Nursing Process
NCLEX Question: A nurse administers acetaminophen 650 mg PO to a febrile client. Thirty minutes later, the nurse retakes the client's temperature and notes it has decreased from 101.2°F to 99.4°F. Which phase of the nursing process is the nurse performing when rechecking the temperature?
A) Assessment
B) Implementation
C) Evaluation
D) Planning
The correct answer is C: Evaluation. Rechecking the client's temperature after administering an antipyretic evaluates the client's physical response to the nursing intervention and determines whether the outcome goal was met. Assessment is gathering initial data, Implementation is giving the medication, and Planning is setting the goal."
CURRICULAR ALIGNMENT & CITATION: 1- NEW 2026 NUR 155_156 - Unit 1 - Nursing Process_Student.pptx (Slide 12); Yoost & Crawford (4th ed.) Chapter 9.
NCLEX Question: The nurse is preparing to perform a physical assessment of a client's abdomen. In what order should the nurse execute the physical assessment techniques?
A) Inspection, Palpation, Percussion, Auscultation
B) Inspection, Auscultation, Percussion, Palpation
C) Auscultation, Inspection, Palpation, Percussion
D) Palpation, Auscultation, Percussion, Inspection
"Welcome to Category 2 for $100! The correct answer is B: Inspection, Auscultation, Percussion, Palpation. For abdominal exams, auscultation MUST precede percussion and palpation because touching or manipulating the abdomen can alter bowel sounds and produce false hyperactive or hypoactive readings."
CURRICULAR ALIGNMENT & CITATION: 2- NEW 2026 NUR 155_156 - Unit 1 - Physical Assessment_Student (1).pptx (Slide 17); Yoost & Crawford (4th ed.) Chapter 20; NUR 155 Exam Concepts.
NCLEX Question: While taking routine vital signs, the nurse palpates an irregular radial pulse rate of 86 bpm in an adult client. What is the nurse's immediate next action?
A) Document the finding as normal sinus arrhythmia.
B) Administer a PRN dose of digoxin immediately.
C) Auscultate the apical pulse at the 5th ICS LMCL for one full minute.
D) Re-assess the radial pulse in 4 hours during the next vital sign round.
"Welcome to Category 3 for $100! The correct answer is C! Whenever a nurse detects an irregular radial pulse, the immediate mandatory next step is to auscultate the apical pulse for one full minute to determine the true heart rate and evaluate for a pulse deficit."
CURRICULAR ALIGNMENT & CITATION: 4- NEW 2026 NUR 155_156 - Unit 2 - Vital Signs_Faculty.pptx (Slide 8, 9, 21); Yoost & Crawford (4th ed.) Chapter 19; NUR 155 Exam Concepts.
NCLEX Question: The nurse is providing care for a client diagnosed with Clostridium difficile (C. diff) enterocolitis. Which hand hygiene modality is MANDATORY following patient contact?
A) Applying an alcohol-based hand rub for 15 seconds until dry.
B) Washing hands thoroughly with antimicrobial soap and warm water for at least 20 seconds.
C) Rinsing hands with chlorhexidine gluconate solution without water.
D) Wearing clean gloves continuously without performing hand hygiene between tasks.
The correct answer is B! Soap and water handwashing is MANDATORY when caring for clients with C. difficile or spore-forming pathogens, as well as when hands are visibly soiled or dirty, because alcohol-based hand rubs DO NOT kill C. diff bacterial spores!"
CURRICULAR ALIGNMENT & CITATION: 5- NEW 2026 NUR 155_156 - Unit 2 - Asepsis and Infection Control_Faculty.pptx (Slide 11); Yoost & Crawford (4th ed.) Chapter 26; NUR 155 Exam Concepts.
NCLEX Question: The nurse is calling a healthcare provider to report a critical change in a client's condition. The nurse states: 'I am calling about Mr. Jones in Room 302. His blood pressure dropped to 84/50 mmHg and he is experiencing chest tightness.' Which component of the ISBARR framework is the nurse delivering?
