NSG 100
EXAM 2
2026 Q&A
CONTAINS:
✓ Advanced health assessment concepts (subjective vs. objective data, documentation
standards)
✓ Sterile technique and infection prevention (Foley catheter insertion, sterile field
maintenance)
✓ Pain assessment and management (non-pharmacological interventions)
✓ Abdominal assessment sequence (Inspection, Auscultation, Percussion, Palpation)
✓ Isolation and transmission-based precautions (Contact precautions, MRSA care)
✓ Medication administration principles (subcutaneous heparin injections, site
selection)
✓ Fluid balance and dehydration assessment findings
✓ Respiratory care and incentive spirometer education
✓ Legal and ethical nursing concepts (assault vs. battery)
✓ NCLEX-style multiple-choice and select-all-that-apply questions with detailed
rationales
,A nurse is performing an admission assessment for a client admitted to the medical unit with
pneumonia. The client states, "I have been having chest pain and a fever for the last three days." The
nurse documents this information under which section of the health assessment?
A) Objective data
B) Review of systems
C) Subjective data
D) Physical examination
Correct Answer: C) Subjective data
Explanation / Rationale:
Subjective data is what the client tells you about their health, including symptoms, sensations,
feelings, and perceptions. This information is often referred to as "symptoms" and can only be verified
by the client. Chest pain and fever as reported by the client are classic examples of subjective data.
Option A, Objective data, refers to findings that are directly measurable or observable by the nurse,
such as a temperature of 102°F or crackles heard in the lungs. Option B, Review of systems, is a
specific method of gathering data about the client's past and current health status of each body
system, but the statement itself is categorized as subjective. Option D, Physical examination, involves
the nurse collecting objective data through inspection, percussion, palpation, and auscultation.
The nurse is preparing to insert a Foley catheter into a female client. To maintain the sterile field,
which action by the nurse is correct?
A) Pouring the antiseptic solution into the sterile field tray before donning sterile gloves
B) Picking up the catheter with the dominant hand after the sterile glove on that hand has touched the
bed linens
C) Avoiding reaching over the sterile field to adjust the lighting
D) Placing the sterile drape on the client's thigh with the upper edge of the drape touching the perineum
Correct Answer: C) Avoiding reaching over the sterile field to adjust the lighting
,Explanation / Rationale:
A sterile field is considered contaminated if anything unsterile comes into contact with it, including the
nurse's body or clothing. Reaching over the sterile field risks accidental contamination (e.g., sleeve
brushing against supplies or a drop of sweat falling into the field). Therefore, the nurse should never
reach over the sterile field. Option A is incorrect because the nurse should first don sterile gloves to set
up the field; pouring solution before gloving contaminates the outside of the bottle or the fluid
trajectory. Option B is incorrect because if the sterile glove touches the bed linens (which are not
sterile), the glove is contaminated, and the catheter is now contaminated. Option D is incorrect
because the sterile drape must not touch unsterile areas; placing the edge directly against the
perineum (which has not been prepped yet) risks contamination of the drape.
A nurse is caring for a client who is postoperative following a hip replacement. The client reports pain
of 8 on a scale of 0 to 10. Which non-pharmacological intervention should the nurse implement first?
A) Encourage the client to listen to calming music
B) Reposition the client to a more comfortable alignment
C) Apply a cold compress to the surgical site
D) Teach the client guided imagery techniques
Correct Answer: B) Reposition the client to a more comfortable alignment
Explanation / Rationale:
When managing pain, nurses should utilize the nursing process and prioritize interventions that
address the physiological source of discomfort first if possible. Repositioning a postoperative client can
relieve pressure on incision sites, reduce muscle tension, and improve comfort without the use of
drugs. While options A, C, and D are valid complementary therapies, repositioning is often the
immediate, low-tech, high-impact intervention that can alleviate pain caused by immobility or poor
body mechanics. Option C might be contraindicated depending on the physician's order and the type
of surgery (cold vs. heat), and Options A and D require more client participation and may not provide
immediate relief for acute physical pain.
