NUR2214 EXAM 1 STUDY GUIDE 2026 COMPLETE
QUESTIONS WITH CORRECT DETAILED ANSWERS ||
100% GUARANTEED PASS <RECENT VERSION>
1. A nurse is providing care based on Maslow's Hierarchy of Needs. Which client action should
the nurse address first?
A. A client expressing feelings of loneliness.
B. A client with a new diagnosis of diabetes who has questions about their diet.
C. A client with an oxygen saturation of 82% who is struggling to breathe.
D. A client who is worried about losing their job after discharge.
Answer: C
C. A client with an oxygen saturation of 82% who is struggling to breathe. ✓
Rationale: According to Maslow, physiological needs (like oxygenation) are the most
fundamental and must be addressed before higher-level needs (safety, love/belonging, esteem,
self-actualization).
2. The nurse is interviewing a client. Which statement is an example of a closed-ended
question?
A. "How would you describe your pain?"
B. "What brought you to the hospital today?"
C. "Are you having pain now?"
D. "Tell me more about how you're feeling."
Answer: C
C. "Are you having pain now?" ✓
Rationale: A closed-ended question typically elicits a one-word, "yes" or "no" answer, limiting
the depth of the client's response.
3. During the assessment phase of the nursing process, the nurse should:
A. Formulate nursing diagnoses.
B. Collect and organize client data.
C. Determine the effectiveness of interventions.
D. Carry out the prescribed nursing actions.
Answer: B
B. Collect and organize client data. ✓
,Rationale: Assessment is the first step of the nursing process and involves the systematic
collection of both subjective and objective data.
4. A client has a nursing diagnosis of "Risk for Impaired Skin Integrity related to immobility."
This is an example of what type of nursing diagnosis?
A. Problem-Focused
B. Risk
C. Health-Promotion
D. Syndrome
Answer: B
B. Risk ✓
Rationale: A risk diagnosis is used when the client is vulnerable to developing a health problem
but does not currently have it. The defining characteristics are the risk factors themselves.
5. The primary purpose of the evaluation step in the nursing process is to:
A. Identify new problems.
B. Determine if client goals have been met.
C. Update the client's care plan.
D. Document the care provided.
Answer: B
B. Determine if client goals have been met. ✓
Rationale: Evaluation involves reviewing the client's responses to interventions and comparing
them to the expected outcomes (goals) set during the planning phase.
6. A nurse is teaching a client about a new medication. Which action best demonstrates the
concept of client-centered care?
A. The nurse provides written information at an 8th-grade reading level.
B. The nurse asks the client about their cultural beliefs regarding medication.
C. The nurse administers the medication exactly on time.
D. The nurse documents the teaching in the chart.
Answer: B
B. The nurse asks the client about their cultural beliefs regarding medication. ✓
Rationale: Client-centered care involves respecting the client's preferences, values, and needs,
which includes their cultural beliefs and practices.
7. Which action by a nursing student requires immediate intervention by the nurse preceptor?
A. The student washes their hands for 15 seconds with soap and water.
B. The student dons sterile gloves to clean a sterile wound.
,C. The student checks the client's armband before administering medication.
D. The student documents a focused assessment.
Answer: B
B. The student dons sterile gloves to clean a sterile wound. ✓
Rationale: Cleaning a wound requires clean technique, not sterile technique. Using sterile gloves
inappropriately indicates a knowledge deficit in infection control principles that requires
correction.
8. A client is admitted with pneumonia. Which assessment finding is a subjective data?
A. Temperature of 101.5°F (38.6°C)
B. Crackles heard in the lower lung lobes
C. Client's statement, "I feel short of breath"
D. Respiratory rate of 24 breaths per minute
Answer: C
C. Client's statement, "I feel short of breath" ✓
Rationale: Subjective data is information reported by the client and cannot be verified by
another person. It is often called a symptom.
9. The nurse is preparing to insert a Foley catheter. Which action is essential to maintain
surgical asepsis?
A. Keeping sterile objects above waist level.
B. Using an alcohol-based hand rub for 20 seconds.
C. Opening the sterile package away from the body first.
D. Considering the outer 1-inch edge of the sterile field as contaminated.
Answer: D
D. Considering the outer 1-inch edge of the sterile field as contaminated. ✓
Rationale: This is a fundamental principle of sterile technique. The edges of a sterile field are
considered unsterile.
10. Which vital sign is considered the fifth vital sign?
A. Oxygen Saturation
B. Pain
C. Level of Consciousness
D. Capillary Refill
Answer: B
B. Pain ✓
, Rationale: The American Pain Society coined the term, and it is widely accepted that pain should
be assessed along with temperature, pulse, respiration, and blood pressure.
11. A nurse is delegating the task of taking vital signs for a stable client to an Unlicensed
Assistive Personnel (UAP). This is an example of:
A. Advocacy
B. Prioritization
C. Supervision
D. Assignment
Answer: D
D. Assignment ✓
Rationale: Assignment refers to the routine care and tasks that are within the UAP's job
description and that the nurse delegates. Supervision is the guidance and direction the nurse
provides.
12. When documenting a client's response to pain medication, the nurse should use which
part of a SOAP note?
A. Subjective
B. Objective
C. Assessment
D. Plan
Answer: B
B. Objective ✓
Rationale: The client's response (e.g., vital signs, observed behavior) is objective, measurable
data. The initial report of pain would be subjective.
13. A client with heart failure has 2+ pitting edema in their lower extremities. The nurse
documents this as:
A. Mild pitting edema
B. Moderate pitting edema
C. Severe pitting edema
D. Deep pitting edema
Answer: B
B. Moderate pitting edema ✓
*Rationale: On a 0-4+ scale, 2+ edema is characterized by a 2mm depth that disappears in 10-15
seconds, indicating moderate pitting.*
QUESTIONS WITH CORRECT DETAILED ANSWERS ||
100% GUARANTEED PASS <RECENT VERSION>
1. A nurse is providing care based on Maslow's Hierarchy of Needs. Which client action should
the nurse address first?