A) Background
B) Situation
C) Assessment
D) Recommendation
The correct answer is B! Situation identifies the client, location, and immediate concise reason for the call or acute problem. Background provides clinical context/history. Assessment gives recent vitals/findings. Recommendation suggests actions."
CURRICULAR ALIGNMENT & CITATION: 3- NEW 2026 NUR 155_156 - Unit 2 - Documentation_Faculty.pptx (Slide 13); Yoost & Crawford (4th ed.) Chapter 10; NUR 155 Exam Concepts.
NCLEX Question: The nurse is formulating a plan of care for a postoperative client with impaired mobility. Which outcome statement represents a correctly written SMART goal?
A) The nurse will ambulate the client down the hallway twice daily.
B) The client will walk 50 feet in the hallway using a walker by post-op day 2.
C) The client will demonstrate improved mobility and feel less pain soon.
D) The client will understand how to use a walker properly before discharge.
"For $200, the correct answer is B! A SMART goal must be Specific, Measurable, Attainable, Relevant, and Time-bound. Option B is patient-centered ('The client will...'), measurable ('walk 50 feet'), and has a specific timeframe ('by post-op day 2'). Option A is a nurse action, not a patient goal. Options C and D lack objective measurement."
CURRICULAR ALIGNMENT & CITATION: 1- NEW 2026 NUR 155_156 - Unit 1 - Nursing Process_Student.pptx (Slide 9); Yoost & Crawford (4th ed.) Chapter 8; NUR 155 Exam Concepts.
NCLEX Question: The nurse is assessing a client's cranial nerves and eyes during a general physical exam. Which finding indicates expected normal pupillary responses (PERRLA)?
A) Pupils are asymmetrical, dilating when light is shined directly into the eye.
B) Pupils are equal, round, react to light directly and consensually, and accommodate to near vision.
C) Pupils remain fixed at 6 mm when light is introduced and fail to converge.
D) Distant vision measured at 20/200 on the Snellen chart without corrective lenses.
"For $200, the correct answer is B! PERRLA stands for Pupils Equal, Round, Reactive to Light (both direct and consensual constrictions), and Accommodation (pupils constrict and eyes converge when focusing on a near object). Option D (20/200) represents legal blindness on the Snellen chart."
CURRICULAR ALIGNMENT & CITATION: 2- NEW 2026 NUR 155_156 - Unit 1 - Physical Assessment_Student (1).pptx (Slide 10); Yoost & Crawford (4th ed.) Chapter 20; NUR 155 Exam Concepts.
NCLEX Question: A nurse uses a blood pressure cuff that is too narrow (small) relative to the circumference of the client's upper arm. How will this technical error impact the blood pressure reading?
A) It will produce a falsely high blood pressure reading.
B) It will produce a falsely low blood pressure reading.
C) It will cause an accurate systolic but falsely low diastolic reading.
D) It will have no effect on the blood pressure measurement.
"For $200, the correct answer is A! A BP cuff that is too small or wrapped too loosely yields a falsely high reading because excessive pressure is required to occlude the artery. Conversely, a cuff that is too wide yields a falsely low reading."
CURRICULAR ALIGNMENT & CITATION: 4- NEW 2026 NUR 155_156 - Unit 2 - Vital Signs_Faculty.pptx (Slide 18); Yoost & Crawford (4th ed.) Chapter 19; NUR 155 Exam Concepts.
NCLEX Question: Which patient population is at the HIGHEST risk for developing a Healthcare-Associated Infection (HAI) such as a CAUTI or CLABSI?
A) A healthy 25-year-old admitted for an elective closed extremity fracture repair.
B) An immunocompromised 72-year-old client with an indwelling urinary catheter and central venous line.
C) A 45-year-old client admitted with uncomplicated hypertension and no invasive lines.
D) An 18-year-old athlete receiving physical therapy for a knee sprain.
"For $200, the correct answer is B! High-risk populations for HAIs include immunosuppressed individuals, older adults, surgical/trauma patients, chronically ill individuals, and anyone with invasive devices (indwelling urinary catheters, central venous lines, mechanical ventilators)."
