure without deviation
B) Recognizing that a client's blood pressure drop is significant and notifying the provider
with a recommendation
C) Documenting vital signs exactly as measured
D) Delegating all tasks to unlicensed assistive personnel
Answer: B — Rationale: Clinical judgment involves analyzing data, recognizing significant changes,
and taking appropriate action. Recognizing a BP drop and communicating with the provider
demonstrates interpretation and decision-making.-11
11. A patient has a blood pressure of 82/50 mmHg, heart rate of 122 bpm, and reports feeling
lightheaded. The nurse immediately places the patient in Trendelenburg position and calls
the provider. This action demonstrates:
A) Proper delegation
B) Clinical judgment and timely intervention
C) Evaluation of a care plan
D) Ethical decision-making
Answer: B — Rationale: The nurse recognized abnormal cues (hypotension, tachycardia), prioritized
the risk of shock, and took immediate action. This is clinical judgment in action.-3
12. A nursing student asks why the nursing process is considered cyclical rather than linear.
Which response by the instructor is most accurate?
A) "Each phase must be completed exactly once per client encounter."
B) "The process ends after evaluation unless the client deteriorates."
C) "Information from evaluation often leads back to reassessment or new diagnoses."
D) "Physicians must approve each cycle before nurses can proceed."
Answer: C — Rationale: The nursing process is cyclical because evaluation results may modify the
plan, requiring reassessment or new diagnoses.-9
13. The nurse has just received report on four clients. Which client should the nurse assess first?
A) A client with COPD and SpO2 of 89% on 2L nasal cannula
B) A client post-appendectomy day 2 with temperature of 38.3°C (101°F)
C) A client with heart failure and 3+ pitting edema
D) A client with new-onset confusion and a bounding pulse
Answer: D — Rationale: New-onset confusion with a bounding pulse suggests increased intracranial
pressure, hypercapnia, or fluid overload affecting cerebral perfusion. A change in neurological status
is always the priority over chronic or expected findings.-11
14. A nurse is caring for four clients. Which client should the nurse see first?
A) A client with a scheduled wound dressing change
B) A client with new-onset shortness of breath and SpO2 of 88%
C) A client requesting pain medication for a headache
D) A client who needs discharge teaching
— Herzing University with answers and
rationale graded A+
Unit 1: Nursing Process & Clinical Judgment
1. A nurse is collecting data from a client who reports abdominal pain. Which action represents
the assessment phase of the nursing process?
A) Administering prescribed pain medication
B) Setting a goal for pain relief within 1 hour
C) Measuring vital signs and asking the client to describe the pain
D) Re-evaluating the client's pain level 30 minutes after intervention
Answer: C — Rationale: The assessment phase involves systematic data collection. Measuring vital
signs and obtaining the client's description of pain are assessment activities. Administering
medication is implementation, setting goals is planning, and re-evaluation is evaluation.-11
2. Which phase of the nursing process involves the nurse collecting subjective and objective
data about a patient's health status?
A) Planning
B) Diagnosis
C) Assessment
D) Evaluation
Answer: C — Rationale: Assessment is the first step of the nursing process where the nurse
systematically gathers information. This includes both subjective data reported by the patient and
objective data observed by the nurse.-4
3. A nurse gathers data about a patient's heart rate, blood pressure, lung sounds, and patient-
reported nausea. Which step of the nursing process is this?
A) Planning
B) Assessment
C) Implementation
D) Evaluation
Answer: B — Rationale: Assessment involves collecting both subjective (patient-reported nausea)
and objective (vital signs, lung sounds) data to establish a baseline.-3
4. During the planning phase, the nurse establishes a client goal. Which statement is an
example of a correctly written client goal?
A) "The nurse will assist the client to ambulate."
B) "The client will ambulate 50 feet with a walker by the end of the shift."
C) "The client should walk more every day."
D) "The nurse will encourage fluid intake."
Answer: B — Rationale: A proper client goal is SMART: Specific, Measurable, Attainable, Relevant,
and Time-bound. Option B specifies the client, the behavior, the distance, the method, and the
timeframe. Goals should be client-focused, not nurse-focused.-11
, 5. The nurse writes the following in a care plan: "Patient will ambulate 50 feet with a walker by
the end of the shift." This is an example of:
A) Nursing diagnosis
B) Goal/Outcome statement
C) Nursing intervention
D) Subjective data
Answer: B — Rationale: This is a measurable, patient-centered goal created during the Planning
phase. It is time-bound and specific.-3
6. A nurse is caring for a patient who is 24 hours post-surgery. The patient reports incisional
pain at a level of 7/10. The nurse administers the prescribed PRN analgesic. Thirty minutes
later, the nurse reassesses the patient's pain as 3/10. This reassessment represents which
step of the nursing process?
