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NSG 100
Exams 1 - 4 & Final
Introduction to Nursing Concepts
Germanna Community College
High-Yield Qs to mirror the Actual Exam
Verified Answers with Rationales
This Exam Features:
NSG 100 Exams 1-4 & Final – Introduction to
Nursing Concepts – Germanna Community
College. This resource includes high-yield
questions designed to mirror the actual exam ,
with verified answers and clear rationales to help nursing
students master key concepts. Ideal for exam prep, concept
review, and confidence building before test day.
Table of Contents
NSG 100 Exam 1 .................................................................... 2
NSG 100 Exam 2 .................................................................. 28
NSG 100 Exam 3 .................................................................. 41
NSG 100 Exam 4 .................................................................. 67
NSG 100 Final Exam .......................................................... 100
NSG 100 Exam 1
The nurse prioritizes care for a patient who is recovering from a below the knee amputation secondary to complications of diabetes mellitus. Which intervention is identified as the priority for this patient using Maslow's hierarchy of needs?
A.The nurse teaches the patient how to properly change dressings on the right-leg amputation site. B.The nurse teaches the patient proper home safety techniques to prevent diabetic wounds. C.The patient joins the local American Diabetes Association support group. D.The patient attends classes to deal with body image.
ANSWER: A When prioritizing care based on Maslow's hierarchy of needs, physiological needs will come before safety, social, and esteem needs. Caring for an amputation site is meeting a physiological need. Attending a class to deal with body-image issues addresses an esteem need. Teaching the patient about safety techniques to prevent diabetic wounds addresses a safety need. Joining a support group meets an esteem need.
life-threatening situation. It would not meet the criteria for urgent or emergent/immediate.
The medical surgical nurse is planning the day immediately after receiving report. Which should be the primary nursing intervention when prioritizing care?
A.Ascertaining interventions B.Assessing patient situations C.Analyzing collected data D.Assigning staff to patients
ANSWER: The first step when prioritizing care is assessment. Assessment is the process of gathering information to make decisions. Assessment includes knowing individual patients' health statuses to prepare for anticipated or unanticipated changes. Ascertaining interventions would occur after the assessment. Analyzing collected data would occur after an assessment. Assigning staff to patients would occur after knowing the number and level of caregivers available to provide care.
A nurse is admitting a client who reports increased thirst and fatigue. Which of the following actions should the nurse include in the assessment step of the nursing process?
A.Take action to restore the client's health. B.Ask the client when the condition started. C.Reach a conclusion about the client's health status. D.Set goals for the client's recovery.
ANSWER: B Assessment is the first step of the nursing process, where the nurse gathers subjective and objective information about the client's condition.
An alert, oriented patient is admitted to the hospital with chest pain. From whom should the nurse collect primary data on this patient?
A.Family member B.Physician C.Another nurse D.Patient
ANSWER: D Primary data consist of information obtained directly from a patient.
The nurse is reviewing assessment data collected from a patient with pneumonia. Which data should the nurse identify as subjective?
A.Report of difficulty breathing B.Presence of cough C.Observation of yellow sputum D.Rapid breathing
ANSWER: A Subjective data are those that the patient feels, such as difficulty breathing. Objective data are those that the nurse can observe, measure, feel, hear, or smell.
The nurse is explaining how to develop an appropriate nursing diagnosis. Which participant statement indicates an appropriate understanding?
A."A nursing diagnosis is developed after the nurse evaluates the interventions provided." B."A nursing diagnosis is derived after the nurse develops the plan of care for the patient." C."A nursing diagnosis is determined by the medical diagnosis and current patient needs." D."A nursing diagnosis is based on clinical judgment that is derived from assessment data."
ANSWER: D The nursing diagnosis is derived after collecting objective and subjective data from the
Systematic decision-making method focusing on identifying and treating responses of individuals or groups to actual or potential alterations in health best describes:
A.Critical Thinking B.Clinical Reasoning C.Clinical Judgement D.Nursing Process
ANSWER: D According to NANDA, the nursing process is a five-part systematic decision-making method focusing on identifying and treating responses of individuals or groups to actual or potential alterations in health. ACEN defines critical thinking as, the deliberate nonlinear process of collecting, interpreting, analyzing, drawing conclusions about, presenting, and evaluating information that is both factual and belief-based. Clinical reasoning-thinking process by which a nurse reaches a clinical judgement. A clinical judgment is the nurse's determination and provision of appropriate care to the patient, refers to the result (outcome) of critical thinking or clinical reasoning-the conclusion, decision, or opinion made.
