NU131 Exam 2 Nursing and Healthcare I
Actual Exam 2026/2027 with Detailed
Rationales | Complete Exam-Style Questions
| Pass Guaranteed – A+ Graded
SECTION 1: Fundamentals of Nursing Practice (QSEN
Competencies, Evidence-Based Practice, Nursing Process:
ADPIE) — 12 Questions
Nursing Process Unfolding Case — Questions 1–5
Patient Profile: Mrs. Eleanor Vance, 78 years old, was admitted to the medical-surgical unit
following an exacerbation of heart failure. She reports shortness of breath, 3+ pitting edema
in bilateral lower extremities, and a 5-pound weight gain over the past week. Her vital signs
are: BP 162/94 mmHg, HR 108 bpm, RR 26/min, SpO₂ 89% on room air, temperature 37.2°C
(99.0°F). She lives alone and has difficulty remembering her medication regimen.
Q1: During the initial admission assessment, the nurse notes Mrs. Vance's SpO₂ of 89% on
room air, bilateral crackles in the lower lung fields, and the patient statement, "I can't catch
my breath when I walk to the bathroom." Which action represents the correct application of
the Assessment phase of the nursing process?
A. Documenting a nursing diagnosis of "Impaired Gas Exchange" in the electronic health
record before completing the physical examination
B. Clustering the objective data (SpO₂ 89%, crackles) with the subjective data (dyspnea on
exertion) to form a complete assessment database
C. Administering supplemental oxygen at 2 L/min via nasal cannula and notifying the provider
of the findings
D. Establishing a goal that the patient will maintain an SpO₂ ≥ 92% within 24 hours of oxygen
therapy initiation
,Correct Answer: B
Rationale: Correct because the Assessment phase of ADPIE focuses exclusively on
gathering, validating, and clustering subjective and objective data into a comprehensive
database; QSEN competencies for patient-centered care require that nurses complete a
thorough assessment before formulating diagnoses or interventions, ensuring that all
subsequent clinical decisions are evidence-based and grounded in accurate patient data.
Q2: Based on the assessment data, the nurse formulates the following nursing diagnoses for
Mrs. Vance: (1) Excess Fluid Volume related to compromised regulatory mechanisms as
evidenced by 3+ pitting edema and 5-pound weight gain; (2) Risk for Falls related to
orthostatic hypotension and generalized weakness; (3) Noncompliance with medication
regimen related to cognitive impairment as evidenced by patient report of difficulty
remembering doses. Which diagnosis is correctly classified according to NANDA-I
taxonomy?
A. Excess Fluid Volume is a risk nursing diagnosis because it identifies a vulnerability to
develop the problem
B. Risk for Falls is a problem-focused nursing diagnosis because it describes an undesirable
human response to a health condition
C. Noncompliance is a health promotion nursing diagnosis because it motivates the patient
toward a higher level of wellness
D. Excess Fluid Volume is a problem-focused nursing diagnosis because it describes an
existing human response supported by defining characteristics
Correct Answer: D
Rationale: Correct because NU131 fundamentals emphasizes NANDA-I taxonomy, which
classifies Excess Fluid Volume as a problem-focused diagnosis when defining
characteristics (3+ pitting edema, weight gain) are present; QSEN competencies require
accurate diagnostic classification to ensure that planning and interventions address actual
rather than potential patient problems.
Q3: The nurse collaborates with Mrs. Vance to develop her plan of care. Which goal
statement meets the SMART criteria and aligns with evidence-based practice for heart failure
management?
A. "The patient will have better breathing soon after starting treatment"
B. "The nurse will administer furosemide 40 mg IV as ordered to reduce fluid overload"
,C. "The patient will demonstrate a 2-pound weight loss and an SpO₂ ≥ 92% on 2 L NC by day 3
of hospitalization"
D. "The patient will never experience shortness of breath again during hospitalization"
Correct Answer: C
Rationale: Correct because the nursing process (ADPIE) prioritizes SMART goals that are
Specific, Measurable, Achievable, Relevant, and Time-bound; evidence-based practice for
heart failure management indicates that measurable weight loss and oxygen saturation
targets provide objective benchmarks for evaluating therapeutic response and guide safe,
patient-centered interventions.
Q4: During the implementation phase, the nurse delegates the task of obtaining daily weights
to the unlicensed assistive personnel (UAP). Which action by the nurse demonstrates correct
application of the Five Rights of Delegation?
