DRAKE STATE COMMUNITY AND TECHNICAL COLLEGE – NUR 113 & NUR 114: NURSING
CONCEPTS I + II – QUESTIONS AND ANSWERS | 2026/2027 LATEST UPDATE
SECTION 1: CARE COORDINATION, CLINICAL JUDGMENT, AND FOUNDATIONAL NURSING
CONCEPTS
Questions 1–10
1. Which action best demonstrates the nursing process as a systematic method of
clinical decision-making?
A) Collecting data, identifying problems, planning care, implementing interventions,
and evaluating outcomes
B) Administering medications before completing the assessment
C) Waiting for the healthcare provider to identify every nursing problem
D) Documenting care only after the patient is discharged
Correct Answer: A) Collecting data, identifying problems, planning care, implementing
interventions, and evaluating outcomes
Rationale: The nursing process provides a systematic framework for individualized nursing
care. Assessment supplies information used to identify nursing problems and establish
priorities. Planning and implementation address identified needs, while evaluation
determines whether desired outcomes were achieved and whether the plan requires
modification.
2. A nurse receives handoff information about four clients. Which finding should receive
the highest priority for immediate assessment?
A) A client requesting assistance with bathing
B) A client with new-onset difficulty breathing
C) A client asking when breakfast will arrive
D) A client awaiting routine discharge instructions
Correct Answer: B) A client with new-onset difficulty breathing
Rationale: New respiratory difficulty can indicate impaired oxygenation and represents a
potentially life-threatening problem. Airway and breathing concerns generally receive
priority over routine comfort, hygiene, or administrative needs. The nurse should rapidly
assess respiratory status and initiate appropriate interventions while seeking additional
assistance when indicated.
, 3. What is the primary purpose of establishing measurable nursing outcomes?
A) To replace nursing assessment
B) To eliminate the need for documentation
C) To provide criteria for determining whether care was effective
D) To guarantee that complications cannot occur
Correct Answer: C) To provide criteria for determining whether care was effective
Rationale: Measurable outcomes establish observable criteria against which patient progress
can be evaluated. They help the nurse determine whether interventions produced the desired
response. Outcomes should be individualized, realistic, and time limited when appropriate
rather than serving as guarantees that complications will never occur.
4. When several patient needs occur simultaneously, which principle should guide
initial prioritization?
A) Address the request made most recently
B) Address the patient who has the longest hospital stay
C) Complete all documentation before providing care
D) Address threats to airway, breathing, circulation, or immediate safety first
Correct Answer: D) Address threats to airway, breathing, circulation, or immediate safety
first
Rationale: Physiologic instability and immediate threats to life take precedence over routine
needs. Airway, breathing, circulation, and serious safety concerns can deteriorate rapidly.
Prioritization does not depend simply on who asks first or who has been hospitalized longest,
because urgency and potential harm must guide clinical decisions.
5. A nursing student asks why assessment should occur before implementation of most
interventions. Which response is most accurate?
A) Assessment identifies patient data needed to individualize the intervention
B) Assessment is primarily performed for billing purposes
C) Assessment guarantees the diagnosis is medically correct
D) Assessment eliminates the need for reassessment
Correct Answer: A) Assessment identifies patient data needed to individualize the
intervention
Rationale: Assessment provides the subjective and objective information necessary for safe,
individualized care. Without adequate assessment, an intervention may fail to address the
,actual problem or may be unsafe. Assessment is ongoing, so the nurse also reassesses after
interventions to determine the patient's response.
6. Which activity most directly represents evaluation in the nursing process?
A) Recording the patient's admission history
B) Comparing the patient's current response with the expected outcome
C) Selecting nursing interventions before assessment
D) Identifying available hospital resources
Correct Answer: B) Comparing the patient's current response with the expected outcome
Rationale: Evaluation determines whether the patient's response matches the expected
outcome. The nurse compares current findings with established criteria and then continues,
modifies, or terminates interventions as appropriate. Evaluation therefore closes one cycle of
clinical reasoning while generating information for subsequent assessment and planning.
7. Which statement best describes delegation?
A) The nurse transfers accountability for the entire patient's care to another worker
B) The nurse gives away professional responsibility for clinical judgment
C) The nurse assigns an appropriate task while retaining accountability for the overall
nursing process
D) The nurse delegates every task that takes more than five minutes
Correct Answer: C) The nurse assigns an appropriate task while retaining accountability for
the overall nursing process
Rationale: Delegation involves assigning an appropriate activity to a qualified individual
under suitable circumstances. The registered nurse retains accountability for nursing care
and must provide appropriate direction and follow-up. Tasks requiring nursing judgment
generally should not be delegated simply because they are time consuming.
