NUR 104 MIDTERM EXAM (EXCELSIOR
COLLEGE) NEWEST 2026 ACTUAL EXAM
TEST BANK| NUR104 NURSING
FUNDAMENTALS MID-TERM REVIEW
WITH COMPLETE 300 REAL EXAM
QUESTIONS AND CORRECT VERIFIED
ANSWERS/ ALREADY GRADED A+
(MOST RECENT!!)
Nursing Process & Clinical Judgment
Q1: 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
Correct Answer: B. Assessment, Diagnosis, Planning, Implementation,
Evaluation
Rationale: ADPIE provides a systematic framework that guides clinical
reasoning. Assessment collects data, Diagnosis identifies problems,
Planning establishes goals, Implementation carries out interventions, and
Evaluation measures outcomes .
,Q2: During the nursing process, the nurse identifies a patient problem
based on assessment data. This action occurs during which phase?
A. Assessment
B. Diagnosis
C. Planning
D. Implementation
Correct Answer: B. Diagnosis
Rationale: Diagnosis involves analyzing assessment data to recognize
actual or potential health problems, forming the basis for the care plan .
Q3: Which phase of the nursing process involves gathering and
analyzing data about a patient's health status?
A. Diagnosis
B. Planning
C. Assessment
D. Evaluation
Correct Answer: C. Assessment
Rationale: Assessment is the first step where the nurse collects subjective
and objective data to establish a comprehensive health picture .
Q4: According to the NCSBN Clinical Judgment Measurement Model
(CJMM), which is the correct order of steps?
A. Assessment, Diagnosis, Planning, Implementation, Evaluation
B. Recognize Cues, Analyze Cues, Prioritize Hypotheses, Generate Solutions,
Take Action, Evaluate Outcomes
C. Assessment, Planning, Implementation, Evaluation
D. Identify, Diagnose, Plan, Act, Evaluate
Correct Answer: B. Recognize Cues, Analyze Cues, Prioritize
Hypotheses, Generate Solutions, Take Action, Evaluate Outcomes
,Rationale: The NCSBN CJMM provides the framework for Next Generation
NCLEX (NGN) items and guides clinical reasoning .
Patient Safety & Fall Prevention
Q5: What is the most common type of inpatient accident in healthcare
facilities?
A. Medication errors
B. Falls
C. Burns
D. Surgical site infections
Correct Answer: B. Falls
Rationale: Falls are the leading inpatient accident, often due to mobility
limitations, medications, and environmental hazards. Fall prevention
remains a top priority in hospital safety initiatives .
Q6: Which intervention reduces the risk of falls for ambulatory
patients?
A. Keeping the bed in a high position
B. Using skid-proof footwear
C. Restraining the patient preemptively
D. Dimming the room lights
Correct Answer: B. Using skid-proof footwear
Rationale: Properly fitted skid-proof footwear prevents slipping. The bed
should be in a low position for safe entry/exit. Restraints are used only after
alternatives fail, and dim lighting increases fall risk .
Q7: A nurse is assessing an older adult's risk for falls. Which finding
increases the patient's risk?
, A. Upper extremity strength 5/5
B. Lower extremity weakness
C. Age 55 years
D. Normal orthostatic blood pressure
Correct Answer: B. Lower extremity weakness
Rationale: Lower extremity weakness impairs balance and mobility,
increasing fall risk. Age 65 or older is a risk factor, not 55 .
Q8: An unconscious patient is at high risk for pressure injuries. How
often should the patient be repositioned?
A. Every 1 hour
B. Every 2 hours
C. Every 3 hours
D. Every 4 hours
Correct Answer: B. Every 2 hours
Rationale: Repositioning every 2 hours minimizes prolonged pressure and
ischemia to tissues. Unconscious patients lack protective reflexes to shift
weight .
Q9: Which environmental factor in a healthcare facility can contribute
to sensory overload?
A. Natural sunlight
B. Noise pollution
C. Soft background music
D. Neutral wall colors
Correct Answer: B. Noise pollution
Rationale: Excessive or unpredictable noise, such as alarms, conversations,
and equipment sounds, can overstimulate patients and lead to confusion or
agitation .