A nurse is caring for a group of clients. Which of the following actions by the nurse demonstrates the use of critical thinking skills?
A.Administer an influenza vaccine after asking a client about allergies. B.Check a client's armband before dispensing daily thyroid medication to a client who has hypothyroidism. C.Give a client who has type 1 diabetes mellitus her morning dose of insulin after checking her blood glucose level. D.Intervene after reviewing arterial blood gas results for a client who is on mechanical ventilation.
ANSWER: D
The nurse is using critical thinking when analyzing a client's critical issues and then planning to intervene with an appropriate action.
The registered nurse (RN) is explaining Tanner's clinical judgment model to a student nurse. Which element should the RN explain is needed first to make a clinical judgment?
A.Intuition B.Initiation of practice C.Nursing school education D.Multiple years of experience
ANSWER: C According to Tanner's clinical judgment model, thinking like a nurse begins with nursing education, which teaches fundamental nursing skills and knowledge. Intuition develops from experience and nursing knowledge over time. Initiation of practice does improve critical thinking skills but is not the initiating factor.
During the process of reflection, what is the most appropriate question for a nurse to ask himself or herself?
A."What could I have done differently?" B."What's going on right now?" C."How can the patient's status change?" D."What should I do to communicate this information?"
ANSWER: A Reflection is the action of retrospectively making sense of occurrences, experiences, situations, or decisions and learning from them. What did or did not work? What could have been done differently to achieve better outcomes?
Entering a room at 2:00 am, a nurse notes that the patient is not in bed; the patient is sitting in the chair and states that she is having difficulty sleeping. Employing critical thinking, the nurse responds by:
A.Noticing B.Interpreting C.Responding D.Reflecting
ANSWER: B The step of interpreting in Tanner's clinal judgment model includes: Comparing and contrasting data, clustering related information, recognizing inconsistencies, checking accuracy and reliability, distinguishing relevant from irrelevant information and determining the importance of information
Which of the statements best describes the purpose of the nursing process?
A.Deliver care to a client in an organized way. B.Implement a plan that is close to the medical model. C.Identify client needs and deliver care to meet those needs. D.Make sure that standardized care is available to clients.
ANSWER: C The purpose of the nursing process is to diagnose and treat human responses to actual or potential health problems. Simply described as identifying a client's actual or potential healthcare problems or needs, establishing plans to meet the identified needs, and delivering specific nursing interventions to meet those needs. The Nursing Process is the framework within which nurses provide care to patients in an organized and effective manner, it is not the purpose. The nursing process is not part of the medical model. The nursing process is individualized for each client's care plan. It is not about standardizing care.
The nurse is planning care for a new patient with unstable blood glucose levels. Which should be the priority action by the nurse?
A.Establish a specific nursing diagnosis. B.Complete an assessment on the client.
C.Create a plan of nursing care for the client. D.Carry out solutions to manage the problem.
ANSWER: B The five steps of the nursing process are assessment, diagnosis, planning implementation, and evaluation. The nurse should first perform a thorough assessment and then create a nursing diagnosis based on the assessment data. The nurse should then create a plan of care with nursing interventions to address the diagnosis, follow the plan, and then evaluate the effectiveness of the nursing interventions.
Which patient should the nurse assess first after receiving the change-of-shift report?
A.A patient with type 1 diabetes mellitus with blood glucose of 82 mg/dL (range 70-130mg/dL) B.A patient with hypertension with a blood pressure of 168/88 mmHg (normal BP less than 120mmHg/less than 80mmHg) C.A patient with a bowel obstruction who is complaining of nausea D.A patient with heart failure who is complaining of shortness of breath
ANSWER: D Using the ABCs (airway, breathing, and circulation) as a guide, the nurse should first assess the patient with shortness of breath. This would take priority over a patient complaining of nausea, a patient with an elevated (but not critically elevated) blood pressure, and a patient with a normal blood glucose reading.
