EXAM 1: NUR 101(Latest 2026 Update) Health
Assessment Guide Actual Exam | Questions & Correct
Detailed Answers/NUR 101 Exam 1 |Graded A+ | Fortis
The clinical instructor is discussing about the Nursing Process. She
mentioned that when a cluster of actual or high-risk diagnosis are
present because of a certain situation it is called:
A. Wellness nursing diagnosis
B. Actual nursing diagnosis
C. Syndrome nursing diagnosis
D. Risk nursing diagnosis
C. Syndrome nursing diagnosis
Presence of both actual and high-risk diagnosis is called a syndrome
nursing diagnosis. Wellness nursing diagnosis focuses on the clinical
judgment on an individual from a specific to higher level of wellness.
Actual diagnoses are clinical judgment of the nurse that is validated.
A risk diagnosis is based on the clinical are based on clinical
judgment that the client may develop vulnerability to the problem.
The nurse in charge measures a patient's temperature at 101 degrees F.
What is the equivalent centigrade temperature?
A. 36.3 degrees C
B. 37.95 degrees C
C. 40.03 degrees C
D. 38.01 degrees C
B. 37.95
pg. 1
,To convert °F to °C use this formula, ( °F - 32 ) (0.55). While when
converting °C to °F use this formula, ( °C x 1.8) + 32. Note that 0.55
is 5/9 and 1.8 is 9/5.
During a change-of-shift report, it would be important for the nurse
relinquishing responsibility for care of the patient to communicate.
Which of the following facts to the nurse assuming responsibility for
care of the patient?
A. That the patient verbalized, "My headache is gone."
B. That the patient's barium enema performed 3 days ago was
negative
C. Patient's NGT was removed 2 hours ago
D. Patient's family came for a visit this morning.
C. Patient's NGT was removed 2 hours ago
The change-of-shift report should indicate significant recent changes
in the patient's condition that the nurse assuming responsibility for
care of the patient will need to monitor. The other options are not
critical enough to include in the report
A client is receiving 115 ml/hr of continuous IVF. The nurse notices
that the venipuncture site is red and swollen. Which of the following
interventions would the nurse perform first?
A. Stop the infusion
B. Call the attending physician
C. Slow that infusion to 20 ml/hr
D. Place a cold towel on the site
A. Stop the infusion
pg. 2
,The sign and symptoms indicate extravasation so the IVF should be
stopped immediately and put warm not cold towel on the affected site.
Which data would be of greatest concern to the nurse when
completing the nursing assessment of a 68-year-old woman
hospitalized due to Pneumonia?
A. Oriented to date, time and place
B. Clear breath sounds
C. Capillary refill greater than 3 seconds and buccal cyanosis
D. Hemoglobin of 13 g/dl
C. Capillary refill greater than 3 seconds and buccal cyanosis
Capillary refill greater than 3 seconds and buccal cyanosis indicate
decreased oxygen to the tissues which requires immediate
attention/intervention. Oriented to date, time and place, hemoglobin
of 13 g/dl are normal data.
What is the order of the nursing process?
A. Assessing, diagnosing, implementing, evaluating, planning
B. Diagnosing, assessing, planning, implementing, evaluating
C. Assessing, diagnosing, planning, implementing, evaluating
D. Planning, evaluating, diagnosing, assessing, implementing
C. Assessing, diagnosing, planning, implementing, evaluating
pg. 3
, The correct order of the nursing process is assessing, diagnosing,
planning, implementing, evaluating.
Which of the following is the most important purpose of planning
care with a patient?
A. Development of a standardized NCP.
B. Expansion of the current taxonomy of nursing diagnosis
C. Making of individualized patient care
D. Incorporation of both nursing and medical diagnoses in patient
care
C. Making of individualized patient care
To be effective, the nursing care plan developed in the planning phase
of the nursing process must reflect the individualized needs of the
patient.
What nursing action is appropriate when obtaining a sterile urine
specimen from an indwelling catheter to prevent infection?