A) Assessment
B) Diagnosis
C) Implementation
D) Evaluation
Answer: D — Rationale: Evaluation is the final step where the nurse determines if the interventions
were effective by comparing the patient's current status to the expected outcomes.-3
7. A nurse is evaluating whether a client has met the goal to "void within 8 hours after catheter
removal." The client voided 200 mL 6 hours after catheter removal. What should the nurse
document?
A) Goal not met; client did not void
B) Goal met; client voided within the specified time frame
C) Goal partially met; the volume was insufficient
D) Goal cannot be evaluated
Answer: B — Rationale: The goal was met because the client voided within the 8-hour timeframe.
The goal did not specify a minimum volume. The evaluative statement should document the
outcome and supporting data.-11
8. A nurse is evaluating a patient's response to pain medication. Which finding indicates the
goal has been met?
A) Patient reports pain is 8/10
B) Patient is sleeping
C) Patient reports pain is 2/10 and is able to take deep breaths
D) Patient requests more medication
Answer: C — Rationale: The goal of pain management is to reduce pain to a tolerable level (2/10)
and improve function (deep breathing). Sleeping can be a side effect, not necessarily an indicator of
adequate pain relief.-3
9. The nurse is using the NCSBN Clinical Judgment Model. After recognizing cues and analyzing
them, what is the next step?
A) Evaluate outcomes
B) Generate solutions
C) Prioritize hypotheses
D) Take action
, Answer: C — Rationale: The order is: Recognize Cues → Analyze Cues → Prioritize Hypotheses →
Generate Solutions → Take Action → Evaluate Outcomes.-3
10. Which action demonstrates the use of clinical judgment?
A) Following a standard procedure without deviation
B) Recognizing that a client's blood pressure drop is significant and notifying the provider
with a recommendation
C) Documenting vital signs exactly as measured
D) Delegating all tasks to unlicensed assistive personnel
Answer: B — Rationale: Clinical judgment involves analyzing data, recognizing significant changes,
and taking appropriate action. Recognizing a BP drop and communicating with the provider
demonstrates interpretation and decision-making.-11
11. A patient has a blood pressure of 82/50 mmHg, heart rate of 122 bpm, and reports feeling
lightheaded. The nurse immediately places the patient in Trendelenburg position and calls
the provider. This action demonstrates:
A) Proper delegation
B) Clinical judgment and timely intervention
C) Evaluation of a care plan
D) Ethical decision-making
Answer: B — Rationale: The nurse recognized abnormal cues (hypotension, tachycardia), prioritized
the risk of shock, and took immediate action. This is clinical judgment in action.-3
12. A nursing student asks why the nursing process is considered cyclical rather than linear.
Which response by the instructor is most accurate?
A) "Each phase must be completed exactly once per client encounter."
B) "The process ends after evaluation unless the client deteriorates."
C) "Information from evaluation often leads back to reassessment or new diagnoses."
D) "Physicians must approve each cycle before nurses can proceed."
Answer: C — Rationale: The nursing process is cyclical because evaluation results may modify the
plan, requiring reassessment or new diagnoses.-9
13. The nurse has just received report on four clients. Which client should the nurse assess first?
A) A client with COPD and SpO2 of 89% on 2L nasal cannula
B) A client post-appendectomy day 2 with temperature of 38.3°C (101°F)
C) A client with heart failure and 3+ pitting edema
D) A client with new-onset confusion and a bounding pulse
Answer: D — Rationale: New-onset confusion with a bounding pulse suggests increased intracranial
pressure, hypercapnia, or fluid overload affecting cerebral perfusion. A change in neurological status
is always the priority over chronic or expected findings.-11
14. A nurse is caring for four clients. Which client should the nurse see first?
A) A client with a scheduled wound dressing change
B) A client with new-onset shortness of breath and SpO2 of 88%
C) A client requesting pain medication for a headache
D) A client who needs discharge teaching