CURRICULAR ALIGNMENT & CITATION: 5- NEW 2026 NUR 155_156 - Unit 2 - Asepsis and Infection Control_Faculty.pptx (Slide 4, 7); Yoost & Crawford (4th ed.) Chapter 26; NUR 155 Exam Concepts.
NCLEX Question: A nurse documents patient care using the Focus Charting (DAR) format. Which entry correctly reflects the 'A' (Action) component of a DAR note?
A) Client reports severe incisional pain rated 8/10.
B) Positioned client in semi-Fowler's position and administered morphine 2 mg IV push as ordered.
C) Client states pain decreased to 2/10 thirty minutes after IV medication.
D) Surgical incision clean, dry, and intact without redness.
"For $200, the correct answer is B! DAR Focus Charting: Data = subjective/objective findings (Option A); Action = nursing interventions executed (Option B); Response = patient evaluation/outcome (Option C)."
CURRICULAR ALIGNMENT & CITATION: 3- NEW 2026 NUR 155_156 - Unit 2 - Documentation_Faculty.pptx (Slide 10); Yoost & Crawford (4th ed.) Chapter 10.
NCLEX Question: During an admission assessment, the nurse records clinical findings. Which item should the nurse document as subjective data?
A) Client states, 'I feel like an elephant is sitting on my chest.'
B) Pitting edema 2+ observed in bilateral lower extremities.
C) Auscultation of fine crackles in bilateral lung bases.
D) Laboratory blood glucose reading of 210 mg/dL.
"For $300, the correct answer is A! Subjective data consists of symptoms, sensations, and health history reported directly by the patient ('what the patient says'). Options B, C, and D are objective data—observable signs, physical examination findings, and diagnostic lab values measured by the nurse."
CURRICULAR ALIGNMENT & CITATION: 1- NEW 2026 NUR 155_156 - Unit 1 - Nursing Process_Student.pptx (Slide 5); Yoost & Crawford (4th ed.) Chapter 6.
NCLEX Question: A nurse is auscultating heart sounds on an adult client. Where should the nurse position the stethoscope to listen to the Mitral valve area and assess the Point of Maximal Impulse (PMI)?
A) Second intercostal space at the right sternal border.
B) Second intercostal space at the left sternal border.
C) Fourth intercostal space at the left lower sternal border.
D) Fifth intercostal space at the left midclavicular line.
"For $300, the correct answer is D! The Mitral valve area and Apical Pulse (PMI) are located at the 5th intercostal space at the left midclavicular line. Remember the mnemonic 'ALL PIGS EAT TOO MUCH': Aortic (2nd ICS RSB), Pulmonic (2nd ICS LSB), Erb's point (3rd ICS LSB), Tricuspid (4th ICS LSB), and Mitral (5th ICS LMCL)."
CURRICULAR ALIGNMENT & CITATION: 2- NEW 2026 NUR 155_156 - Unit 1 - Physical Assessment_Student (1).pptx (Slide 15); Yoost & Crawford (4th ed.) Chapter 20; NUR 155 Exam Concepts.
NCLEX Question: The nurse is evaluating a client with an elevated oral body temperature of 101.6°F (38.7°C). Which additional clinical findings should the nurse expect to observe in a febrile client?
A) Bradycardia, pale cold clammy skin, and hypoventilation.
B) Tachycardia, flushed warm skin, malaise, thirst, and shivering.
C) Decreased pulse pressure, hypothermia, and excessive hunger.
D) Constricted pupils, hypertension, and lethargy.
"For $300, the correct answer is B! Expected clinical findings during a fever (hyperthermia/febrile state) include tachycardia, increased respiratory rate, flushed warm dry skin, malaise, anorexia, thirst, headache, and shivering/chills."
CURRICULAR ALIGNMENT & CITATION: 4- NEW 2026 NUR 155_156 - Unit 2 - Vital Signs_Faculty.pptx (Slide 3, 6); Yoost & Crawford (4th ed.) Chapter 19; NUR 155 Exam Concepts.