A patient is admitted to the hospital with pneumonia. The nurse develops a plan of care with a nursing diagnosis of Impaired Gas Exchange related to inadequate ventilation secondary to atelectasis.
Which goal includes all elements of a goal statement?
A.The patient will demonstrate correct use of the incentive spirometer after the teaching session.
B.Provide culturally competent care. C.Determine need for special services. Promote contentment in the patient.
ANSWER: B The nurse should ask about dietary preferences related to religion and ethnicity to provide culturally competent care. The nurse would discuss dietary needs that relate to disease processes with the healthcare provider. The nurse would communicate the needs for special services through the healthcare provider. The nurse would ask the patient about food preferences to promote contentment in the patient.
Which of the following are examples of nurse initiated (independent) nursing interventions? (Select all that apply.)
A.Medication administration B.Medication teaching C.Patient positioning Family teaching
ANSWER: B,C,D Independent nursing interventions do not require an order from another health care professional. Examples of independent nursing interventions include patient positioning and education. Administering medication requires an order from a physician or other health care professional.
Which statement best describes the evaluation phase of the nursing process?
A.Evaluation is performed throughout all phases of the nursing process. B.Evaluation is performed only after nursing interventions are performed. C.Evaluation focuses on determining changes and preventing complications. D.Evaluation is determined based on gathering subjective and objective data.
ANSWER: A Evaluation is performed throughout all phases of the nursing process. It is a constant, fluid process that is used to determine the effectiveness of planned interventions and
includes reassessment of the patient. It is not only performed after nursing interventions. Implementation focuses on determining changes and preventing complications. Assessment is based on gathering subjective and objective data.
The nurse is preparing to discharge a patient after a hospital stay. Which task should the nurse perform to determine if goals have been met?
A.Collect data related to the goal and make decisions about nursing care effectiveness. B.Collect data to develop new nursing diagnoses for the home health nurse to follow. C.Collect data to provide discharge instructions to follow when at home. D.Collect data related to patient-specific outcomes for accrediting bodies.
ANSWER: A Outcomes are evaluated to determine if the patient's goals have been met and for the effectiveness of the plan of care. Based on the evaluation, the plan of care is continued, modified, or terminated. The nurse will collect data at discharge to determine if the goals have been met and make decisions about nursing care effectiveness. If home health care is ordered at discharge, the home health nurse will develop a plan of care pertinent to self-care. The nurse provides discharge instructions based on healthcare provider orders, but this is not related to nursing diagnoses. The hospital will collect data for accrediting agencies, but this is not related to the nursing diagnoses and goal attainment.
The nurse determines that the patient has not met the plan of care for the nursing diagnosis Skin Integrity, Impaired because the wound has not healed within the time frame specified. The nurse chooses to revise the plan of care. Which step should the nurse perform first?
A.Talk to the healthcare provider. B.Set a new, reachable goal.
process includes three steps: comparing data against standards to identify significant cues, clustering cues to generate tentative hypotheses, and identifying gaps and inconsistencies. Listing client strengths and resources occurs later in the process of writing a nursing diagnosis. Comparing data with medical problems is not done when analyzing collected data.
Which of the following data are considered subjective?
A.The patient complaint of lower back pain B.The patient blood pressure of 118/ C.Patients reported history of pneumonia D.Diagnostic study results
ANSWER: A,C Subjective data (what the client says) includes: Client thoughts, beliefs, feelings, sensations, and perceptions. Information from the Client Health History. Objective data (direct measurements or observation) includes findings from Nursing Physical Examination and diagnostic studies
The nurse is teaching a new nurse about developing an appropriate nursing diagnosis for a patient. Which information should the nurse use to accurately describe nursing diagnosis? (Select all that apply.)
A.Nursing diagnosis describes responses to a health problem. B.A nursing diagnosis is a condition that nurses are licensed to treat. C.A nursing diagnosis is a clinical judgment. D.Nursing diagnosis is flexible and changes based on patient responses. E.Nursing diagnosis is uniform between patients.
