NURS 110 | NURS110 Exam 2: Introduction to
Professional Nursing - WCU Updated and Latest
Questions and Correct Answers with Rationale
1. A nurse is performing an admission assessment on a new patient. Which action by the
nurse represents the assessment phase of the nursing process?
A. Determining if the patient’s pain has decreased after medication.
B. Administering a scheduled dose of intravenous antibiotics.
C. Setting a goal for the patient to walk 50 feet by tomorrow.
D. Measuring the patient’s blood pressure and heart rate.
Correct Answer: D
Expert Explanation: The assessment phase involves the systematic collection of data
about a patient’s health status. Measuring vital signs is a core activity in gathering objective
data to establish a baseline. This step must occur before a diagnosis can be made or a plan
of care can be developed. Accurate data collection ensures that the subsequent steps of the
nursing process are based on the patient’s actual needs. In contrast, measuring pain after
medication is evaluation, while setting goals is part of the planning phase.
2. When prioritizing patient care, which patient should the nurse assess first using the clinical
judgment model?
A. A patient requesting a dressing change for a chronic wound.
B. A patient with a respiratory rate of 28 and oxygen saturation of 88%.
C. A patient reporting mild nausea after eating breakfast.
D. A patient asking for more information about their discharge medications.
Correct Answer: B
Expert Explanation: Prioritization requires the nurse to use clinical judgment to identify
the most urgent physiological needs. According to the ABC (Airway, Breathing, Circulation)
framework, respiratory distress takes precedence over non-urgent issues. An oxygen
saturation of 88% indicates potential hypoxia, which is a life-threatening condition if left
untreated. Chronic wound care and discharge education are important but can be safely
delayed while stabilizing an acute respiratory problem. Addressing the most critical patient
first ensures patient safety and prevents further clinical deterioration.
3. The nurse is documenting patient care in the electronic health record. Which entry is the
most accurate example of objective documentation?
A. The patient seems to be having a good day today.
B. Patient’s surgical incision is 5 cm long, red, and warm to the touch.
,C. The patient complained of severe abdominal pain.
D. The nurse believes the patient is not following the prescribed diet.
Correct Answer: B
Expert Explanation: Objective documentation describes observable and measurable facts
rather than opinions or interpretations. Describing the length and appearance of an
incision provides clear data that other healthcare providers can verify. Subjective terms
like ‘seems to be’ or ‘believes’ should be avoided as they reflect the nurse’s bias.
Professional standards require nurses to record exactly what they see, hear, feel, or smell
during an assessment. This type of precise documentation is essential for legal protection
and for monitoring the progress of the patient’s condition.
4. A nurse is caring for an older adult patient at high risk for falls. Which nursing intervention
most effectively promotes patient safety?
A. Keeping all four side rails up on the patient’s bed at all times.
B. Placing the call light within the patient’s reach and rounding hourly.
C. Instructing the patient to stay in bed until the physical therapist arrives.
D. Administering a sedative to ensure the patient rests during the night.
Correct Answer: B
Expert Explanation: Safety interventions should focus on proactive measures that
empower the patient while providing supervision. Ensuring the call light is reachable
allows the patient to request assistance before attempting to get up alone. Hourly rounding
helps address patient needs such as toileting or positioning, which are common reasons for
unassisted movement. Using four side rails is often considered a restraint and can actually
increase the risk of injury if a patient tries to climb over them. Effective fall prevention
relies on consistent communication and environmental modifications rather than physical
or chemical restraints.
5. Which communication technique is considered therapeutic when a patient expresses fear
about an upcoming surgery?
A. Saying, ‘Don’t worry, you have the best surgeon in the city.’
B. Stating, ‘Tell me more about what specifically concerns you regarding the surgery.’
C. Asking, ‘Why are you feeling afraid of such a common procedure?’
D. Suggesting, ‘You should focus on the positive outcomes instead of your fears.’
Correct Answer: B
Expert Explanation: Therapeutic communication focuses on the patient’s feelings and
encourages them to express their concerns. Using open-ended statements like ‘tell me
more’ invites the patient to elaborate without feeling judged. Providing false reassurance or
, asking ‘why’ questions can block further communication and make the patient feel
defensive. Focusing on the patient’s unique experience demonstrates empathy and builds a
trusting nurse-patient relationship. This approach allows the nurse to identify specific
stressors and provide appropriate education or emotional support.