A. Assigning the UAP to assess lung sounds and document changes in respiratory status
before weighing the patient
B. Instructing the UAP to use the same scale, at the same time each morning, after voiding,
and with the patient wearing similar clothing, then supervising and evaluating the results
C. Delegating the task without further communication because daily weights are within the
UAP's scope of practice in all states
D. Asking the UAP to interpret the weight trends and notify the provider if the patient gains
more than 2 pounds
Correct Answer: B
Rationale: Correct because QSEN competencies for teamwork and collaboration require
nurses to apply the Five Rights of Delegation (right task, right circumstance, right person,
right direction/communication, right supervision/evaluation); standard of care for heart
failure monitoring includes consistent weight measurement technique to ensure data
accuracy for clinical decision-making.
Q5: On day 3, Mrs. Vance's weight has decreased by 2.4 pounds, her SpO₂ is 94% on 2 L NC,
and she states, "I can walk to the bathroom without getting winded now." The nurse reviews
these outcomes against the established goals. Which statement correctly describes the
Evaluation phase of the nursing process?
, A. The nurse revises the nursing diagnosis to "Impaired Gas Exchange" because the patient
still requires supplemental oxygen
B. The nurse determines that the goals have been partially met and continues the current plan
of care while reassessing readiness for discharge teaching
C. The nurse discontinues all nursing care because the patient's condition has completely
resolved
D. The nurse immediately discontinues the oxygen and documents that the patient is ready
for discharge without further assessment
Correct Answer: B
Rationale: Correct because the nursing process (ADPIE) prioritizes evaluation as a
continuous cycle of comparing outcomes to goals, determining goal achievement status, and
deciding whether to continue, modify, or terminate the plan; evidence-based practice indicates
that partial goal achievement requires ongoing intervention and reassessment to ensure safe
transition to self-management.
Q6: A nurse is reviewing a research article to answer the clinical question: "In adult patients
with pressure injuries, does negative pressure wound therapy compared to standard moist
wound dressing result in faster healing time?" Which component of the PICO format is
represented by "faster healing time"?
A. Population
B. Intervention
C. Comparison
D. Outcome
Correct Answer: D
Rationale: Correct because QSEN competencies for evidence-based practice require nurses
to understand the PICO format, where the Outcome represents the measurable result of
interest; "faster healing time" is the desired measurable endpoint that guides literature search
and clinical decision-making in pressure injury management.
Q7: During shift handoff, the receiving nurse asks the outgoing nurse to provide a structured
report using SBAR. Which statement by the outgoing nurse demonstrates correct use of the
Recommendation component?
Actual Exam 2026/2027 with Detailed
Rationales | Complete Exam-Style Questions
| Pass Guaranteed – A+ Graded
SECTION 1: Fundamentals of Nursing Practice (QSEN
Competencies, Evidence-Based Practice, Nursing Process:
ADPIE) — 12 Questions
Nursing Process Unfolding Case — Questions 1–5
Patient Profile: Mrs. Eleanor Vance, 78 years old, was admitted to the medical-surgical unit
following an exacerbation of heart failure. She reports shortness of breath, 3+ pitting edema
in bilateral lower extremities, and a 5-pound weight gain over the past week. Her vital signs
are: BP 162/94 mmHg, HR 108 bpm, RR 26/min, SpO₂ 89% on room air, temperature 37.2°C
(99.0°F). She lives alone and has difficulty remembering her medication regimen.
Q1: During the initial admission assessment, the nurse notes Mrs. Vance's SpO₂ of 89% on
room air, bilateral crackles in the lower lung fields, and the patient statement, "I can't catch
my breath when I walk to the bathroom." Which action represents the correct application of
the Assessment phase of the nursing process?
A. Documenting a nursing diagnosis of "Impaired Gas Exchange" in the electronic health
record before completing the physical examination
B. Clustering the objective data (SpO₂ 89%, crackles) with the subjective data (dyspnea on
exertion) to form a complete assessment database
C. Administering supplemental oxygen at 2 L/min via nasal cannula and notifying the provider
of the findings
D. Establishing a goal that the patient will maintain an SpO₂ ≥ 92% within 24 hours of oxygen
therapy initiation
,Correct Answer: B
Rationale: Correct because the Assessment phase of ADPIE focuses exclusively on
gathering, validating, and clustering subjective and objective data into a comprehensive
database; QSEN competencies for patient-centered care require that nurses complete a
thorough assessment before formulating diagnoses or interventions, ensuring that all
subsequent clinical decisions are evidence-based and grounded in accurate patient data.
Q2: Based on the assessment data, the nurse formulates the following nursing diagnoses for
Mrs. Vance: (1) Excess Fluid Volume related to compromised regulatory mechanisms as
evidenced by 3+ pitting edema and 5-pound weight gain; (2) Risk for Falls related to
orthostatic hypotension and generalized weakness; (3) Noncompliance with medication
regimen related to cognitive impairment as evidenced by patient report of difficulty
remembering doses. Which diagnosis is correctly classified according to NANDA-I
taxonomy?
