Exam | 180 Questions with Correct Answers
Academic Year: 2025/2026
Credential: BSN/ADN Pre-Licensure
Format: Multiple-Choice
Alignment: NCLEX-RN Test Plan
Reference: Potter & Perry Fundamentals of Nursing, NCSBN Clinical Judgment
Model
Section I: Nursing Process, Clinical Judgment & Safety/Infection Control
(Q1–Q45)
1. A nurse is assessing a client who reports postoperative pain. Which step of the
nursing process is the nurse implementing?
Assessment
2. A nurse identifies that a client’s blood pressure is elevated and decides to
reposition the client and recheck in 15 minutes. This action reflects which phase of
the nursing process?
Implementation
3. A nurse evaluates a client’s response to a pain medication and documents that
the pain level decreased from 8 to 3 on a 0-10 scale. This is an example of:
Evaluation
4. The nurse formulates the following statement: “Impaired skin integrity related to
pressure as evidenced by redness over the sacrum.” This is an example of a:
Nursing diagnosis
,5. Which step of the nursing process involves collecting objective and subjective
data?
Assessment
6. A nurse uses the Clinical Judgment Measurement Model (NCJMM) to prioritize
care. The first step in this model is:
Recognize cues
7. After recognizing that a client’s respiratory rate has increased from 18 to 32
breaths per minute, the nurse identifies a potential problem. This step in clinical
judgment is called:
Analyze cues
8. A nurse decides to suction a client who has audible gurgling in the airway. This
action represents which clinical judgment step?
Take action
9. A client’s oxygen saturation drops to 88% on room air. The nurse administers
oxygen at 2 L/min via nasal cannula. After 10 minutes the saturation is 94%. The
nurse determines the intervention was effective. This reflects:
Evaluate outcomes
10. Which of the following is an example of subjective data?
“I feel nauseated.”
11. Which of the following is an example of objective data?
Blood pressure 110/70 mmHg
, 12. A nurse gathers data from a client, family members, and the medical record.
This is known as:
Comprehensive assessment
13. A nurse is preparing to insert a urinary catheter. Which action is most
important to prevent infection?
Maintaining sterile technique
14. A client on contact precautions requires a wound dressing change. The nurse
should wear:
Gloves and gown
15. Which infection control precaution is appropriate for a client with active
pulmonary tuberculosis?
Airborne precautions
16. A nurse is caring for a client with Clostridioides difficile (C. diff). Which type
of precaution is required?
Contact precautions
17. The single most effective way to prevent the spread of infection in health care
is:
Hand hygiene
18. A nurse must perform hand hygiene before and after client contact. Which
product is effective against C. diff spores?
Soap and water (not alcohol-based hand rub)