Exam 1: NSG3100 / NSG 3100 (Latest )
Fundamental Concepts & Skills for Nursing Practice
100 Multiple Choice Questions with Bold Italic
Answers and Italic Explanations \ updated
1. A nurse is caring for a client and identifies that the client has difficulty breathing. The client's
oxygen saturation is 88%. What is the nurse's priority action?
A) Document the findings in the client's chart
B) Place the client in a high-Fowler's position and notify the provider
C) Administer a PRN sedative to calm the client
D) Ask the client to rate their pain on a scale of 0-10
The client is experiencing respiratory distress with hypoxia. The priority action is to position the client to
maximize oxygenation (high-Fowler's) and notify the provider for further orders. Documentation is
important but not the priority, and a sedative would worsen respiratory depression.
2. A nurse is performing an admission assessment. Which data source is considered primary?
A) Family member's description of the client's symptoms
B) The client's verbal description of their symptoms
C) The client's medical record from another facility
D) The emergency department provider's notes
The client is the primary source of data. Family members, medical records, and other healthcare
providers are secondary sources of information.
3. A nurse is formulating a nursing diagnosis. Which statement demonstrates correct NANDA-I
format?
A) Risk for Infection related to surgical incision as evidenced by redness
B) Acute Pain related to incisional trauma as evidenced by client report of 8/10 pain
C) Acute Pain related to surgical incision as evidenced by client report of pain
D) Pain caused by surgery
The correct format is "Nursing Diagnosis (problem) related to (etiology) as evidenced by (defining
characteristics)". "Acute Pain related to surgical incision as evidenced by client report of pain" includes all
,three components correctly. Option A uses "Risk for" incorrectly with "as evidenced by" (risk diagnoses
use "as evidenced by" only when describing risk factors, not actual defining characteristics).
4. A nurse is evaluating a client's response to pain medication. The client received morphine 30
minutes ago. What is the nurse's expected action?
A) Document that the medication was given
B) Reassess the client's pain level 30-60 minutes after administration
C) Administer another dose of medication
D) Notify the provider of the client's response
After administering pain medication, the nurse should reassess the client's pain level within 30 to 60
minutes to evaluate the effectiveness of the intervention .
5. A nurse is prioritizing client care. Which framework should the nurse use to determine the priority
nursing diagnosis?
A) Erikson's Stages of Development
B) Maslow's Hierarchy of Needs
C) Piaget's Theory of Cognitive Development
D) Kohlberg's Theory of Moral Development
Maslow's Hierarchy of Needs helps the nurse prioritize care by addressing physiologic needs (airway,
breathing, circulation) before higher-level needs such as safety, love/belonging, esteem, and self-
actualization .
6. A nurse is writing a client goal. Which statement represents a correctly written goal?
A) "The client will be less anxious."
B) "The client will ambulate 50 feet with a walker by discharge."
C) "The client will have improved mobility."
D) "The nurse will assist the client with ambulation."
A correctly written goal is specific, measurable, realistic, and time-bound. "The client will ambulate 50
feet with a walker by discharge" meets these criteria. Goals should focus on what the client will achieve,
not what the nurse will do.
7. A nurse is documenting subjective data. Which statement is an example of subjective data?
A) Client's blood pressure is 140/90 mm Hg
B) Client's incision is red and warm to touch
C) Client states, "I feel nauseated and dizzy."
D) Client's oxygen saturation is 94% on room air
, Subjective data is information the client reports, such as feelings, perceptions, and symptoms. Objective
data is measurable and observable, including vital signs, physical assessment findings, and laboratory
results .
8. A nurse is assessing a client who reports a headache. Which question is an example of an open-
ended question?
A) "Is your headache a throbbing pain?"
B) "Can you tell me more about your headache?"
C) "Did you take any medication for your headache?"
D) "Is the pain a 7 on a scale of 0 to 10?"
An open-ended question allows the client to provide detailed information and is phrased to elicit more
than a yes/no answer. "Can you tell me more about your headache?" is open-ended .
9. A nurse is reviewing a client's plan of care. What is the purpose of evaluating the plan of care?
A) To determine if the nursing interventions were cost-effective
B) To determine if the client's goals and outcomes were achieved
C) To determine if the provider agrees with the nursing diagnoses
D) To determine if the client should be discharged
Evaluation is the final step of the nursing process and determines whether the client's goals and expected
outcomes have been achieved .
10. A nurse is writing a nursing diagnosis for a client at risk for falls. Which statement is correct?
A) Impaired Physical Mobility related to age
B) Risk for Falls related to history of falls as evidenced by unsteady gait
C) Risk for Falls as evidenced by client's age
D) Impaired Physical Mobility related to muscle weakness
Risk diagnoses are written when the client has the potential to develop a problem. They are formatted as
"Risk for (problem) as evidenced by (risk factors)" .
INFECTION CONTROL & HAND HYGIENE
11. A nurse is observing a new nurse perform hand hygiene. Which action would require the
preceptor to intervene?