6. During the evaluation phase of the nursing process, what is the nurse’s primary
responsibility?
A. To implement the nursing interventions listed in the care plan.
B. To delegate tasks to the unlicensed assistive personnel (UAP).
C. To identify new nursing diagnoses based on the initial assessment.
D. To compare the patient’s current status with the desired outcomes.
Correct Answer: D
Expert Explanation: Evaluation is the final step of the nursing process where the nurse
determines if the goals were met. By comparing the patient’s response to the expected
outcomes, the nurse can judge the effectiveness of the interventions. If the outcomes were
not achieved, the nurse must revise the plan of care to better meet the patient’s needs. This
step ensures that nursing care is dynamic and responsive to changes in the patient’s
condition. It is a continuous cycle that requires critical thinking to ensure the best possible
patient results.
7. A registered nurse (RN) is delegating tasks to an unlicensed assistive personnel (UAP).
Which task is appropriate for the RN to delegate?
A. Assessing a patient’s breath sounds after a breathing treatment.
B. Teaching a patient how to use an incentive spirometer.
C. Assisting a stable patient with a bed bath and oral hygiene.
D. Evaluating the effectiveness of a patient’s pain medication.
Correct Answer: C
Expert Explanation: Delegation must follow professional guidelines that distinguish
between clinical judgment and technical tasks. The RN can delegate routine activities of
daily living, such as bathing, to a UAP for stable patients. Tasks involving assessment,
teaching, or evaluation require the advanced knowledge and judgment of a licensed nurse
and cannot be delegated. Proper delegation allows the RN to focus on complex clinical
needs while ensuring basic patient care is completed. The nurse remains accountable for
the overall care of the patient and the outcome of the delegated task.
8. According to the Tanner Model of Clinical Judgment, which action is part of the ‘Noticing’
phase?
A. The nurse decides to call the healthcare provider for an order.
B. The nurse concludes that the patient is likely experiencing shock.
Professional Nursing - WCU Updated and Latest
Questions and Correct Answers with Rationale
1. A nurse is performing an admission assessment on a new patient. Which action by the
nurse represents the assessment phase of the nursing process?
A. Determining if the patient’s pain has decreased after medication.
B. Administering a scheduled dose of intravenous antibiotics.
C. Setting a goal for the patient to walk 50 feet by tomorrow.
D. Measuring the patient’s blood pressure and heart rate.
Correct Answer: D
Expert Explanation: The assessment phase involves the systematic collection of data
about a patient’s health status. Measuring vital signs is a core activity in gathering objective
data to establish a baseline. This step must occur before a diagnosis can be made or a plan
of care can be developed. Accurate data collection ensures that the subsequent steps of the
nursing process are based on the patient’s actual needs. In contrast, measuring pain after
medication is evaluation, while setting goals is part of the planning phase.
2. When prioritizing patient care, which patient should the nurse assess first using the clinical
judgment model?
A. A patient requesting a dressing change for a chronic wound.
B. A patient with a respiratory rate of 28 and oxygen saturation of 88%.
C. A patient reporting mild nausea after eating breakfast.
D. A patient asking for more information about their discharge medications.
Correct Answer: B
Expert Explanation: Prioritization requires the nurse to use clinical judgment to identify
the most urgent physiological needs. According to the ABC (Airway, Breathing, Circulation)
framework, respiratory distress takes precedence over non-urgent issues. An oxygen
saturation of 88% indicates potential hypoxia, which is a life-threatening condition if left
untreated. Chronic wound care and discharge education are important but can be safely
delayed while stabilizing an acute respiratory problem. Addressing the most critical patient
first ensures patient safety and prevents further clinical deterioration.
3. The nurse is documenting patient care in the electronic health record. Which entry is the
most accurate example of objective documentation?
A. The patient seems to be having a good day today.
B. Patient’s surgical incision is 5 cm long, red, and warm to the touch.
,C. The patient complained of severe abdominal pain.