A. Use sterile gloves when obtaining urine
B. Open the drainage bag and pour out the urine
C. Disconnect the catheter from the tubing and get urine
D. Aspirate urine from the tubing port using a sterile syringe
D. Aspirate urine from the tubing port using a sterile syringe
pg. 4
Assessment Guide Actual Exam | Questions & Correct
Detailed Answers/NUR 101 Exam 1 |Graded A+ | Fortis
The clinical instructor is discussing about the Nursing Process. She
mentioned that when a cluster of actual or high-risk diagnosis are
present because of a certain situation it is called:
A. Wellness nursing diagnosis
B. Actual nursing diagnosis
C. Syndrome nursing diagnosis
D. Risk nursing diagnosis
C. Syndrome nursing diagnosis
Presence of both actual and high-risk diagnosis is called a syndrome
nursing diagnosis. Wellness nursing diagnosis focuses on the clinical
judgment on an individual from a specific to higher level of wellness.
Actual diagnoses are clinical judgment of the nurse that is validated.
A risk diagnosis is based on the clinical are based on clinical
judgment that the client may develop vulnerability to the problem.
The nurse in charge measures a patient's temperature at 101 degrees F.
What is the equivalent centigrade temperature?
A. 36.3 degrees C
B. 37.95 degrees C
C. 40.03 degrees C
D. 38.01 degrees C
B. 37.95
pg. 1
,To convert °F to °C use this formula, ( °F - 32 ) (0.55). While when
converting °C to °F use this formula, ( °C x 1.8) + 32. Note that 0.55
is 5/9 and 1.8 is 9/5.
During a change-of-shift report, it would be important for the nurse
relinquishing responsibility for care of the patient to communicate.
Which of the following facts to the nurse assuming responsibility for
care of the patient?
A. That the patient verbalized, "My headache is gone."
B. That the patient's barium enema performed 3 days ago was
negative
C. Patient's NGT was removed 2 hours ago
D. Patient's family came for a visit this morning.
C. Patient's NGT was removed 2 hours ago
The change-of-shift report should indicate significant recent changes
in the patient's condition that the nurse assuming responsibility for
care of the patient will need to monitor. The other options are not
critical enough to include in the report
A client is receiving 115 ml/hr of continuous IVF. The nurse notices
that the venipuncture site is red and swollen. Which of the following
interventions would the nurse perform first?
A. Stop the infusion
B. Call the attending physician
C. Slow that infusion to 20 ml/hr
D. Place a cold towel on the site
A. Stop the infusion
pg. 2
,The sign and symptoms indicate extravasation so the IVF should be
stopped immediately and put warm not cold towel on the affected site.
Which data would be of greatest concern to the nurse when
completing the nursing assessment of a 68-year-old woman
hospitalized due to Pneumonia?
A. Oriented to date, time and place
B. Clear breath sounds
C. Capillary refill greater than 3 seconds and buccal cyanosis
D. Hemoglobin of 13 g/dl
C. Capillary refill greater than 3 seconds and buccal cyanosis
Capillary refill greater than 3 seconds and buccal cyanosis indicate
decreased oxygen to the tissues which requires immediate
attention/intervention. Oriented to date, time and place, hemoglobin
of 13 g/dl are normal data.
What is the order of the nursing process?
A. Assessing, diagnosing, implementing, evaluating, planning
B. Diagnosing, assessing, planning, implementing, evaluating
C. Assessing, diagnosing, planning, implementing, evaluating
D. Planning, evaluating, diagnosing, assessing, implementing
C. Assessing, diagnosing, planning, implementing, evaluating
pg. 3
, The correct order of the nursing process is assessing, diagnosing,
planning, implementing, evaluating.
Which of the following is the most important purpose of planning
care with a patient?
A. Development of a standardized NCP.
B. Expansion of the current taxonomy of nursing diagnosis
C. Making of individualized patient care
D. Incorporation of both nursing and medical diagnoses in patient
care
C. Making of individualized patient care
To be effective, the nursing care plan developed in the planning phase
of the nursing process must reflect the individualized needs of the
patient.
What nursing action is appropriate when obtaining a sterile urine
specimen from an indwelling catheter to prevent infection?
A. Use sterile gloves when obtaining urine
B. Open the drainage bag and pour out the urine
C. Disconnect the catheter from the tubing and get urine
D. Aspirate urine from the tubing port using a sterile syringe
D. Aspirate urine from the tubing port using a sterile syringe
pg. 4
