NURS 101 – Exam 2 Prep (Complete) | Fundamentals of Nursing |
2025 | Comprehensive Review Notes
Subjective - correct answer Which data do we collect first? Objective/Subjective
Right breast, to use as a baseline - correct answer If patient informs you of a pain in the left
breast, which breast do you first assess?
The patient (if a child, it's their parent) - correct answer Who is the primary source of data?
Secondary - correct answer Lab results are a ______________ source of data
Follow-up assessment - correct answer A patient had just been given opioids to address pain in
their back, what type of assessment is performed some time after administration
Initial assessment (Head-to-toe)
Even though he has been in the hospital before, - correct answer A patient gets admitted to
your floor at the hospital, you notice they have a history of being admitted there in the past,
He's in to address a newly acquired infection, what type of assessment do you perform?
Focused assessment on abdomen, and then head-to-toe (initial assessment) as the day goes on
or after patient has been stabilized.
Remember since its Abdominal we do the IAPP method Palpate last) - correct answer A patient
comes in for abdominal pain, says he feels a churning sensation and is grimacing in pain, what
type of assessment do you perform?
Follow-up assessment
(Yes, even if its a week later, because its following up on the same issue/condition) - correct
answer A patient comes in for a check up on a wound that was cauterized a week prior, what
type of assessment is performed when he arrives?
IPPA
-Inspection
-Palpation
-Percussion
-Auscultation - correct answer What is the order of assessment?
normal finding, less likely to have an abscess or mass (abscess is usually indicated by dull sound)
- correct answer A student is performing an assessment on an elderly patient, as he's
percussing their abdomen, he noticed there is a hollow sound, what is that an indication of?
,Abdomen, IAPP method
Inspection
Auscultation
Percussion
Palpation - correct answer Every system we follow the IPPA method while assessing EXCEPT
which body system? What method do we use to asses instead?
True - correct answer True or False: Palpation is last in abdominal assessment because it can
illicit pain and create false bowel sounds
1. Problem statement
2. Etiology (What its related to/ caused by)
3. Symptoms (Evidence) - correct answer When formulating a Nursing Diagnosis Statement, it is
composed of 3 parts:
False, you can only use NANDA approved Nursing Diagnoses - correct answer True or False: As a
Registered Nurse, you are expected to come up with your own Nursing Diagnosis.
Specific
Measurable
Attainable
Realistic
Time-bound - correct answer Define SMART goals:
Right Person
Right Task
Right Circumstance
Right Direction/Communication
Right Supervision - correct answer Name 5 Rights in Nursing Delegation discussed in lecture
The patient will - correct answer You should always start the goal statement with ______
______ ______
B) Heart rate of 54 bpm
Why? Bradycardia (HR <60 bpm) in a heart failure patient on possible digoxin or beta-blockers
can indicate toxicity or worsening cardiac function.
, Crackles and edema are expected CHF findings but should still be monitored.
O2 saturation of 92% is mildly low but not critical. - correct answer A 78-year-old male patient
with a history of chronic heart failure (CHF) and diabetes is admitted for shortness of breath
and fatigue. The nurse notes:
BP: 100/62 mmHg,
HR: 54 bpm,
RR: 22,
O2 sat: 92%
Crackles in both lungs, 2+ pitting edema in the lower extremities
Daily weight increase of 3 lbs. (1.4 kg) in two days
Which assessment finding requires the nurse's immediate attention?
A) Crackles in both lungs
B) Heart rate of 54 bpm
C) 2+ pitting edema
D) O2 saturation of 92%
C) Ineffective Tissue Perfusion related to hypertension and kidney disease
Why? High BP and kidney disease impair perfusion, leading to end-organ damage (e.g.,
decreased urine output, headache, vision changes).
Excess Fluid Volume is a concern in CKD but is not the priority over life-threatening
hypertension. - correct answer A 45-year-old patient with stage 3 chronic kidney disease (CKD)
and uncontrolled hypertension is admitted with a BP of 190/110 mmHg. The patient reports:
Headache and blurry vision
Decreased urine output
Mild shortness of breath
What is the most appropriate nursing diagnosis?
