NUR 104 EXAM 200 ACTUAL QUESTIONS AND CORRECT
VERIFIED ANSWERS WITH RATIONALE LATEST 2026
ALREADY GRADED A+
This NUR 104 exam comprehensively evaluates foundational nursing
knowledge across multiple domains. It assesses the nursing process (ADPIE)
and clinical judgment (NCSBN CJMM), medication administration safety
including the six rights and error management, and pharmacological
principles across major drug classes. The exam covers respiratory conditions
(COPD, asthma, pneumonia, tuberculosis), cardiovascular pharmacology
(anticoagulants, antiarrhythmics, heart failure drugs), endocrine disorders
(diabetes, thyroid), neurologic conditions (Parkinson's, Alzheimer's, seizures,
pain management), psychiatric medications (antidepressants, antipsychotics,
mood stabilizers), and cultural competence. It emphasizes adverse effect
monitoring, drug interactions, patient education, and clinical decision-making
in diverse patient populations across the lifespan.
1. A patient states, "I would like to be able to decrease my risk for heart disease. I
started eating better but there is more I can do." What analysis would the RN
determine for this patient?
A) Risk-prone health behavior
B) Ineffective role performance
C) Deficient knowledge
D) Readiness for enhanced health management
Answer: D
Rationale: The patient is expressing a desire to improve their health and has
already taken action, indicating Readiness for enhanced health management, a
wellness nursing diagnosis. Risk-prone health behavior would be indicated by a
pattern of behaviors that threaten health despite awareness. Deficient knowledge
would be indicated by a lack of understanding rather than an expressed desire to
learn more.
2. What is the correct sequence of the NCSBN Clinical Judgment Measurement
Model?
,A) Assess → Diagnose → Plan → Implement → Evaluate
B) Recognize Cues → Analyze Cues → Prioritize Hypotheses → Generate
Solutions → Take Action → Evaluate Outcomes
C) Recognize Cues → Generate Solutions → Analyze Cues → Take Action →
Evaluate Outcomes
D) Assess → Analyze → Plan → Implement → Evaluate
Answer: B
Rationale: The NCSBN Clinical Judgment Measurement Model (CJMM) provides
the framework for Next Generation NCLEX items. The six steps in order are:
Recognize Cues, Analyze Cues, Prioritize Hypotheses, Generate Solutions, Take
Action, and Evaluate Outcomes.
3. A nursing action that is performed after collaboration with other healthcare team
members is a(n):
A) Independent nursing action
B) Interdependent nursing action
C) Dependent nursing action
D) Collaborative nursing action
Answer: B
Rationale: Interdependent nursing actions are those carried out in collaboration
with other healthcare team members (e.g., physical therapists, dietitians,
physicians). Independent actions are within the nurse's autonomous scope, while
dependent actions require a provider order.
4. For a patient with impaired skin integrity, which expected patient outcome
meets the criteria for being measurable?
A) Patient has a willingness for enhanced health
B) Patient is demonstrating risk-prone health behavior
C) Patient shows ineffective role performance
D) Experience no further skin breakdown by the next clinic visit
Answer: D
Rationale: Measurable outcomes must be specific, observable, and time-bound.
"Experience no further skin breakdown by the next clinic visit" specifies an
outcome and timeframe, making it measurable. Vague outcomes like "willingness"
are not measurable.
5. When developing a patient plan of care, which is an independent nursing action?
A) Administer a stool softener at bedtime every day
B) Request a high fiber diet from nutrition services
C) Collaborate with physical therapist to modify activity orders
,D) Check the common side effects of the drug
Answer: A
Rationale: Independent nursing actions are those the nurse can legally and
autonomously prescribe and implement. Administering a stool softener (as a
standing order) is an independent nursing action. Requesting a diet change requires
a provider order and collaborating with PT is interdependent.
6. A client with a psychiatric disorder was voluntarily admitted and now wishes to
be discharged from the hospital, against medical advice. Which aspect would be
most important for the nurse to determine?
A) Ability to care for self
B) Degree of danger to self and others
C) Level of psychosis
D) Intended compliance with aftercare
Answer: B
Rationale: When a voluntarily admitted psychiatric patient requests discharge
against medical advice, the priority is to determine if the patient poses a danger to
themselves or others. If the patient is a danger, the provider may initiate
involuntary commitment proceedings.
7. A team of RNs is researching the occurrence of pressure injury throughout the
hospital. How does the use of standardized language in the electronic health record
(EHR) increase efficiency in data gathering?
