CORRECT DETAILED ANSWERS with RATIONALES
ALREADY GRADED A+
1. The first step of the nursing process is:
A. Diagnosis
B. Assessment
C. Planning
D. Implementation
Answer: B. Assessment
Rationale: Data collection must occur before clinical decisions are made.
2. Which vital sign requires immediate intervention?
A. Temp 37°C
B. RR 30/min
C. HR 88 bpm
D. BP 120/80
Answer: B. RR 30/min
Rationale: Tachypnea may indicate respiratory distress.
,3. Medical asepsis refers to:
A. Sterile technique
B. Clean technique to reduce microorganisms
C. Surgical field sterility
D. Isolation only
Answer: B. Clean technique to reduce microorganisms
Rationale: Medical asepsis reduces infection spread.
4. Which is an example of subjective data?
A. BP reading
B. Lab result
C. Patient reports pain
D. Oxygen saturation
Answer: C. Patient reports pain
Rationale: Subjective data comes from patient perception.
5. Normal adult heart rate is:
A. 40–60 bpm
B. 60–100 bpm
C. 100–140 bpm
D. 120–160 bpm
, Answer: B. 60–100 bpm
Rationale: This is the accepted normal range.
6. Which action breaks sterile technique?
A. Keeping sterile field in view
B. Reaching across sterile field
C. Using sterile gloves
D. Opening sterile pack carefully
Answer: B. Reaching across sterile field
Rationale: Crossing sterile field contaminates it.
7. Priority nursing intervention follows which principle?
A. Alphabetical order
B. Urgency of condition
C. Physician preference
D. Family request
Answer: B. Urgency of condition
Rationale: Life-threatening needs are addressed first.
8. Which sign indicates hypoxia?