NURS 231 FINAL EXAM 2023 SPRING SESSION
PREMIUM EXAM WITH SOLUTIONS GRADED A+.
Section 1: Nursing Process & Critical Thinking
1. A nurse is using the nursing process to care for a client. Which step involves analyzing
data and identifying client problems?
A) Assessment
B) Diagnosis
C) Planning
D) Evaluation
Answer: B
Rationale: Diagnosis is the step where the nurse analyzes assessment data to identify client
problems, strengths, and health risks.
2. During which phase of the nursing process does the nurse establish priorities and write
client goals?
A) Assessment
B) Diagnosis
C) Planning
D) Implementation
Answer: C
Rationale: Planning involves setting measurable short- and long-term goals and expected
outcomes, and selecting interventions.
3. A nurse reviews a client’s lab results before administering a medication. This action
reflects which aspect of critical thinking?
A) Intuition
B) Scientific knowledge base
C) Experience
D) Attitudes
Answer: B
Rationale: Using lab data to guide medication administration demonstrates application of
scientific knowledge.
4. Which statement is an example of a properly written client outcome?
A) “Client will walk unassisted.”
B) “Client will ambulate 50 feet with a walker by 3/15/23.”
, C) “Client will try to walk better.”
D) “Nurse will assist client to walk.”
Answer: B
Rationale: Outcomes must be specific, measurable, achievable, realistic, and time-bound
(SMART).
5. A nurse evaluates that a client’s pain level decreased from 8 to 3 after medication. This
occurs in which step?
A) Assessment
B) Diagnosis
C) Implementation
D) Evaluation
Answer: D
Rationale: Evaluation measures the client’s response to interventions and progress toward
goals.
6. The nurse identifies “Risk for falls” as a nursing diagnosis. Which type is this?
A) Actual
B) Risk
C) Health promotion
D) Syndrome
Answer: B
Rationale: Risk nursing diagnoses describe vulnerabilities to potential problems, not current
issues.
7. Which is an example of a collaborative problem?
A) Acute pain
B) Risk for infection
C) Potential complication of hemorrhage post-op
D) Impaired skin integrity
Answer: C
Rationale: Collaborative problems require both nursing and medical interventions, such as
monitoring for hemorrhage.
8. A nurse uses Maslow’s hierarchy to prioritize care. Which problem should be addressed
first?
A) Low self-esteem
B) Lack of social support
C) Ineffective airway clearance
, D) Spiritual distress
Answer: C
Rationale: Airway clearance is a physiological need and top priority according to Maslow.
9. The nurse documents: “Client states, ‘I’m anxious about surgery.’” This is which type of
data?
A) Objective
B) Subjective
C) Inferential
D) Historical
Answer: B
Rationale: Subjective data are spoken by the client (or family) and cannot be observed
directly.
10. A nurse auscultates crackles in lung bases. This is:
A) Subjective data
B) Secondary data
C) Objective data
D) Interpretive data
Answer: C
Rationale: Objective data are measurable, observable, and verifiable (e.g., physical exam
findings).
11. The nurse writes: “Ineffective breathing pattern related to pain as evidenced by
shallow respirations of 24/min.” This is an example of:
A) Goal
B) Intervention
C) Nursing diagnosis
D) Medical diagnosis
Answer: C
Rationale: This is a PES (problem, etiology, signs/symptoms) format for a nursing diagnosis.
12. A nurse repositions a client every 2 hours. This is which type of intervention?
A) Independent
B) Dependent
C) Interdependent
D) Collaborative
, Answer: A
Rationale: Independent nursing interventions do not require a provider’s order.
13. Which action demonstrates evaluation?
A) Asking about pain level after giving medication
B) Palpating the bladder for distention
C) Setting a goal for ambulation
D) Administering an antibiotic
Answer: A
Rationale: Evaluation occurs after interventions to determine effectiveness.
14. A nurse uses the SBAR tool when calling a provider. The “B” stands for:
A) Background
B) Breathing
C) Baseline
D) Brief
Answer: A
Rationale: SBAR = Situation, Background, Assessment, Recommendation.
15. Which nursing diagnosis is written correctly?
A) Pain related to surgery
B) Acute pain related to surgical incision as evidenced by client reports of 7/10 pain
C) Acute pain related to incision
D) Pain
Answer: B
Rationale: Includes problem, etiology, and defining characteristics (evidence).
Section 2: Infection Control & Safety (Q 16-35)
16. The most effective way to prevent the spread of infection is:
A) Wearing gloves
B) Hand hygiene
C) Wearing a mask
D) Sterilizing equipment
Answer: B
PREMIUM EXAM WITH SOLUTIONS GRADED A+.