A) Standardization of information is comprehensive and consistent
B) Other disciplines clearly understand language
C) Compliance with privacy is ensured
D) Free text allows clearer description of patient data
Answer: A
Rationale: Standardized language in the EHR ensures data is comprehensive and
consistent across the organization, enabling efficient data gathering for quality
improvement. Standardized terminology (e.g., NANDA, NIC, NOC) allows for
aggregation of data to identify trends and outcomes. Free text makes data
aggregation difficult.
8. What is the correct order of the nursing process?
A) Assessment, Planning, Diagnosis, Implementation, Evaluation
B) Assessment, Diagnosis, Planning, Implementation, Evaluation
C) Diagnosis, Assessment, Planning, Implementation, Evaluation
D) Planning, Assessment, Diagnosis, Implementation, Evaluation
Answer: B
, Rationale: The correct order of the nursing process is Assessment → Diagnosis →
Planning → Implementation → Evaluation (ADPIE). This systematic framework
guides clinical reasoning and is foundational to nursing practice.
9. During a private conversation, a client with borderline personality disorder asks
the nurse to keep his secret and then displays multiple, self-inflicted, superficial
lacerations on his forearms. What is the most appropriate way for the nurse to
respond?
A) "That's it! You're on suicide precautions."
B) "I'm going to tell your physician. Do you want to tell me why you did that?"
C) "Tell me what type of instrument you used. I'm concerned about infection."
D) "The team needs to know when something important occurs in treatment. I need
to tell the others, but let's talk about it first."
Answer: D
Rationale: This response maintains the therapeutic alliance while establishing
professional boundaries. The nurse acknowledges the need to share critical
information with the treatment team while validating the client's feelings. Telling
the client "let's talk about it first" provides emotional support.
10. A nurse is monitoring a client for signs of early alcohol withdrawal. Which
most consistent assessment finding would the nurse expect?
A) Heart rate of 120 to 140 beats/minute
B) Heart rate of 50 to 60 beats/minute
C) Blood pressure of 100/70 mm Hg
D) Blood pressure of 140/80 mm Hg
Answer: A
Rationale: Early alcohol withdrawal is characterized by sympathetic nervous
system overactivity, including tachycardia (heart rate 120-140 bpm), hypertension,
tremors, and anxiety. Bradycardia and hypotension are not associated with early
withdrawal.
11. The nurse hears an emergency announcement for an external disaster. Based on
this announcement, what is the critical information the nurse should be concerned
with?
A) Occurs outside the facility and impacts normal operations
B) Occurs within the facility and requires evacuation
C) Involves a single patient only
D) Requires immediate discharge of all patients
Answer: A
VERIFIED ANSWERS WITH RATIONALE LATEST 2026
ALREADY GRADED A+
This NUR 104 exam comprehensively evaluates foundational nursing
knowledge across multiple domains. It assesses the nursing process (ADPIE)
and clinical judgment (NCSBN CJMM), medication administration safety
including the six rights and error management, and pharmacological
principles across major drug classes. The exam covers respiratory conditions
(COPD, asthma, pneumonia, tuberculosis), cardiovascular pharmacology
(anticoagulants, antiarrhythmics, heart failure drugs), endocrine disorders
(diabetes, thyroid), neurologic conditions (Parkinson's, Alzheimer's, seizures,
pain management), psychiatric medications (antidepressants, antipsychotics,
mood stabilizers), and cultural competence. It emphasizes adverse effect
monitoring, drug interactions, patient education, and clinical decision-making
in diverse patient populations across the lifespan.
1. A patient states, "I would like to be able to decrease my risk for heart disease. I
started eating better but there is more I can do." What analysis would the RN
determine for this patient?
A) Risk-prone health behavior
B) Ineffective role performance
C) Deficient knowledge
D) Readiness for enhanced health management
Answer: D
Rationale: The patient is expressing a desire to improve their health and has
already taken action, indicating Readiness for enhanced health management, a
wellness nursing diagnosis. Risk-prone health behavior would be indicated by a
pattern of behaviors that threaten health despite awareness. Deficient knowledge
would be indicated by a lack of understanding rather than an expressed desire to
learn more.
2. What is the correct sequence of the NCSBN Clinical Judgment Measurement
Model?
,A) Assess → Diagnose → Plan → Implement → Evaluate
B) Recognize Cues → Analyze Cues → Prioritize Hypotheses → Generate
Solutions → Take Action → Evaluate Outcomes
C) Recognize Cues → Generate Solutions → Analyze Cues → Take Action →
Evaluate Outcomes
D) Assess → Analyze → Plan → Implement → Evaluate
Answer: B
Rationale: The NCSBN Clinical Judgment Measurement Model (CJMM) provides
the framework for Next Generation NCLEX items. The six steps in order are:
Recognize Cues, Analyze Cues, Prioritize Hypotheses, Generate Solutions, Take
Action, and Evaluate Outcomes.