8. Which situation most clearly requires the nurse to use clinical judgment rather than
simply follow a routine?
A) Replacing an empty tissue box
B) Recording a previously verified room number
C) Delivering a standard meal tray
D) Interpreting a sudden change in mental status and determining the appropriate response
Correct Answer: D) Interpreting a sudden change in mental status and determining the
appropriate response
, Rationale: Clinical judgment requires interpretation of patient information and selection of
an appropriate response. A sudden change in mental status may signal hypoxia, infection,
metabolic disturbance, medication effects, or another serious condition. Recognizing the
significance of the change requires assessment, analysis, prioritization, and action.
9. Which documentation practice best supports continuity of care?
A) Recording objective findings, interventions, patient responses, and relevant
communication accurately
B) Documenting only abnormal findings and omitting interventions
C) Recording anticipated care as though it had already occurred
D) Waiting until the end of the week to enter routine observations
Correct Answer: A) Recording objective findings, interventions, patient responses, and
relevant communication accurately
Rationale: Accurate documentation communicates the patient's condition and the care
provided to members of the healthcare team. Entries should reflect what was assessed,
done, communicated, and observed. Documentation should be timely and factual rather
than based on assumptions or retrospective reconstruction of care.
10. A nurse notices that an intervention has not produced the expected patient
response. What is the most appropriate next step?
A) Continue the intervention indefinitely
B) Reassess the patient and determine whether the plan requires modification
C) Delete the original nursing documentation
D) Assume that the outcome will eventually occur
Correct Answer: B) Reassess the patient and determine whether the plan requires
modification
Rationale: An unexpected response indicates that reassessment is necessary. The nurse
should determine whether the assessment was accurate, whether the intervention was
appropriate, and whether the patient's condition has changed. Continuing an ineffective
intervention without reassessment can delay recognition of deterioration or another
underlying problem.
SECTION 2: INFECTION, INFLAMMATION, AND TISSUE INTEGRITY
Questions 11–20
CONCEPTS I + II – QUESTIONS AND ANSWERS | 2026/2027 LATEST UPDATE
SECTION 1: CARE COORDINATION, CLINICAL JUDGMENT, AND FOUNDATIONAL NURSING
CONCEPTS
Questions 1–10
1. Which action best demonstrates the nursing process as a systematic method of
clinical decision-making?
A) Collecting data, identifying problems, planning care, implementing interventions,
and evaluating outcomes
B) Administering medications before completing the assessment
C) Waiting for the healthcare provider to identify every nursing problem
D) Documenting care only after the patient is discharged
Correct Answer: A) Collecting data, identifying problems, planning care, implementing
interventions, and evaluating outcomes
Rationale: The nursing process provides a systematic framework for individualized nursing
care. Assessment supplies information used to identify nursing problems and establish
priorities. Planning and implementation address identified needs, while evaluation
determines whether desired outcomes were achieved and whether the plan requires
modification.
2. A nurse receives handoff information about four clients. Which finding should receive
the highest priority for immediate assessment?
A) A client requesting assistance with bathing
B) A client with new-onset difficulty breathing
C) A client asking when breakfast will arrive
D) A client awaiting routine discharge instructions
Correct Answer: B) A client with new-onset difficulty breathing
Rationale: New respiratory difficulty can indicate impaired oxygenation and represents a
potentially life-threatening problem. Airway and breathing concerns generally receive
priority over routine comfort, hygiene, or administrative needs. The nurse should rapidly
assess respiratory status and initiate appropriate interventions while seeking additional
assistance when indicated.
, 3. What is the primary purpose of establishing measurable nursing outcomes?
A) To replace nursing assessment
B) To eliminate the need for documentation
C) To provide criteria for determining whether care was effective
D) To guarantee that complications cannot occur
Correct Answer: C) To provide criteria for determining whether care was effective
Rationale: Measurable outcomes establish observable criteria against which patient progress
can be evaluated. They help the nurse determine whether interventions produced the desired
response. Outcomes should be individualized, realistic, and time limited when appropriate
rather than serving as guarantees that complications will never occur.