NCLEX Question: The nurse is caring for a client admitted with active pulmonary tuberculosis (TB). Which transmission-based isolation precautions and PPE must the nurse implement?
A) Contact Precautions: Gown and gloves required upon entering room.
B) Droplet Precautions: Surgical mask required within 3 feet of client.
C) Airborne Precautions: Fit-tested N95 respirator mask and negative-pressure airborne infection isolation room (AIIR).
D) Standard Precautions: Protective eyewear and sterile gloves only.
"For $300, the correct answer is C! Airborne Precautions are required for pathogens transmitted by small airborne droplet nuclei (Tuberculosis, Measles, Varicella). Essential requirements include a negative-pressure room (AIIR) with 6-12 air exchanges/hr and a fit-tested N95 respirator mask."
CURRICULAR ALIGNMENT & CITATION: 5- NEW 2026 NUR 155_156 - Unit 2 - Asepsis and Infection Control_Faculty.pptx (Slide 14); Yoost & Crawford (4th ed.) Chapter 26; NUR 155 Exam Concepts.
NCLEX Question: The nurse is reviewing written medication orders. According to The Joint Commission official 'Do Not Use' list, which abbreviation is PROHIBITED due to high risk of medication errors?
A) PRN
B) QOD
C) PO
D) mL
"For $300, the correct answer is B! Joint Commission 'Do Not Use' list: 'U' or 'u' (units), 'IU' (international units), 'QD' / 'QOD' (write 'every day' or 'every other day'), trailing zero ('5.0 mg'), lack of leading zero ('.5 mg' -> write '0.5 mg'), 'MS' / 'MSO4' / 'MgSO4'."
CURRICULAR ALIGNMENT & CITATION: 3- NEW 2026 NUR 155_156 - Unit 2 - Documentation_Faculty.pptx (Slide 4); Yoost & Crawford (4th ed.) Chapter 10; NUR 155 Exam Concepts.
NCLEX Question: The nurse is writing a 3-part problem-focused NANDA-I nursing diagnosis for a client experiencing acute shortness of breath and wheezing. Which format is grammatically and clinically correct?
A) Asthma related to bronchospasm as evidenced by wheezing and dyspnea.
B) Impaired Gas Exchange related to bronchoconstriction as evidenced by SpO2 88% and dyspnea.
C) Risk for Impaired Gas Exchange related to wheezing and shortness of breath.
D) Ineffective Airway Clearance as evidenced by COPD related to mucus accumulation.
"For $400, the correct answer is B! A 3-part problem-focused nursing diagnosis follows the PES format: Problem (NANDA label) + Etiology ('related to') + Signs/Symptoms ('as evidenced by'). Option A incorrectly uses a medical diagnosis ('Asthma') as the problem label. Option C is a risk diagnosis, which does not have an 'as evidenced by' defining characteristic."
CURRICULAR ALIGNMENT & CITATION: 1- NEW 2026 NUR 155_156 - Unit 1 - Nursing Process_Student.pptx (Slide 7, 17); Yoost & Crawford (4th ed.) Chapter 7.
NCLEX Question: While auscultating the lung fields of a client with heart failure, the nurse hears high-pitched, discontinuous popping sounds on inspiration that do not clear with coughing. How should the nurse document these adventitious breath sounds?
A) Fine Crackles (Rales)
B) Wheezes
C) Rhonchi
D) Pleural Friction Rub
"For $400, the correct answer is A! Fine crackles (rales) are brief, high-pitched, popping sounds caused by sudden air entry opening collapsed alveoli or fluid in lung bases (common in heart failure and pneumonia). Wheezes (Option B) are high-pitched whistling sounds from constricted airways. Rhonchi (Option C) are low-pitched snoring sounds from mucus that usually clear with coughing."
CURRICULAR ALIGNMENT & CITATION: 2- NEW 2026 NUR 155_156 - Unit 1 - Physical Assessment_Student (1).pptx (Slide 13); Yoost & Crawford (4th ed.) Chapter 20; NUR 155 Exam Concepts.
NCLEX Question: The nurse places a pulse oximeter sensor on a client's finger. Which statement accurately describes the clinical utility and limitations of pulse oximetry (SpO2)?