3. A nursing action that is performed after collaboration with other healthcare team
members is a(n):
A) Independent nursing action
B) Interdependent nursing action
C) Dependent nursing action
D) Collaborative nursing action
Answer: B
Rationale: Interdependent nursing actions are those carried out in collaboration
with other healthcare team members (e.g., physical therapists, dietitians,
physicians). Independent actions are within the nurse's autonomous scope, while
dependent actions require a provider order.
4. For a patient with impaired skin integrity, which expected patient outcome
meets the criteria for being measurable?
A) Patient has a willingness for enhanced health
B) Patient is demonstrating risk-prone health behavior
C) Patient shows ineffective role performance
D) Experience no further skin breakdown by the next clinic visit
Answer: D
Rationale: Measurable outcomes must be specific, observable, and time-bound.
"Experience no further skin breakdown by the next clinic visit" specifies an
outcome and timeframe, making it measurable. Vague outcomes like "willingness"
are not measurable.
5. When developing a patient plan of care, which is an independent nursing action?
A) Administer a stool softener at bedtime every day
B) Request a high fiber diet from nutrition services
C) Collaborate with physical therapist to modify activity orders
,D) Check the common side effects of the drug
Answer: A
Rationale: Independent nursing actions are those the nurse can legally and
autonomously prescribe and implement. Administering a stool softener (as a
standing order) is an independent nursing action. Requesting a diet change requires
a provider order and collaborating with PT is interdependent.
6. A client with a psychiatric disorder was voluntarily admitted and now wishes to
be discharged from the hospital, against medical advice. Which aspect would be
most important for the nurse to determine?
A) Ability to care for self
B) Degree of danger to self and others
C) Level of psychosis
D) Intended compliance with aftercare
Answer: B
Rationale: When a voluntarily admitted psychiatric patient requests discharge
against medical advice, the priority is to determine if the patient poses a danger to
themselves or others. If the patient is a danger, the provider may initiate
involuntary commitment proceedings.
7. A team of RNs is researching the occurrence of pressure injury throughout the
hospital. How does the use of standardized language in the electronic health record
(EHR) increase efficiency in data gathering?
A) Standardization of information is comprehensive and consistent
B) Other disciplines clearly understand language
C) Compliance with privacy is ensured
D) Free text allows clearer description of patient data
Answer: A
Rationale: Standardized language in the EHR ensures data is comprehensive and
consistent across the organization, enabling efficient data gathering for quality
improvement. Standardized terminology (e.g., NANDA, NIC, NOC) allows for
aggregation of data to identify trends and outcomes. Free text makes data
aggregation difficult.
8. What is the correct order of the nursing process?
A) Assessment, Planning, Diagnosis, Implementation, Evaluation
B) Assessment, Diagnosis, Planning, Implementation, Evaluation
C) Diagnosis, Assessment, Planning, Implementation, Evaluation
D) Planning, Assessment, Diagnosis, Implementation, Evaluation
Answer: B
, Rationale: The correct order of the nursing process is Assessment → Diagnosis →
Planning → Implementation → Evaluation (ADPIE). This systematic framework
guides clinical reasoning and is foundational to nursing practice.
9. During a private conversation, a client with borderline personality disorder asks
the nurse to keep his secret and then displays multiple, self-inflicted, superficial
lacerations on his forearms. What is the most appropriate way for the nurse to
respond?
A) "That's it! You're on suicide precautions."
B) "I'm going to tell your physician. Do you want to tell me why you did that?"
C) "Tell me what type of instrument you used. I'm concerned about infection."
D) "The team needs to know when something important occurs in treatment. I need
to tell the others, but let's talk about it first."
Answer: D
Rationale: This response maintains the therapeutic alliance while establishing
professional boundaries. The nurse acknowledges the need to share critical
information with the treatment team while validating the client's feelings. Telling
the client "let's talk about it first" provides emotional support.
10. A nurse is monitoring a client for signs of early alcohol withdrawal. Which
most consistent assessment finding would the nurse expect?
A) Heart rate of 120 to 140 beats/minute
B) Heart rate of 50 to 60 beats/minute
C) Blood pressure of 100/70 mm Hg
D) Blood pressure of 140/80 mm Hg
Answer: A
Rationale: Early alcohol withdrawal is characterized by sympathetic nervous
system overactivity, including tachycardia (heart rate 120-140 bpm), hypertension,
tremors, and anxiety. Bradycardia and hypotension are not associated with early
withdrawal.
11. The nurse hears an emergency announcement for an external disaster. Based on
this announcement, what is the critical information the nurse should be concerned
with?
A) Occurs outside the facility and impacts normal operations
B) Occurs within the facility and requires evacuation
C) Involves a single patient only
D) Requires immediate discharge of all patients
Answer: A
