NUR 104 EXAM / NUR104 MIDTERM EXAM 2026/2027 ACCURATE
EXAM REAL QUESTIONS AND CORRECT DETAILED ANSWERS
WITH RATIONALES (100% CORRECT VERIFIED SOLUTIONS) A NEW
UPDATED VERSION 2026 |GUARANTEED PASS A+ |EXCELSIOR
COLLEGE
1. A nurse is planning care for a client with hypertension. Which outcome is most appropriate for the
client’s plan of care?
a) The client will verbalize an understanding of the disease process within 1 hour.
b) The client’s blood pressure will be maintained below 130/80 mm Hg within 1 month.
c) The nurse will teach the client about low-sodium foods during this shift.
d) The client will take their medication as prescribed by the next clinic visit.
CORRECT ANSWER: b) The client’s blood pressure will be maintained below 130/80 mm Hg within 1
month.
Rationale: This is a measurable, client-centered outcome with a specific time frame. Option (a) lacks a
realistic time frame for a complex topic, (c) is a nursing intervention, not a client outcome, and (d) is
vague regarding measurement.
2. During a physical assessment, the nurse notes that a client’s jugular veins are distended while in a
semi-Fowler’s position. This finding is most indicative of which condition?
a) Hypovolemia
b) Right-sided heart failure
c) Decreased central venous pressure
d) Arterial insufficiency
CORRECT ANSWER: b) Right-sided heart failure.
Rationale: Jugular venous distention (JVD) in a semi-upright position reflects increased central venous
pressure, a hallmark of right-sided heart failure. Hypovolemia and decreased central venous pressure
would cause flat jugular veins.
3. A nurse is using evidence-based practice (EBP) to address a rise in catheter-associated urinary tract
infections (CAUTIs). Place the steps of EBP in the correct order.
,a) Ask a clinical question; collect the best evidence; evaluate the evidence; integrate evidence with
clinical expertise; evaluate outcomes.
b) Collect the best evidence; ask a clinical question; evaluate the evidence; integrate evidence with
clinical expertise; evaluate outcomes.
c) Evaluate outcomes; integrate evidence with clinical expertise; ask a clinical question; collect the best
evidence; evaluate the evidence.
d) Ask a clinical question; integrate evidence with clinical expertise; collect the best evidence; evaluate
the evidence; evaluate outcomes.
CORRECT ANSWER: a) Ask a clinical question; collect the best evidence; evaluate the evidence; integrate
evidence with clinical expertise; evaluate outcomes.
Rationale: The correct sequence of EBP steps begins with formulating a question (PICOT), followed by
collecting, appraising, integrating evidence with expertise, and finally evaluating the outcome.
4. A client is admitted with a diagnosis of pneumonia. The nurse auscultates coarse crackles in the right
lower lobe. Which action should the nurse take first?
a) Notify the healthcare provider.
b) Administer the prescribed PRN cough suppressant.
c) Assist the client to a sitting position and encourage deep breathing.
d) Increase the client’s oxygen flow rate to 4 L/min.
CORRECT ANSWER: c) Assist the client to a sitting position and encourage deep breathing.
Rationale: Positioning the client upright (Fowler’s) and encouraging deep breathing promotes lung
expansion and mobilization of secretions, which is the priority nursing intervention for airway clearance.
5. A nurse is reviewing a client’s laboratory results and notes a potassium level of 5.8 mEq/L. Which of
the following ECG changes should the nurse expect to observe?
a) Flattened T waves
b) Prominent U waves
c) Peaked T waves
d) Prolonged PR interval
CORRECT ANSWER: c) Peaked T waves.
Rationale: Hyperkalemia (high potassium) typically presents with tall, peaked T waves. Flattened T
waves and prominent U waves are associated with hypokalemia.
,6. According to Erikson’s theory of psychosocial development, a 20-year-old college student who is
exploring different career paths and personal relationships is in which stage?
a) Industry vs. Inferiority
b) Identity vs. Role Confusion
c) Intimacy vs. Isolation
d) Autonomy vs. Shame and Doubt
CORRECT ANSWER: b) Identity vs. Role Confusion.
*Rationale: The primary task of adolescence (ages 12-20) is forming a sense of identity. While intimacy is
the next stage, the exploration of careers and relationships described is characteristic of identity
formation.*
7. A nurse is preparing to administer a subcutaneous injection of heparin. Which technique is correct?
a) Aspirate before injection to ensure the needle is not in a blood vessel.
b) Massage the site vigorously after injection to enhance absorption.
c) Insert the needle at a 90-degree angle using a 1-inch needle for an average-sized client.
d) Administer the injection in the deltoid muscle for fastest absorption.
CORRECT ANSWER: c) Insert the needle at a 90-degree angle using a 1-inch needle for an average-sized
client.