A) Risk for Injury related to visual disturbances
B) Excess Fluid Volume related to impaired renal function
C) Ineffective Tissue Perfusion related to hypertension and kidney disease
D) Deficient Knowledge related to lack of understanding of medication regimen
2025 | Comprehensive Review Notes
Subjective - correct answer Which data do we collect first? Objective/Subjective
Right breast, to use as a baseline - correct answer If patient informs you of a pain in the left
breast, which breast do you first assess?
The patient (if a child, it's their parent) - correct answer Who is the primary source of data?
Secondary - correct answer Lab results are a ______________ source of data
Follow-up assessment - correct answer A patient had just been given opioids to address pain in
their back, what type of assessment is performed some time after administration
Initial assessment (Head-to-toe)
Even though he has been in the hospital before, - correct answer A patient gets admitted to
your floor at the hospital, you notice they have a history of being admitted there in the past,
He's in to address a newly acquired infection, what type of assessment do you perform?
Focused assessment on abdomen, and then head-to-toe (initial assessment) as the day goes on
or after patient has been stabilized.
Remember since its Abdominal we do the IAPP method Palpate last) - correct answer A patient
comes in for abdominal pain, says he feels a churning sensation and is grimacing in pain, what
type of assessment do you perform?
Follow-up assessment
(Yes, even if its a week later, because its following up on the same issue/condition) - correct
answer A patient comes in for a check up on a wound that was cauterized a week prior, what
type of assessment is performed when he arrives?
IPPA
-Inspection
-Palpation
-Percussion
-Auscultation - correct answer What is the order of assessment?
normal finding, less likely to have an abscess or mass (abscess is usually indicated by dull sound)
- correct answer A student is performing an assessment on an elderly patient, as he's
percussing their abdomen, he noticed there is a hollow sound, what is that an indication of?
,Abdomen, IAPP method
Inspection
Auscultation
Percussion
Palpation - correct answer Every system we follow the IPPA method while assessing EXCEPT
which body system? What method do we use to asses instead?
True - correct answer True or False: Palpation is last in abdominal assessment because it can
illicit pain and create false bowel sounds
1. Problem statement
2. Etiology (What its related to/ caused by)
3. Symptoms (Evidence) - correct answer When formulating a Nursing Diagnosis Statement, it is
composed of 3 parts:
False, you can only use NANDA approved Nursing Diagnoses - correct answer True or False: As a
Registered Nurse, you are expected to come up with your own Nursing Diagnosis.
Specific
Measurable
Attainable
Realistic
Time-bound - correct answer Define SMART goals:
Right Person
Right Task
Right Circumstance
Right Direction/Communication
Right Supervision - correct answer Name 5 Rights in Nursing Delegation discussed in lecture
The patient will - correct answer You should always start the goal statement with ______
______ ______
B) Heart rate of 54 bpm
Why? Bradycardia (HR <60 bpm) in a heart failure patient on possible digoxin or beta-blockers
can indicate toxicity or worsening cardiac function.
, Crackles and edema are expected CHF findings but should still be monitored.
O2 saturation of 92% is mildly low but not critical. - correct answer A 78-year-old male patient
with a history of chronic heart failure (CHF) and diabetes is admitted for shortness of breath
and fatigue. The nurse notes:
BP: 100/62 mmHg,
HR: 54 bpm,
RR: 22,
O2 sat: 92%
Crackles in both lungs, 2+ pitting edema in the lower extremities
Daily weight increase of 3 lbs. (1.4 kg) in two days
Which assessment finding requires the nurse's immediate attention?
A) Crackles in both lungs
B) Heart rate of 54 bpm
C) 2+ pitting edema
D) O2 saturation of 92%
C) Ineffective Tissue Perfusion related to hypertension and kidney disease
Why? High BP and kidney disease impair perfusion, leading to end-organ damage (e.g.,
decreased urine output, headache, vision changes).
Excess Fluid Volume is a concern in CKD but is not the priority over life-threatening
hypertension. - correct answer A 45-year-old patient with stage 3 chronic kidney disease (CKD)
and uncontrolled hypertension is admitted with a BP of 190/110 mmHg. The patient reports:
Headache and blurry vision
Decreased urine output
Mild shortness of breath
What is the most appropriate nursing diagnosis?
A) Risk for Injury related to visual disturbances
B) Excess Fluid Volume related to impaired renal function
C) Ineffective Tissue Perfusion related to hypertension and kidney disease
D) Deficient Knowledge related to lack of understanding of medication regimen
