NUR 1020 FINAL EXAM 300 QUESTIONS AND CORRECT
ANSWERS WITH RATIONALES LATEST UPDATE OF THE
YEAR
SECTION 1: THE NURSING PROCESS & CRITICAL THINKING (Questions 1-30)
1. A nurse is admitting a client to the medical-surgical unit. Which action by the
nurse is considered the priority during the assessment phase of the nursing
process?
A. Formulating a nursing DIAGNOSIS
B. Collecting subjective and objective data
C. Setting goals for the client's care
D. Administering prescribed medications
Correct Answer: B
Rationale: The assessment phase involves collecting comprehensive data
(subjective from the client/family and objective from physical exam/labs) to form
a baseline. Formulating a diagnosis (A) is the second step. Setting goals (C) is
planning. Administering meds (D) is implementation.
2. A nurse reviews a client's laboratory data and notes a potassium level of 5.8
mEq/L. This is an example of which type of data?
A. Subjective data
B. Objective data
C. Cue clustering
D. Nursing diagnosis
Correct Answer: B
,Rationale: Objective data are measurable, observable facts obtained through
assessment (vital signs, labs, physical exam). Subjective data (A) are what the
client tells you (symptoms). Cue clustering (C) is grouping data to form a pattern.
3. A client states, "I feel anxious about my surgery tomorrow." The nurse
documents this as which type of data?
A. Objective data
B. Primary subjective data
C. Secondary subjective data
D. Inferential data
Correct Answer: B
Rationale: Primary subjective data come directly from the client's own verbal
description of their feelings, perceptions, or symptoms. It cannot be measured or
observed by the nurse.
4. The nurse is formulating a nursing diagnosis for a client with impaired mobility.
Which part of the nursing diagnosis is the "PES" format's "E"?
A. Problem
B. Signs and symptoms
C. Etiology (related factors)
D. Evaluation criteria
Correct Answer: C
Rationale: The PES format stands for Problem (P), Etiology (E - the cause or related
factors), and Signs/Symptoms (S - defining characteristics).
,5. A nurse writes the following diagnosis: "Impaired Skin Integrity related to
immobility as evidenced by stage 2 pressure injury on the coccyx." Which part of
this statement is the "defining characteristic"?
A. Impaired Skin Integrity
B. Related to immobility
C. Stage 2 pressure injury on the coccyx
D. As evidenced by
Correct Answer: C
Rationale: The defining characteristics (signs/symptoms) are the clinical cues that
support the diagnosis. "Stage 2 pressure injury on the coccyx" is the evidence.
"Impaired Skin Integrity" is the problem (A). "Related to immobility" is the etiology
(B).
6. During the planning phase, the nurse establishes a goal for a client with
dehydration: "The client will have a urine output of at least 30 mL/hr within 24
hours." This is an example of a:
A. Short-term goal
B. Long-term goal
C. Outcome criterion
D. Nursing intervention
Correct Answer: A
Rationale: Short-term goals are achievable within a few hours to a few days
(usually less than a week). Long-term goals (B) take weeks or months. Outcome
criteria (C) are measurable standards used to evaluate goal attainment.
, 7. A nurse is prioritizing care for four clients. According to Maslow's Hierarchy of
Needs, which client should the nurse attend to first?
A. A client who is anxious about a new diagnosis of diabetes
B. A client who is refusing to eat because of religious beliefs
C. A client who has a respiratory rate of 10 breaths/min and is somnolent
D. A client who asks for help to ambulate to the bathroom
Correct Answer: C
Rationale: Maslow's hierarchy places physiological needs (airway, breathing,
circulation, food, water, elimination) as the highest priority. Respiratory
depression is a life-threatening physiological need that takes precedence over
safety (D), social (B), or self-esteem/self-actualization (A).
8. The nurse implements a standing order for PRN pain medication for a
postoperative client. This is an example of which type of nursing intervention?
A. Independent intervention
B. Dependent intervention
C. Interdependent (collaborative) intervention
D. Standing order implementation
Correct Answer: C
Rationale: Interdependent interventions are carried out in collaboration with
other healthcare team members (e.g., implementing a physician's standing order
for PRN meds). Independent (A) are nurse-initiated (e.g., repositioning).