*Rationale: Subcutaneous injections for heparin are typically given at a 90-degree angle with a 1-inch
needle if skinfold is sufficient. Aspiration is not recommended as it can cause tissue damage, massage is
contraindicated due to bleeding risk, and heparin is not given IM.*
8. A nurse is caring for a client with a nasogastric tube attached to continuous suction. Which electrolyte
imbalance is the client at highest risk for developing?
a) Hyperkalemia
b) Hypercalcemia
c) Metabolic alkalosis
d) Metabolic acidosis
CORRECT ANSWER: c) Metabolic alkalosis.
Rationale: Continuous nasogastric suction removes gastric acid (hydrochloric acid), leading to a loss of
hydrogen ions and chloride. This results in metabolic alkalosis and hypokalemia, not hyperkalemia.
, 9. The nurse is applying the nursing process to a client’s care. Which step involves the collection and
analysis of client data to identify health issues?
a) Planning
b) Evaluation
c) Assessment
d) Implementation
CORRECT ANSWER: c) Assessment.
Rationale: Assessment is the first step of the nursing process, involving the systematic collection of
subjective and objective data to establish a baseline and identify actual or potential health problems.
10. A client is receiving a blood transfusion. Fifteen minutes after the start, the client reports chills and
lower back pain. What is the nurse’s priority action?
a) Slow the infusion rate and assess vital signs.
b) Administer acetaminophen as ordered for the chills.
c) Stop the transfusion and keep the IV line open with normal saline.
d) Notify the healthcare provider immediately.
CORRECT ANSWER: c) Stop the transfusion and keep the IV line open with normal saline.
Rationale: Chills and back pain are signs of a potential hemolytic transfusion reaction. The priority is to
stop the transfusion immediately to prevent further reaction and maintain IV access with saline for
potential emergency medications.
11. A nurse is teaching a client with diabetes mellitus about foot care. Which statement by the client
indicates a need for further teaching?
a) “I will wear shoes that fit properly and are made of leather.”
b) “I will soak my feet in hot water every day to soften calluses.”
c) “I will cut my toenails straight across.”
d) “I will inspect my feet daily for blisters or redness.”
CORRECT ANSWER: b) “I will soak my feet in hot water every day to soften calluses.”
Rationale: Soaking feet can lead to maceration and increased risk of infection. The client should wash
feet with lukewarm water and mild soap. Cutting nails straight across, wearing proper shoes, and daily
inspection are correct practices.
EXAM REAL QUESTIONS AND CORRECT DETAILED ANSWERS
WITH RATIONALES (100% CORRECT VERIFIED SOLUTIONS) A NEW
UPDATED VERSION 2026 |GUARANTEED PASS A+ |EXCELSIOR
COLLEGE
1. A nurse is planning care for a client with hypertension. Which outcome is most appropriate for the
client’s plan of care?
a) The client will verbalize an understanding of the disease process within 1 hour.
b) The client’s blood pressure will be maintained below 130/80 mm Hg within 1 month.
c) The nurse will teach the client about low-sodium foods during this shift.
d) The client will take their medication as prescribed by the next clinic visit.
CORRECT ANSWER: b) The client’s blood pressure will be maintained below 130/80 mm Hg within 1
month.
Rationale: This is a measurable, client-centered outcome with a specific time frame. Option (a) lacks a
realistic time frame for a complex topic, (c) is a nursing intervention, not a client outcome, and (d) is
vague regarding measurement.
2. During a physical assessment, the nurse notes that a client’s jugular veins are distended while in a
semi-Fowler’s position. This finding is most indicative of which condition?
a) Hypovolemia
b) Right-sided heart failure
c) Decreased central venous pressure
d) Arterial insufficiency
CORRECT ANSWER: b) Right-sided heart failure.
Rationale: Jugular venous distention (JVD) in a semi-upright position reflects increased central venous
pressure, a hallmark of right-sided heart failure. Hypovolemia and decreased central venous pressure
would cause flat jugular veins.
3. A nurse is using evidence-based practice (EBP) to address a rise in catheter-associated urinary tract
infections (CAUTIs). Place the steps of EBP in the correct order.
,a) Ask a clinical question; collect the best evidence; evaluate the evidence; integrate evidence with
clinical expertise; evaluate outcomes.
b) Collect the best evidence; ask a clinical question; evaluate the evidence; integrate evidence with
clinical expertise; evaluate outcomes.
c) Evaluate outcomes; integrate evidence with clinical expertise; ask a clinical question; collect the best
evidence; evaluate the evidence.
d) Ask a clinical question; integrate evidence with clinical expertise; collect the best evidence; evaluate
the evidence; evaluate outcomes.
CORRECT ANSWER: a) Ask a clinical question; collect the best evidence; evaluate the evidence; integrate
evidence with clinical expertise; evaluate outcomes.