A) SpO2 measures arterial blood pH directly and is unaffected by peripheral perfusion.
B) Pulse oximetry can detect early hypoxemia before clinical signs like cyanosis appear.
C) Dark fingernail polish and carbon monoxide poisoning increase SpO2 accuracy.
D) Normal SpO2 range is 85% to 90% for a healthy adult client.
"For $400, the correct answer is B! Pulse oximetry noninvasively calculates arterial oxygen saturation and can detect hypoxemia before overt clinical signs like skin/nailbed cyanosis manifest. Sources of inaccurate readings include dark nail polish, artificial nails, peripheral vasoconstriction, carbon monoxide poisoning, and dark skin pigmentation."
CURRICULAR ALIGNMENT & CITATION: 4- NEW 2026 NUR 155_156 - Unit 2 - Vital Signs_Faculty.pptx (Slide 19); Yoost & Crawford (4th ed.) Chapter 19; NUR 155 Exam Concepts.
NCLEX Question: The nurse is exiting an isolation room after caring for a client on Contact and Droplet precautions. In what correct order should the nurse DOFF (remove) Personal Protective Equipment (PPE)?
A) Mask, Gown, Goggles, Gloves
B) Gloves, Goggles/Face Shield, Gown, Mask/Respirator
C) Gown, Gloves, Mask, Goggles
D) Gloves, Mask, Gown, Goggles
"For $400, the correct answer is B! CDC Doffing Sequence (most contaminated to least contaminated): 1. Gloves, 2. Goggles/Face Shield, 3. Gown, 4. Mask or Respirator, followed immediately by Hand Hygiene. Donning Sequence: 1. Gown, 2. Mask/Respirator, 3. Goggles/Face Shield, 4. Gloves."
CURRICULAR ALIGNMENT & CITATION: 5- NEW 2026 NUR 155_156 - Unit 2 - Asepsis and Infection Control_Faculty.pptx (Slide 14); Yoost & Crawford (4th ed.) Chapter 26; NUR 155 Exam Concepts.
NCLEX Question: During a clinical emergency, a primary care provider shouts a verbal order to the nurse: 'Administer 0.4 mg nitroglycerin sublingually stat!' What is the nurse's MANDATORY next action?
A) Administer the medication immediately and write the order in the chart later.
B) Repeat the order back verbatim to the provider to confirm accuracy before administering.
C) Ask the unit secretary to enter the verbal order into the electronic medical record.
D) Refuse to carry out any verbal order under any clinical circumstances.
"For $400, the correct answer is B! For verbal or telephone orders, the receiving RN MUST repeat the order back verbatim ('read-back'), document it in the EMR as a verbal/telephone order, and ensure the ordering provider co-signs it within the institutional timeframe."
CURRICULAR ALIGNMENT & CITATION: 3- NEW 2026 NUR 155_156 - Unit 2 - Documentation_Faculty.pptx (Slide 15, 17); Yoost & Crawford (4th ed.) Chapter 10; NUR 155 Exam Concepts.
NCLEX Question: The nurse is prioritizing care for four assigned clients using Maslow's Hierarchy of Needs. Which client diagnosis must the nurse attend to FIRST?
A) A client with Acute Pain rated 8/10 following abdominal surgery.
B) A client with Risk for Falls related to unsteady gait and dizziness.
C) A client with Impaired Gas Exchange related to fluid accumulation in alveoli.
D) A client with Risk for Social Isolation related to protective isolation.
"For $500, the correct answer is C! According to Maslow's Hierarchy of Needs and ABCs (Airway, Breathing, Circulation), physiological threats to oxygenation and gas exchange take immediate top priority before pain (Option A), safety/fall risk (Option B), or psychosocial needs (Option D)."
CURRICULAR ALIGNMENT & CITATION: 1- NEW 2026 NUR 155_156 - Unit 1 - Nursing Process_Student.pptx (Slide 10, 21); Yoost & Crawford (4th ed.) Chapter 8; NUR 155 Exam Concepts.