Dependent (B) require a specific provider order (e.g., giving a scheduled med).
ANSWERS WITH RATIONALES LATEST UPDATE OF THE
YEAR
SECTION 1: THE NURSING PROCESS & CRITICAL THINKING (Questions 1-30)
1. A nurse is admitting a client to the medical-surgical unit. Which action by the
nurse is considered the priority during the assessment phase of the nursing
process?
A. Formulating a nursing DIAGNOSIS
B. Collecting subjective and objective data
C. Setting goals for the client's care
D. Administering prescribed medications
Correct Answer: B
Rationale: The assessment phase involves collecting comprehensive data
(subjective from the client/family and objective from physical exam/labs) to form
a baseline. Formulating a diagnosis (A) is the second step. Setting goals (C) is
planning. Administering meds (D) is implementation.
2. A nurse reviews a client's laboratory data and notes a potassium level of 5.8
mEq/L. This is an example of which type of data?
A. Subjective data
B. Objective data
C. Cue clustering
D. Nursing diagnosis
Correct Answer: B
,Rationale: Objective data are measurable, observable facts obtained through
assessment (vital signs, labs, physical exam). Subjective data (A) are what the
client tells you (symptoms). Cue clustering (C) is grouping data to form a pattern.
3. A client states, "I feel anxious about my surgery tomorrow." The nurse
documents this as which type of data?
A. Objective data
B. Primary subjective data
C. Secondary subjective data
D. Inferential data
Correct Answer: B
Rationale: Primary subjective data come directly from the client's own verbal
description of their feelings, perceptions, or symptoms. It cannot be measured or
observed by the nurse.
4. The nurse is formulating a nursing diagnosis for a client with impaired mobility.
Which part of the nursing diagnosis is the "PES" format's "E"?
A. Problem
B. Signs and symptoms
C. Etiology (related factors)
D. Evaluation criteria
Correct Answer: C
Rationale: The PES format stands for Problem (P), Etiology (E - the cause or related
factors), and Signs/Symptoms (S - defining characteristics).
,5. A nurse writes the following diagnosis: "Impaired Skin Integrity related to
immobility as evidenced by stage 2 pressure injury on the coccyx." Which part of
this statement is the "defining characteristic"?
A. Impaired Skin Integrity
B. Related to immobility
C. Stage 2 pressure injury on the coccyx
D. As evidenced by
Correct Answer: C
Rationale: The defining characteristics (signs/symptoms) are the clinical cues that
support the diagnosis. "Stage 2 pressure injury on the coccyx" is the evidence.
"Impaired Skin Integrity" is the problem (A). "Related to immobility" is the etiology
(B).
6. During the planning phase, the nurse establishes a goal for a client with
dehydration: "The client will have a urine output of at least 30 mL/hr within 24
hours." This is an example of a:
A. Short-term goal
B. Long-term goal
C. Outcome criterion
D. Nursing intervention
Correct Answer: A
Rationale: Short-term goals are achievable within a few hours to a few days
(usually less than a week). Long-term goals (B) take weeks or months. Outcome
criteria (C) are measurable standards used to evaluate goal attainment.
, 7. A nurse is prioritizing care for four clients. According to Maslow's Hierarchy of
Needs, which client should the nurse attend to first?
A. A client who is anxious about a new diagnosis of diabetes
B. A client who is refusing to eat because of religious beliefs
C. A client who has a respiratory rate of 10 breaths/min and is somnolent
D. A client who asks for help to ambulate to the bathroom
Correct Answer: C
Rationale: Maslow's hierarchy places physiological needs (airway, breathing,
circulation, food, water, elimination) as the highest priority. Respiratory
depression is a life-threatening physiological need that takes precedence over
safety (D), social (B), or self-esteem/self-actualization (A).
8. The nurse implements a standing order for PRN pain medication for a
postoperative client. This is an example of which type of nursing intervention?
A. Independent intervention
B. Dependent intervention
C. Interdependent (collaborative) intervention
D. Standing order implementation
Correct Answer: C
Rationale: Interdependent interventions are carried out in collaboration with
other healthcare team members (e.g., implementing a physician's standing order
for PRN meds). Independent (A) are nurse-initiated (e.g., repositioning).
Dependent (B) require a specific provider order (e.g., giving a scheduled med).