Rationale: The correct sequence of EBP steps begins with formulating a question (PICOT), followed by
collecting, appraising, integrating evidence with expertise, and finally evaluating the outcome.
4. A client is admitted with a diagnosis of pneumonia. The nurse auscultates coarse crackles in the right
lower lobe. Which action should the nurse take first?
a) Notify the healthcare provider.
b) Administer the prescribed PRN cough suppressant.
c) Assist the client to a sitting position and encourage deep breathing.
d) Increase the client’s oxygen flow rate to 4 L/min.
CORRECT ANSWER: c) Assist the client to a sitting position and encourage deep breathing.
Rationale: Positioning the client upright (Fowler’s) and encouraging deep breathing promotes lung
expansion and mobilization of secretions, which is the priority nursing intervention for airway clearance.
5. A nurse is reviewing a client’s laboratory results and notes a potassium level of 5.8 mEq/L. Which of
the following ECG changes should the nurse expect to observe?
a) Flattened T waves
b) Prominent U waves
c) Peaked T waves
d) Prolonged PR interval
CORRECT ANSWER: c) Peaked T waves.
Rationale: Hyperkalemia (high potassium) typically presents with tall, peaked T waves. Flattened T
waves and prominent U waves are associated with hypokalemia.
,6. According to Erikson’s theory of psychosocial development, a 20-year-old college student who is
exploring different career paths and personal relationships is in which stage?
a) Industry vs. Inferiority
b) Identity vs. Role Confusion
c) Intimacy vs. Isolation
d) Autonomy vs. Shame and Doubt
CORRECT ANSWER: b) Identity vs. Role Confusion.
*Rationale: The primary task of adolescence (ages 12-20) is forming a sense of identity. While intimacy is
the next stage, the exploration of careers and relationships described is characteristic of identity
formation.*
7. A nurse is preparing to administer a subcutaneous injection of heparin. Which technique is correct?
a) Aspirate before injection to ensure the needle is not in a blood vessel.
b) Massage the site vigorously after injection to enhance absorption.
c) Insert the needle at a 90-degree angle using a 1-inch needle for an average-sized client.
d) Administer the injection in the deltoid muscle for fastest absorption.
CORRECT ANSWER: c) Insert the needle at a 90-degree angle using a 1-inch needle for an average-sized
client.
*Rationale: Subcutaneous injections for heparin are typically given at a 90-degree angle with a 1-inch
needle if skinfold is sufficient. Aspiration is not recommended as it can cause tissue damage, massage is
contraindicated due to bleeding risk, and heparin is not given IM.*
8. A nurse is caring for a client with a nasogastric tube attached to continuous suction. Which electrolyte
imbalance is the client at highest risk for developing?
a) Hyperkalemia
b) Hypercalcemia
c) Metabolic alkalosis
d) Metabolic acidosis
CORRECT ANSWER: c) Metabolic alkalosis.
Rationale: Continuous nasogastric suction removes gastric acid (hydrochloric acid), leading to a loss of
hydrogen ions and chloride. This results in metabolic alkalosis and hypokalemia, not hyperkalemia.
, 9. The nurse is applying the nursing process to a client’s care. Which step involves the collection and
analysis of client data to identify health issues?
a) Planning
b) Evaluation
c) Assessment
d) Implementation
CORRECT ANSWER: c) Assessment.
Rationale: Assessment is the first step of the nursing process, involving the systematic collection of
subjective and objective data to establish a baseline and identify actual or potential health problems.
10. A client is receiving a blood transfusion. Fifteen minutes after the start, the client reports chills and
lower back pain. What is the nurse’s priority action?
a) Slow the infusion rate and assess vital signs.
b) Administer acetaminophen as ordered for the chills.
c) Stop the transfusion and keep the IV line open with normal saline.
d) Notify the healthcare provider immediately.
CORRECT ANSWER: c) Stop the transfusion and keep the IV line open with normal saline.
Rationale: Chills and back pain are signs of a potential hemolytic transfusion reaction. The priority is to
stop the transfusion immediately to prevent further reaction and maintain IV access with saline for
potential emergency medications.
11. A nurse is teaching a client with diabetes mellitus about foot care. Which statement by the client
indicates a need for further teaching?
a) “I will wear shoes that fit properly and are made of leather.”
b) “I will soak my feet in hot water every day to soften calluses.”
c) “I will cut my toenails straight across.”
d) “I will inspect my feet daily for blisters or redness.”
CORRECT ANSWER: b) “I will soak my feet in hot water every day to soften calluses.”
Rationale: Soaking feet can lead to maceration and increased risk of infection. The client should wash
feet with lukewarm water and mild soap. Cutting nails straight across, wearing proper shoes, and daily
inspection are correct practices.