4. When several patient needs occur simultaneously, which principle should guide
initial prioritization?
A) Address the request made most recently
B) Address the patient who has the longest hospital stay
C) Complete all documentation before providing care
D) Address threats to airway, breathing, circulation, or immediate safety first
Correct Answer: D) Address threats to airway, breathing, circulation, or immediate safety
first
Rationale: Physiologic instability and immediate threats to life take precedence over routine
needs. Airway, breathing, circulation, and serious safety concerns can deteriorate rapidly.
Prioritization does not depend simply on who asks first or who has been hospitalized longest,
because urgency and potential harm must guide clinical decisions.
5. A nursing student asks why assessment should occur before implementation of most
interventions. Which response is most accurate?
A) Assessment identifies patient data needed to individualize the intervention
B) Assessment is primarily performed for billing purposes
C) Assessment guarantees the diagnosis is medically correct
D) Assessment eliminates the need for reassessment
Correct Answer: A) Assessment identifies patient data needed to individualize the
intervention
Rationale: Assessment provides the subjective and objective information necessary for safe,
individualized care. Without adequate assessment, an intervention may fail to address the
,actual problem or may be unsafe. Assessment is ongoing, so the nurse also reassesses after
interventions to determine the patient's response.
6. Which activity most directly represents evaluation in the nursing process?
A) Recording the patient's admission history
B) Comparing the patient's current response with the expected outcome
C) Selecting nursing interventions before assessment
D) Identifying available hospital resources
Correct Answer: B) Comparing the patient's current response with the expected outcome
Rationale: Evaluation determines whether the patient's response matches the expected
outcome. The nurse compares current findings with established criteria and then continues,
modifies, or terminates interventions as appropriate. Evaluation therefore closes one cycle of
clinical reasoning while generating information for subsequent assessment and planning.
7. Which statement best describes delegation?
A) The nurse transfers accountability for the entire patient's care to another worker
B) The nurse gives away professional responsibility for clinical judgment
C) The nurse assigns an appropriate task while retaining accountability for the overall
nursing process
D) The nurse delegates every task that takes more than five minutes
Correct Answer: C) The nurse assigns an appropriate task while retaining accountability for
the overall nursing process
Rationale: Delegation involves assigning an appropriate activity to a qualified individual
under suitable circumstances. The registered nurse retains accountability for nursing care
and must provide appropriate direction and follow-up. Tasks requiring nursing judgment
generally should not be delegated simply because they are time consuming.
8. Which situation most clearly requires the nurse to use clinical judgment rather than
simply follow a routine?
A) Replacing an empty tissue box
B) Recording a previously verified room number
C) Delivering a standard meal tray
D) Interpreting a sudden change in mental status and determining the appropriate response
Correct Answer: D) Interpreting a sudden change in mental status and determining the
appropriate response
, Rationale: Clinical judgment requires interpretation of patient information and selection of
an appropriate response. A sudden change in mental status may signal hypoxia, infection,
metabolic disturbance, medication effects, or another serious condition. Recognizing the
significance of the change requires assessment, analysis, prioritization, and action.
9. Which documentation practice best supports continuity of care?
A) Recording objective findings, interventions, patient responses, and relevant
communication accurately
B) Documenting only abnormal findings and omitting interventions
C) Recording anticipated care as though it had already occurred
D) Waiting until the end of the week to enter routine observations
Correct Answer: A) Recording objective findings, interventions, patient responses, and
relevant communication accurately
Rationale: Accurate documentation communicates the patient's condition and the care
provided to members of the healthcare team. Entries should reflect what was assessed,
done, communicated, and observed. Documentation should be timely and factual rather
than based on assumptions or retrospective reconstruction of care.
10. A nurse notices that an intervention has not produced the expected patient
response. What is the most appropriate next step?
A) Continue the intervention indefinitely
B) Reassess the patient and determine whether the plan requires modification
C) Delete the original nursing documentation
D) Assume that the outcome will eventually occur
Correct Answer: B) Reassess the patient and determine whether the plan requires
modification
Rationale: An unexpected response indicates that reassessment is necessary. The nurse
should determine whether the assessment was accurate, whether the intervention was
appropriate, and whether the patient's condition has changed. Continuing an ineffective
intervention without reassessment can delay recognition of deterioration or another
underlying problem.
SECTION 2: INFECTION, INFLAMMATION, AND TISSUE INTEGRITY
Questions 11–20