NCLEX Question: The nurse assesses a client with lower extremity swelling. Pressing a thumb firmly over the tibia creates a 6 mm deep depression that remains visible for over a minute before rebounding. How should the nurse grade this edema?
A) 1+ Pitting Edema
B) 2+ Pitting Edema
C) 3+ Pitting Edema
D) 4+ Pitting Edema
"For $500, the correct answer is C! Pitting edema scale: 1+ = slight 2 mm pit; 2+ = 4 mm pit; 3+ = deep 6 mm pit that lasts over a minute; 4+ = severe 8 mm pit lasting 2 to 5 minutes."
CURRICULAR ALIGNMENT & CITATION: 2- NEW 2026 NUR 155_156 - Unit 1 - Physical Assessment_Student (1).pptx (Slide 8); Yoost & Crawford (4th ed.) Chapter 20; NUR 155 Exam Concepts.
NCLEX Question: The nurse evaluates a client for orthostatic (postural) hypotension. The client's supine BP is 128/82 mmHg (HR 72 bpm). Upon standing, the BP drops to 104/68 mmHg and HR increases to 94 bpm, with reported lightheadedness. What is the nurse's priority action?
A) Assist the client to sit or lie back down immediately to prevent a fall.
B) Encourage the client to walk around the room to increase venous return.
C) Administer an intravenous bolus of antihypertensive medication.
D) Document the findings as normal physiological adaptation to standing.
"For $500, the correct answer is A! Orthostatic hypotension is defined as a drop in systolic BP of >=20 mmHg or diastolic BP of >=10 mmHg within 3 minutes of standing, accompanied by tachycardia and dizziness. Client safety is paramount—assisting the client back to a sitting or supine position prevents syncope and falls."
CURRICULAR ALIGNMENT & CITATION: 4- NEW 2026 NUR 155_156 - Unit 2 - Vital Signs_Faculty.pptx (Slide 17); Yoost & Crawford (4th ed.) Chapter 19; NUR 155 Exam Concepts.
NCLEX Question: While administering a subcutaneous injection, a nursing student sustains an accidental needlestick puncture wound from a contaminated needle. What is the student's IMMEDIATE first aid action?
A) Squeeze the puncture wound forcefully to apply a tight tourniquet above the site.
B) Encourage gentle bleeding at the puncture site and wash thoroughly with soap and water.
C) Apply a concentrated bleach solution directly onto the wound to sterilize it.
D) Complete an incident report immediately before performing wound care.
"For $500, the correct answer is B! Immediate first aid for a puncture/needlestick exposure: 1) Gently encourage bleeding at the site, 2) Wash thoroughly with soap and water. If splash to eyes/mucous membranes occurs: flush with saline/water for 5-10 minutes continuously. Then report to supervisor and seek treatment."
CURRICULAR ALIGNMENT & CITATION: 5- NEW 2026 NUR 155_156 - Unit 2 - Asepsis and Infection Control_Faculty.pptx (Slide 18, 21); Yoost & Crawford (4th ed.) Chapter 26; NUR 155 Exam Concepts.
NCLEX Question: A client falls while ambulating to the bathroom with a nursing student. After assessing the client for injuries and notifying the physician, the nurse completes an incident (occurrence) report. Which rule governs incident reports?
A) The incident report must be filed directly into the client's permanent medical record.
B) The nurse should document in the clinical progress notes: 'Incident report completed and sent to risk management.'
C) Incident reports are confidential administrative documents and are NOT part of the client's medical record.
D) Incident reports replace the need to document physical assessment findings in the client's chart.
"For $500, the correct answer is C! Incident reports are confidential internal risk management documents used for quality improvement. They are NEVER included in or referred to within the client's permanent medical record! The medical record should contain only objective facts regarding the event and client assessment."
CURRICULAR ALIGNMENT & CITATION: 3- NEW 2026 NUR 155_156 - Unit 2 - Documentation_Faculty.pptx (Slide 16, 18); Yoost & Crawford (4th ed.) Chapter 10; NUR 155 Exam Concepts.