ANSWER: A,B,C,D A nursing diagnosis is a statement of nursing judgment (clinical judgement); a condition that nurses, by virtue of their education, experience, and expertise, are licensed to treat; and a description of the physical, sociocultural, psychologic, and spiritual responses to an illness or health problem. Nursing diagnosis is flexible because
nursing diagnoses can change as the patient's response changes. A medical diagnosis is determined by a physician, can only be treated by a physician, and is a disease process or pathophysiological response that is uniform between patients. Medical diagnosis is constant for as long as the disease process is present in the patient. Results for item 5. 5
A nurse is developing a nursing diagnosis for a client. Which information should she include?
A.Actions to achieve goals B.Expected outcomes C.Factors influencing the client's problem D.Nursing history
ANSWER: C A nursing diagnosis is a written statement describing a client's actual or potential health problem. It includes a specified diagnostic label, factors that influence the client's problem, and any signs or symptoms that help define the diagnostic label. Actions to achieve goals are nursing interventions. Expected outcomes are measurable behavioral goals that the nurse develops during the planning step of the nursing process. The nurse obtains a nursing history during the assessment step of the nursing process.
The nurse develops a nursing diagnosis of Self-Care Deficit related to the patient's inability to perform activities of daily living (ADLs) related to left-sided weakness secondary to cerebrovascular accident. Which component of the nursing diagnosis was noted? (Select all that apply.)
A.Diagnostic label B.Variations C.Data clusters D.Etiology E.Defining characteristics
D.Write priority nursing interventions. E.Relate nursing actions to patient outcomes.
ANSWER: A,B,D Once the assessment and diagnostic phases of the plan of care are completed, the nurse can perform the planning phase. This includes specifying patient goals/desired outcomes, and related priority nursing interventions. Reassessing the patient to update the database to keep it updated is a step for the implementation phase and relating nursing actions to patient outcomes is an activity for the evaluation phase. All other activities can be related to the planning phase.
The nurse is formulating a plan of care for a patient who is diagnosed with cancer. Which factor related to patient goals should the nurse consider? (Select all that apply.)
A.Goal/outcomes should center on the patient. B.Goal/outcomes should be measurable. C.Goal/outcomes should indicate whether treatment is successful. D.Goal/outcomes should be attainable. E.Goals/outcomes may address multiple actions.
ANSWER: A,B,D The patient is always the subject of the goal/outcome and requires a specific, single action to ensure that all nurses understand what the patient needs to do to achieve a goal. Goal/outcomes should be measurable, attainable, relevant, and time-limited. An evaluation, not a goal/outcome statement, will indicate whether interventions were successful.
The nurse selects the nursing diagnosis of Risk for Impaired Skin Integrity related to immobility, dry skin, and surgical incision. Which goal statement represents a properly stated outcome/goal?
A.The client will turn in bed every 2 hours. B.The client will have healthy, intact skin during hospitalization.
C.The client will report the importance of applying lotion to skin daily. D.The client will use a pressure-reducing mattress.
ANSWER: B The goal or outcome should state the opposite of the nursing diagnosis stem. Turning in bed is an intervention that may result in achieving the goal. Applying lotion is an intervention that may result in achieving the goal. Healthy, intact skin is the reverse condition of impaired skin integrity. Using a pressure-reducing mattress is an intervention that may result in achieving the goal.
A client with Parkinson disease is working to improve fine motor skills, especially for completing activities of daily living. Which intervention would be considered a collaborative intervention?
A.Provide assistance as needed with dressing and grooming. B.Reinforce education on the use of assistive devices provided by physical therapy. C.Make sure lighting and space are adequate for the client. D.Administer medications to improve muscle tone.
ANSWER: B Collaborative interventions are actions the nurse carries out with other health team members such as physical therapists, social workers, dietitians, and physicians. Collaborative nursing activities reflect the overlapping responsibilities of, and collegial relationships among, healthcare personnel. Providing assistive devices and educating the client on their proper use would fall into the discipline of physical/occupational therapy, although the nurse will have to assist with reinforcing the teaching and information. Providing assistance and attending to the client's space would be independent interventions. Administering medications would be a dependent intervention.
The nurse reviewed data collected on a patient. Which reason should the nurse keep in mind for developing the plan of care? (Select all that apply.)
A.Ensures individualized patient-centered care