A. Excess Fluid Volume is a risk nursing diagnosis because it identifies a vulnerability to
develop the problem
B. Risk for Falls is a problem-focused nursing diagnosis because it describes an undesirable
human response to a health condition
C. Noncompliance is a health promotion nursing diagnosis because it motivates the patient
toward a higher level of wellness
D. Excess Fluid Volume is a problem-focused nursing diagnosis because it describes an
existing human response supported by defining characteristics
Correct Answer: D
Rationale: Correct because NU131 fundamentals emphasizes NANDA-I taxonomy, which
classifies Excess Fluid Volume as a problem-focused diagnosis when defining
characteristics (3+ pitting edema, weight gain) are present; QSEN competencies require
accurate diagnostic classification to ensure that planning and interventions address actual
rather than potential patient problems.
Q3: The nurse collaborates with Mrs. Vance to develop her plan of care. Which goal
statement meets the SMART criteria and aligns with evidence-based practice for heart failure
management?
A. "The patient will have better breathing soon after starting treatment"
B. "The nurse will administer furosemide 40 mg IV as ordered to reduce fluid overload"
,C. "The patient will demonstrate a 2-pound weight loss and an SpO₂ ≥ 92% on 2 L NC by day 3
of hospitalization"
D. "The patient will never experience shortness of breath again during hospitalization"
Correct Answer: C
Rationale: Correct because the nursing process (ADPIE) prioritizes SMART goals that are
Specific, Measurable, Achievable, Relevant, and Time-bound; evidence-based practice for
heart failure management indicates that measurable weight loss and oxygen saturation
targets provide objective benchmarks for evaluating therapeutic response and guide safe,
patient-centered interventions.
Q4: During the implementation phase, the nurse delegates the task of obtaining daily weights
to the unlicensed assistive personnel (UAP). Which action by the nurse demonstrates correct
application of the Five Rights of Delegation?
A. Assigning the UAP to assess lung sounds and document changes in respiratory status
before weighing the patient
B. Instructing the UAP to use the same scale, at the same time each morning, after voiding,
and with the patient wearing similar clothing, then supervising and evaluating the results
C. Delegating the task without further communication because daily weights are within the
UAP's scope of practice in all states
D. Asking the UAP to interpret the weight trends and notify the provider if the patient gains
more than 2 pounds
Correct Answer: B
Rationale: Correct because QSEN competencies for teamwork and collaboration require
nurses to apply the Five Rights of Delegation (right task, right circumstance, right person,
right direction/communication, right supervision/evaluation); standard of care for heart
failure monitoring includes consistent weight measurement technique to ensure data
accuracy for clinical decision-making.
Q5: On day 3, Mrs. Vance's weight has decreased by 2.4 pounds, her SpO₂ is 94% on 2 L NC,
and she states, "I can walk to the bathroom without getting winded now." The nurse reviews
these outcomes against the established goals. Which statement correctly describes the
Evaluation phase of the nursing process?
, A. The nurse revises the nursing diagnosis to "Impaired Gas Exchange" because the patient
still requires supplemental oxygen
B. The nurse determines that the goals have been partially met and continues the current plan
of care while reassessing readiness for discharge teaching
C. The nurse discontinues all nursing care because the patient's condition has completely
resolved
D. The nurse immediately discontinues the oxygen and documents that the patient is ready
for discharge without further assessment
Correct Answer: B
Rationale: Correct because the nursing process (ADPIE) prioritizes evaluation as a
continuous cycle of comparing outcomes to goals, determining goal achievement status, and
deciding whether to continue, modify, or terminate the plan; evidence-based practice indicates
that partial goal achievement requires ongoing intervention and reassessment to ensure safe
transition to self-management.
Q6: A nurse is reviewing a research article to answer the clinical question: "In adult patients
with pressure injuries, does negative pressure wound therapy compared to standard moist
wound dressing result in faster healing time?" Which component of the PICO format is
represented by "faster healing time"?
A. Population
B. Intervention
C. Comparison
D. Outcome
Correct Answer: D
Rationale: Correct because QSEN competencies for evidence-based practice require nurses
to understand the PICO format, where the Outcome represents the measurable result of
interest; "faster healing time" is the desired measurable endpoint that guides literature search
and clinical decision-making in pressure injury management.
Q7: During shift handoff, the receiving nurse asks the outgoing nurse to provide a structured
report using SBAR. Which statement by the outgoing nurse demonstrates correct use of the
Recommendation component?