When documenting in a client's medical record, which entry demonstrates the best practice in
charting?
A) "Client appears to be in severe pain and is anxious."
B) "Client states, 'I feel like an elephant is sitting on my chest.'"
, C) "Abdominal dressing is dry and intact. No drainage noted."
D) "Client slept well last night."
Correct Answer: B) "Client states, 'I feel like an elephant is sitting on my chest.'"
Explanation / Rationale:
Documentation should be factual, objective, and precise. Quoting the client directly is the gold
standard for documenting subjective complaints because it provides the exact wording used by the
patient without interpretation by the nurse. Option A uses interpretive terms like "appears to be" and
"severe," which are subjective and leave the nurse's opinion open to legal scrutiny. Option C is a good
example of objective charting for an assessment finding, but Option B is superior in the context of
capturing the client's specific symptom description. Option D is vague; "slept well" is a subjective
interpretation unless followed by specific data (e.g., "Client slept uninterrupted for 6 hours").
A nurse is assessing a client's abdomen. Which sequence of assessment techniques should the nurse
follow?
A) Inspection, Auscultation, Percussion, Palpation
B) Inspection, Palpation, Percussion, Auscultation
C) Auscultation, Inspection, Palpation, Percussion
D) Palpation, Percussion, Auscultation, Inspection
Correct Answer: A) Inspection, Auscultation, Percussion, Palpation
Explanation / Rationale:
For abdominal assessment, the standard order is Inspection, Auscultation, Percussion, and Palpation
(IAPP). This differs from other body systems because palpation and percussion can alter bowel sounds.
If the nurse palpates or percusses the abdomen before auscultating, the bowel sounds may change or
temporarily stop, resulting in an inaccurate assessment. Therefore, auscultation must occur before any
physical manipulation of the abdomen. Option B is incorrect because palpating before auscultating
alters bowel sounds. Option C is incorrect because inspection should always occur first to observe for
visible abnormalities before touching the client. Option D is incorrect for the same reasons; inspection
and auscultation are displaced.
EXAM 2
2026 Q&A
CONTAINS:
✓ Advanced health assessment concepts (subjective vs. objective data, documentation
standards)
✓ Sterile technique and infection prevention (Foley catheter insertion, sterile field
maintenance)
✓ Pain assessment and management (non-pharmacological interventions)
✓ Abdominal assessment sequence (Inspection, Auscultation, Percussion, Palpation)
✓ Isolation and transmission-based precautions (Contact precautions, MRSA care)
✓ Medication administration principles (subcutaneous heparin injections, site
selection)
✓ Fluid balance and dehydration assessment findings
✓ Respiratory care and incentive spirometer education
✓ Legal and ethical nursing concepts (assault vs. battery)
✓ NCLEX-style multiple-choice and select-all-that-apply questions with detailed
rationales
,A nurse is performing an admission assessment for a client admitted to the medical unit with
pneumonia. The client states, "I have been having chest pain and a fever for the last three days." The
nurse documents this information under which section of the health assessment?
A) Objective data
B) Review of systems
C) Subjective data
D) Physical examination
Correct Answer: C) Subjective data
Explanation / Rationale:
Subjective data is what the client tells you about their health, including symptoms, sensations,
feelings, and perceptions. This information is often referred to as "symptoms" and can only be verified
by the client. Chest pain and fever as reported by the client are classic examples of subjective data.
Option A, Objective data, refers to findings that are directly measurable or observable by the nurse,
such as a temperature of 102°F or crackles heard in the lungs. Option B, Review of systems, is a
specific method of gathering data about the client's past and current health status of each body
system, but the statement itself is categorized as subjective. Option D, Physical examination, involves
the nurse collecting objective data through inspection, percussion, palpation, and auscultation.
The nurse is preparing to insert a Foley catheter into a female client. To maintain the sterile field,
which action by the nurse is correct?