Section 1: Nursing Process & Critical Thinking
1. A nurse is using the nursing process to care for a client. Which step involves analyzing
data and identifying client problems?
A) Assessment
B) Diagnosis
C) Planning
D) Evaluation
Answer: B
Rationale: Diagnosis is the step where the nurse analyzes assessment data to identify client
problems, strengths, and health risks.
2. During which phase of the nursing process does the nurse establish priorities and write
client goals?
A) Assessment
B) Diagnosis
C) Planning
D) Implementation
Answer: C
Rationale: Planning involves setting measurable short- and long-term goals and expected
outcomes, and selecting interventions.
3. A nurse reviews a client’s lab results before administering a medication. This action
reflects which aspect of critical thinking?
A) Intuition
B) Scientific knowledge base
C) Experience
D) Attitudes
Answer: B
Rationale: Using lab data to guide medication administration demonstrates application of
scientific knowledge.
4. Which statement is an example of a properly written client outcome?
A) “Client will walk unassisted.”
B) “Client will ambulate 50 feet with a walker by 3/15/23.”
, C) “Client will try to walk better.”
D) “Nurse will assist client to walk.”
Answer: B
Rationale: Outcomes must be specific, measurable, achievable, realistic, and time-bound
(SMART).
5. A nurse evaluates that a client’s pain level decreased from 8 to 3 after medication. This
occurs in which step?
A) Assessment
B) Diagnosis
C) Implementation
D) Evaluation
Answer: D
Rationale: Evaluation measures the client’s response to interventions and progress toward
goals.
6. The nurse identifies “Risk for falls” as a nursing diagnosis. Which type is this?
A) Actual
B) Risk
C) Health promotion
D) Syndrome
Answer: B
Rationale: Risk nursing diagnoses describe vulnerabilities to potential problems, not current
issues.
7. Which is an example of a collaborative problem?
A) Acute pain
B) Risk for infection
C) Potential complication of hemorrhage post-op
D) Impaired skin integrity
Answer: C
Rationale: Collaborative problems require both nursing and medical interventions, such as
monitoring for hemorrhage.
8. A nurse uses Maslow’s hierarchy to prioritize care. Which problem should be addressed
first?
A) Low self-esteem
B) Lack of social support
C) Ineffective airway clearance
, D) Spiritual distress
Answer: C
Rationale: Airway clearance is a physiological need and top priority according to Maslow.
9. The nurse documents: “Client states, ‘I’m anxious about surgery.’” This is which type of
data?
A) Objective
B) Subjective
C) Inferential
D) Historical
Answer: B
Rationale: Subjective data are spoken by the client (or family) and cannot be observed
directly.
10. A nurse auscultates crackles in lung bases. This is:
A) Subjective data
B) Secondary data
C) Objective data
D) Interpretive data
Answer: C
Rationale: Objective data are measurable, observable, and verifiable (e.g., physical exam
findings).
11. The nurse writes: “Ineffective breathing pattern related to pain as evidenced by
shallow respirations of 24/min.” This is an example of:
A) Goal
B) Intervention
C) Nursing diagnosis
D) Medical diagnosis
Answer: C
Rationale: This is a PES (problem, etiology, signs/symptoms) format for a nursing diagnosis.
12. A nurse repositions a client every 2 hours. This is which type of intervention?
A) Independent
B) Dependent
C) Interdependent
D) Collaborative
, Answer: A
Rationale: Independent nursing interventions do not require a provider’s order.
13. Which action demonstrates evaluation?
A) Asking about pain level after giving medication
B) Palpating the bladder for distention
C) Setting a goal for ambulation
D) Administering an antibiotic
Answer: A
Rationale: Evaluation occurs after interventions to determine effectiveness.
14. A nurse uses the SBAR tool when calling a provider. The “B” stands for:
A) Background
B) Breathing
C) Baseline
D) Brief
Answer: A
Rationale: SBAR = Situation, Background, Assessment, Recommendation.
15. Which nursing diagnosis is written correctly?
A) Pain related to surgery
B) Acute pain related to surgical incision as evidenced by client reports of 7/10 pain
C) Acute pain related to incision
D) Pain
Answer: B
Rationale: Includes problem, etiology, and defining characteristics (evidence).
Section 2: Infection Control & Safety (Q 16-35)
16. The most effective way to prevent the spread of infection is:
A) Wearing gloves
B) Hand hygiene
C) Wearing a mask
D) Sterilizing equipment
Answer: B