A) The nurse rinses from fingertips to wrists, keeping hands with fingers pointing upward
B) The nurse washes hands for 15-20 seconds using friction
Fundamental Concepts & Skills for Nursing Practice
100 Multiple Choice Questions with Bold Italic
Answers and Italic Explanations \ updated
1. A nurse is caring for a client and identifies that the client has difficulty breathing. The client's
oxygen saturation is 88%. What is the nurse's priority action?
A) Document the findings in the client's chart
B) Place the client in a high-Fowler's position and notify the provider
C) Administer a PRN sedative to calm the client
D) Ask the client to rate their pain on a scale of 0-10
The client is experiencing respiratory distress with hypoxia. The priority action is to position the client to
maximize oxygenation (high-Fowler's) and notify the provider for further orders. Documentation is
important but not the priority, and a sedative would worsen respiratory depression.
2. A nurse is performing an admission assessment. Which data source is considered primary?
A) Family member's description of the client's symptoms
B) The client's verbal description of their symptoms
C) The client's medical record from another facility
D) The emergency department provider's notes
The client is the primary source of data. Family members, medical records, and other healthcare
providers are secondary sources of information.
3. A nurse is formulating a nursing diagnosis. Which statement demonstrates correct NANDA-I
format?
A) Risk for Infection related to surgical incision as evidenced by redness
B) Acute Pain related to incisional trauma as evidenced by client report of 8/10 pain
C) Acute Pain related to surgical incision as evidenced by client report of pain
D) Pain caused by surgery
The correct format is "Nursing Diagnosis (problem) related to (etiology) as evidenced by (defining
characteristics)". "Acute Pain related to surgical incision as evidenced by client report of pain" includes all
,three components correctly. Option A uses "Risk for" incorrectly with "as evidenced by" (risk diagnoses
use "as evidenced by" only when describing risk factors, not actual defining characteristics).
4. A nurse is evaluating a client's response to pain medication. The client received morphine 30
minutes ago. What is the nurse's expected action?
A) Document that the medication was given
B) Reassess the client's pain level 30-60 minutes after administration
C) Administer another dose of medication
D) Notify the provider of the client's response
After administering pain medication, the nurse should reassess the client's pain level within 30 to 60
minutes to evaluate the effectiveness of the intervention .
5. A nurse is prioritizing client care. Which framework should the nurse use to determine the priority
nursing diagnosis?
A) Erikson's Stages of Development
B) Maslow's Hierarchy of Needs
C) Piaget's Theory of Cognitive Development
D) Kohlberg's Theory of Moral Development
Maslow's Hierarchy of Needs helps the nurse prioritize care by addressing physiologic needs (airway,
breathing, circulation) before higher-level needs such as safety, love/belonging, esteem, and self-
actualization .
6. A nurse is writing a client goal. Which statement represents a correctly written goal?
A) "The client will be less anxious."
B) "The client will ambulate 50 feet with a walker by discharge."
C) "The client will have improved mobility."
D) "The nurse will assist the client with ambulation."
A correctly written goal is specific, measurable, realistic, and time-bound. "The client will ambulate 50
feet with a walker by discharge" meets these criteria. Goals should focus on what the client will achieve,
not what the nurse will do.
7. A nurse is documenting subjective data. Which statement is an example of subjective data?
A) Client's blood pressure is 140/90 mm Hg
B) Client's incision is red and warm to touch
C) Client states, "I feel nauseated and dizzy."
D) Client's oxygen saturation is 94% on room air
, Subjective data is information the client reports, such as feelings, perceptions, and symptoms. Objective
data is measurable and observable, including vital signs, physical assessment findings, and laboratory
results .
8. A nurse is assessing a client who reports a headache. Which question is an example of an open-
ended question?
A) "Is your headache a throbbing pain?"
B) "Can you tell me more about your headache?"
C) "Did you take any medication for your headache?"
D) "Is the pain a 7 on a scale of 0 to 10?"
An open-ended question allows the client to provide detailed information and is phrased to elicit more
than a yes/no answer. "Can you tell me more about your headache?" is open-ended .
9. A nurse is reviewing a client's plan of care. What is the purpose of evaluating the plan of care?
A) To determine if the nursing interventions were cost-effective
B) To determine if the client's goals and outcomes were achieved
C) To determine if the provider agrees with the nursing diagnoses
D) To determine if the client should be discharged
Evaluation is the final step of the nursing process and determines whether the client's goals and expected
outcomes have been achieved .
10. A nurse is writing a nursing diagnosis for a client at risk for falls. Which statement is correct?
A) Impaired Physical Mobility related to age
B) Risk for Falls related to history of falls as evidenced by unsteady gait
C) Risk for Falls as evidenced by client's age
D) Impaired Physical Mobility related to muscle weakness
Risk diagnoses are written when the client has the potential to develop a problem. They are formatted as
"Risk for (problem) as evidenced by (risk factors)" .
INFECTION CONTROL & HAND HYGIENE
11. A nurse is observing a new nurse perform hand hygiene. Which action would require the
preceptor to intervene?
A) The nurse rinses from fingertips to wrists, keeping hands with fingers pointing upward
B) The nurse washes hands for 15-20 seconds using friction