A) Pouring the antiseptic solution into the sterile field tray before donning sterile gloves
B) Picking up the catheter with the dominant hand after the sterile glove on that hand has touched the
bed linens
C) Avoiding reaching over the sterile field to adjust the lighting
D) Placing the sterile drape on the client's thigh with the upper edge of the drape touching the perineum
Correct Answer: C) Avoiding reaching over the sterile field to adjust the lighting
,Explanation / Rationale:
A sterile field is considered contaminated if anything unsterile comes into contact with it, including the
nurse's body or clothing. Reaching over the sterile field risks accidental contamination (e.g., sleeve
brushing against supplies or a drop of sweat falling into the field). Therefore, the nurse should never
reach over the sterile field. Option A is incorrect because the nurse should first don sterile gloves to set
up the field; pouring solution before gloving contaminates the outside of the bottle or the fluid
trajectory. Option B is incorrect because if the sterile glove touches the bed linens (which are not
sterile), the glove is contaminated, and the catheter is now contaminated. Option D is incorrect
because the sterile drape must not touch unsterile areas; placing the edge directly against the
perineum (which has not been prepped yet) risks contamination of the drape.
A nurse is caring for a client who is postoperative following a hip replacement. The client reports pain
of 8 on a scale of 0 to 10. Which non-pharmacological intervention should the nurse implement first?
A) Encourage the client to listen to calming music
B) Reposition the client to a more comfortable alignment
C) Apply a cold compress to the surgical site
D) Teach the client guided imagery techniques
Correct Answer: B) Reposition the client to a more comfortable alignment
Explanation / Rationale:
When managing pain, nurses should utilize the nursing process and prioritize interventions that
address the physiological source of discomfort first if possible. Repositioning a postoperative client can
relieve pressure on incision sites, reduce muscle tension, and improve comfort without the use of
drugs. While options A, C, and D are valid complementary therapies, repositioning is often the
immediate, low-tech, high-impact intervention that can alleviate pain caused by immobility or poor
body mechanics. Option C might be contraindicated depending on the physician's order and the type
of surgery (cold vs. heat), and Options A and D require more client participation and may not provide
immediate relief for acute physical pain.
When documenting in a client's medical record, which entry demonstrates the best practice in
charting?
A) "Client appears to be in severe pain and is anxious."
B) "Client states, 'I feel like an elephant is sitting on my chest.'"
, C) "Abdominal dressing is dry and intact. No drainage noted."
D) "Client slept well last night."
Correct Answer: B) "Client states, 'I feel like an elephant is sitting on my chest.'"
Explanation / Rationale:
Documentation should be factual, objective, and precise. Quoting the client directly is the gold
standard for documenting subjective complaints because it provides the exact wording used by the
patient without interpretation by the nurse. Option A uses interpretive terms like "appears to be" and
"severe," which are subjective and leave the nurse's opinion open to legal scrutiny. Option C is a good
example of objective charting for an assessment finding, but Option B is superior in the context of
capturing the client's specific symptom description. Option D is vague; "slept well" is a subjective
interpretation unless followed by specific data (e.g., "Client slept uninterrupted for 6 hours").
A nurse is assessing a client's abdomen. Which sequence of assessment techniques should the nurse
follow?
A) Inspection, Auscultation, Percussion, Palpation
B) Inspection, Palpation, Percussion, Auscultation
C) Auscultation, Inspection, Palpation, Percussion
D) Palpation, Percussion, Auscultation, Inspection
Correct Answer: A) Inspection, Auscultation, Percussion, Palpation
Explanation / Rationale:
For abdominal assessment, the standard order is Inspection, Auscultation, Percussion, and Palpation
(IAPP). This differs from other body systems because palpation and percussion can alter bowel sounds.
If the nurse palpates or percusses the abdomen before auscultating, the bowel sounds may change or
temporarily stop, resulting in an inaccurate assessment. Therefore, auscultation must occur before any
physical manipulation of the abdomen. Option B is incorrect because palpating before auscultating
alters bowel sounds. Option C is incorrect because inspection should always occur first to observe for
visible abnormalities before touching the client. Option D is incorrect for the same reasons; inspection
and auscultation are displaced.