COLLEGE) NEWEST 2026 ACTUAL EXAM
TEST BANK| NUR104 NURSING
FUNDAMENTALS MID-TERM REVIEW
WITH COMPLETE 300 REAL EXAM
QUESTIONS AND CORRECT VERIFIED
ANSWERS/ ALREADY GRADED A+
(MOST RECENT!!)
Nursing Process & Clinical Judgment
Q1: 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
Correct Answer: B. Assessment, Diagnosis, Planning, Implementation,
Evaluation
Rationale: ADPIE provides a systematic framework that guides clinical
reasoning. Assessment collects data, Diagnosis identifies problems,
Planning establishes goals, Implementation carries out interventions, and
Evaluation measures outcomes .
,Q2: During the nursing process, the nurse identifies a patient problem
based on assessment data. This action occurs during which phase?
A. Assessment
B. Diagnosis
C. Planning
D. Implementation
Correct Answer: B. Diagnosis
Rationale: Diagnosis involves analyzing assessment data to recognize
actual or potential health problems, forming the basis for the care plan .
Q3: Which phase of the nursing process involves gathering and
analyzing data about a patient's health status?
A. Diagnosis
B. Planning
C. Assessment
D. Evaluation
Correct Answer: C. Assessment
Rationale: Assessment is the first step where the nurse collects subjective
and objective data to establish a comprehensive health picture .
Q4: According to the NCSBN Clinical Judgment Measurement Model
(CJMM), which is the correct order of steps?
A. Assessment, Diagnosis, Planning, Implementation, Evaluation
B. Recognize Cues, Analyze Cues, Prioritize Hypotheses, Generate Solutions,
Take Action, Evaluate Outcomes
C. Assessment, Planning, Implementation, Evaluation
D. Identify, Diagnose, Plan, Act, Evaluate
Correct Answer: B. Recognize Cues, Analyze Cues, Prioritize
Hypotheses, Generate Solutions, Take Action, Evaluate Outcomes
,Rationale: The NCSBN CJMM provides the framework for Next Generation
NCLEX (NGN) items and guides clinical reasoning .
Patient Safety & Fall Prevention
Q5: What is the most common type of inpatient accident in healthcare
facilities?
A. Medication errors
B. Falls
C. Burns
D. Surgical site infections
Correct Answer: B. Falls
Rationale: Falls are the leading inpatient accident, often due to mobility
limitations, medications, and environmental hazards. Fall prevention
remains a top priority in hospital safety initiatives .
Q6: Which intervention reduces the risk of falls for ambulatory
patients?
A. Keeping the bed in a high position
B. Using skid-proof footwear
C. Restraining the patient preemptively
D. Dimming the room lights
Correct Answer: B. Using skid-proof footwear
Rationale: Properly fitted skid-proof footwear prevents slipping. The bed
should be in a low position for safe entry/exit. Restraints are used only after
alternatives fail, and dim lighting increases fall risk .
Q7: A nurse is assessing an older adult's risk for falls. Which finding
increases the patient's risk?
, A. Upper extremity strength 5/5
B. Lower extremity weakness
C. Age 55 years
D. Normal orthostatic blood pressure
Correct Answer: B. Lower extremity weakness
Rationale: Lower extremity weakness impairs balance and mobility,
increasing fall risk. Age 65 or older is a risk factor, not 55 .
Q8: An unconscious patient is at high risk for pressure injuries. How
often should the patient be repositioned?
A. Every 1 hour
B. Every 2 hours
C. Every 3 hours
D. Every 4 hours
Correct Answer: B. Every 2 hours
Rationale: Repositioning every 2 hours minimizes prolonged pressure and
ischemia to tissues. Unconscious patients lack protective reflexes to shift
weight .
Q9: Which environmental factor in a healthcare facility can contribute
to sensory overload?
A. Natural sunlight
B. Noise pollution
C. Soft background music
D. Neutral wall colors
Correct Answer: B. Noise pollution
Rationale: Excessive or unpredictable noise, such as alarms, conversations,
and equipment sounds, can overstimulate patients and lead to confusion or
agitation .