D. The nurse believes the patient is not following the prescribed diet.
Correct Answer: B
Expert Explanation: Objective documentation describes observable and measurable facts
rather than opinions or interpretations. Describing the length and appearance of an
incision provides clear data that other healthcare providers can verify. Subjective terms
like ‘seems to be’ or ‘believes’ should be avoided as they reflect the nurse’s bias.
Professional standards require nurses to record exactly what they see, hear, feel, or smell
during an assessment. This type of precise documentation is essential for legal protection
and for monitoring the progress of the patient’s condition.
4. A nurse is caring for an older adult patient at high risk for falls. Which nursing intervention
most effectively promotes patient safety?
A. Keeping all four side rails up on the patient’s bed at all times.
B. Placing the call light within the patient’s reach and rounding hourly.
C. Instructing the patient to stay in bed until the physical therapist arrives.
D. Administering a sedative to ensure the patient rests during the night.
Correct Answer: B
Expert Explanation: Safety interventions should focus on proactive measures that
empower the patient while providing supervision. Ensuring the call light is reachable
allows the patient to request assistance before attempting to get up alone. Hourly rounding
helps address patient needs such as toileting or positioning, which are common reasons for
unassisted movement. Using four side rails is often considered a restraint and can actually
increase the risk of injury if a patient tries to climb over them. Effective fall prevention
relies on consistent communication and environmental modifications rather than physical
or chemical restraints.
5. Which communication technique is considered therapeutic when a patient expresses fear
about an upcoming surgery?
A. Saying, ‘Don’t worry, you have the best surgeon in the city.’
B. Stating, ‘Tell me more about what specifically concerns you regarding the surgery.’
C. Asking, ‘Why are you feeling afraid of such a common procedure?’
D. Suggesting, ‘You should focus on the positive outcomes instead of your fears.’
Correct Answer: B
Expert Explanation: Therapeutic communication focuses on the patient’s feelings and
encourages them to express their concerns. Using open-ended statements like ‘tell me
more’ invites the patient to elaborate without feeling judged. Providing false reassurance or
, asking ‘why’ questions can block further communication and make the patient feel
defensive. Focusing on the patient’s unique experience demonstrates empathy and builds a
trusting nurse-patient relationship. This approach allows the nurse to identify specific
stressors and provide appropriate education or emotional support.
6. During the evaluation phase of the nursing process, what is the nurse’s primary
responsibility?
A. To implement the nursing interventions listed in the care plan.
B. To delegate tasks to the unlicensed assistive personnel (UAP).
C. To identify new nursing diagnoses based on the initial assessment.
D. To compare the patient’s current status with the desired outcomes.
Correct Answer: D
Expert Explanation: Evaluation is the final step of the nursing process where the nurse
determines if the goals were met. By comparing the patient’s response to the expected
outcomes, the nurse can judge the effectiveness of the interventions. If the outcomes were
not achieved, the nurse must revise the plan of care to better meet the patient’s needs. This
step ensures that nursing care is dynamic and responsive to changes in the patient’s
condition. It is a continuous cycle that requires critical thinking to ensure the best possible
patient results.
7. A registered nurse (RN) is delegating tasks to an unlicensed assistive personnel (UAP).
Which task is appropriate for the RN to delegate?
A. Assessing a patient’s breath sounds after a breathing treatment.
B. Teaching a patient how to use an incentive spirometer.
C. Assisting a stable patient with a bed bath and oral hygiene.
D. Evaluating the effectiveness of a patient’s pain medication.
Correct Answer: C
Expert Explanation: Delegation must follow professional guidelines that distinguish
between clinical judgment and technical tasks. The RN can delegate routine activities of
daily living, such as bathing, to a UAP for stable patients. Tasks involving assessment,
teaching, or evaluation require the advanced knowledge and judgment of a licensed nurse
and cannot be delegated. Proper delegation allows the RN to focus on complex clinical
needs while ensuring basic patient care is completed. The nurse remains accountable for
the overall care of the patient and the outcome of the delegated task.
8. According to the Tanner Model of Clinical Judgment, which action is part of the ‘Noticing’
phase?
A. The nurse decides to call the healthcare provider for an order.
B. The nurse concludes that the patient is likely experiencing shock.