A. A client expressing feelings of loneliness.
B. A client with a new diagnosis of diabetes who has questions about their diet.
C. A client with an oxygen saturation of 82% who is struggling to breathe.
D. A client who is worried about losing their job after discharge.
Answer: C
C. A client with an oxygen saturation of 82% who is struggling to breathe. ✓
Rationale: According to Maslow, physiological needs (like oxygenation) are the most
fundamental and must be addressed before higher-level needs (safety, love/belonging, esteem,
self-actualization).
2. The nurse is interviewing a client. Which statement is an example of a closed-ended
question?
A. "How would you describe your pain?"
B. "What brought you to the hospital today?"
C. "Are you having pain now?"
D. "Tell me more about how you're feeling."
Answer: C
C. "Are you having pain now?" ✓
Rationale: A closed-ended question typically elicits a one-word, "yes" or "no" answer, limiting
the depth of the client's response.
3. During the assessment phase of the nursing process, the nurse should:
A. Formulate nursing diagnoses.
B. Collect and organize client data.
C. Determine the effectiveness of interventions.
D. Carry out the prescribed nursing actions.
Answer: B
B. Collect and organize client data. ✓
,Rationale: Assessment is the first step of the nursing process and involves the systematic
collection of both subjective and objective data.
4. A client has a nursing diagnosis of "Risk for Impaired Skin Integrity related to immobility."
This is an example of what type of nursing diagnosis?
A. Problem-Focused
B. Risk
C. Health-Promotion
D. Syndrome
Answer: B
B. Risk ✓
Rationale: A risk diagnosis is used when the client is vulnerable to developing a health problem
but does not currently have it. The defining characteristics are the risk factors themselves.
5. The primary purpose of the evaluation step in the nursing process is to:
A. Identify new problems.
B. Determine if client goals have been met.
C. Update the client's care plan.
D. Document the care provided.
Answer: B
B. Determine if client goals have been met. ✓
Rationale: Evaluation involves reviewing the client's responses to interventions and comparing
them to the expected outcomes (goals) set during the planning phase.
6. A nurse is teaching a client about a new medication. Which action best demonstrates the
concept of client-centered care?
A. The nurse provides written information at an 8th-grade reading level.
B. The nurse asks the client about their cultural beliefs regarding medication.
C. The nurse administers the medication exactly on time.
D. The nurse documents the teaching in the chart.
Answer: B
B. The nurse asks the client about their cultural beliefs regarding medication. ✓
Rationale: Client-centered care involves respecting the client's preferences, values, and needs,
which includes their cultural beliefs and practices.
7. Which action by a nursing student requires immediate intervention by the nurse preceptor?
A. The student washes their hands for 15 seconds with soap and water.
B. The student dons sterile gloves to clean a sterile wound.
,C. The student checks the client's armband before administering medication.
D. The student documents a focused assessment.
Answer: B
B. The student dons sterile gloves to clean a sterile wound. ✓
Rationale: Cleaning a wound requires clean technique, not sterile technique. Using sterile gloves
inappropriately indicates a knowledge deficit in infection control principles that requires
correction.
8. A client is admitted with pneumonia. Which assessment finding is a subjective data?
A. Temperature of 101.5°F (38.6°C)
B. Crackles heard in the lower lung lobes
C. Client's statement, "I feel short of breath"
D. Respiratory rate of 24 breaths per minute
Answer: C
C. Client's statement, "I feel short of breath" ✓
Rationale: Subjective data is information reported by the client and cannot be verified by
another person. It is often called a symptom.
9. The nurse is preparing to insert a Foley catheter. Which action is essential to maintain
surgical asepsis?
A. Keeping sterile objects above waist level.
B. Using an alcohol-based hand rub for 20 seconds.
C. Opening the sterile package away from the body first.
D. Considering the outer 1-inch edge of the sterile field as contaminated.
Answer: D
D. Considering the outer 1-inch edge of the sterile field as contaminated. ✓
Rationale: This is a fundamental principle of sterile technique. The edges of a sterile field are
considered unsterile.
10. Which vital sign is considered the fifth vital sign?
A. Oxygen Saturation
B. Pain
C. Level of Consciousness
D. Capillary Refill
Answer: B
B. Pain ✓
, Rationale: The American Pain Society coined the term, and it is widely accepted that pain should
be assessed along with temperature, pulse, respiration, and blood pressure.
11. A nurse is delegating the task of taking vital signs for a stable client to an Unlicensed
Assistive Personnel (UAP). This is an example of:
A. Advocacy
B. Prioritization
C. Supervision
D. Assignment
Answer: D
D. Assignment ✓
Rationale: Assignment refers to the routine care and tasks that are within the UAP's job
description and that the nurse delegates. Supervision is the guidance and direction the nurse
provides.
12. When documenting a client's response to pain medication, the nurse should use which
part of a SOAP note?
A. Subjective
B. Objective
C. Assessment
D. Plan
Answer: B
B. Objective ✓
Rationale: The client's response (e.g., vital signs, observed behavior) is objective, measurable
data. The initial report of pain would be subjective.
13. A client with heart failure has 2+ pitting edema in their lower extremities. The nurse
documents this as:
A. Mild pitting edema
B. Moderate pitting edema
C. Severe pitting edema
D. Deep pitting edema
Answer: B
B. Moderate pitting edema ✓
*Rationale: On a 0-4+ scale, 2+ edema is characterized by a 2mm depth that disappears in 10-15
seconds, indicating moderate pitting.*
