HONDROS NUR 150 EXAM 1 2026/2027 | 100% Correct
Answers with Complete Solutions | Fundamentals of Nursing
| NCLEX-RN Aligned | Hondros College | Pass Guaranteed -
A+ Graded
Domain 1: Nursing Process & Critical Thinking (15 Questions)
Q1: A 68-year-old patient with COPD is admitted with shortness of breath, oxygen
saturation of 88% on room air, respiratory rate of 28 breaths/min, and anxiety. Which
nursing action demonstrates the first step of the nursing process?
A. Administer oxygen via nasal cannula at 2 L/min
B. Document the patient's respiratory rate and oxygen saturation
C. Diagnose the patient with "Impaired Gas Exchange"
D. Establish a goal for oxygen saturation to remain above 92%
Correct Answer: B [CORRECT]
Rationale: The nursing process follows the ADPIE framework: Assessment, Diagnosis,
Planning, Implementation, and Evaluation. Assessment is always the first step and
involves collecting both subjective and objective data. Documenting the respiratory rate
(28 breaths/min) and oxygen saturation (88%) represents objective data collection,
which is the foundation of assessment. Option A represents Implementation, which
cannot occur before assessment and planning. Option C represents the Diagnosis
phase, which requires assessment data first. Option D represents the Planning phase,
which follows diagnosis. Without proper assessment, all subsequent steps are based
on incomplete or inaccurate information, potentially compromising patient safety.
,Q2: During morning assessment, a nurse collects the following data: "Patient states, 'I
feel dizzy when I stand up'" and "Blood pressure 110/70 mmHg supine, 90/60 mmHg
standing." How should the nurse classify this information?
A. Both are objective data
B. Both are subjective data
C. The statement is subjective; the blood pressure readings are objective
D. The statement is objective; the blood pressure readings are subjective
Correct Answer: C [CORRECT]
Rationale: Subjective data consists of information perceived by the patient and cannot
be measured or observed by others, such as feelings, sensations, or symptoms reported
by the patient ("I feel dizzy"). Objective data consists of observable, measurable
information obtained through physical examination, laboratory tests, or diagnostic
procedures (blood pressure readings of 110/70 supine and 90/60 standing). This
orthostatic blood pressure change objectively confirms the patient's subjective
complaint of dizziness, demonstrating how subjective and objective data work together
to provide a complete clinical picture. The other options incorrectly classify these data
types.
Q3: A nurse is caring for four patients. Which patient requires immediate priority
intervention using the ABC (Airway, Breathing, Circulation) framework?
A. A post-operative patient requesting pain medication for a 4/10 pain level
B. A patient with newly diagnosed diabetes asking for dietary education
C. A patient with stridor, retractions, and oxygen saturation of 89%
D. A patient scheduled for discharge who needs medication instructions
,Correct Answer: C [CORRECT]
Rationale: The ABC framework prioritizes life-threatening conditions in order of urgency:
Airway, Breathing, and Circulation. The patient with stridor (high-pitched sound
indicating upper airway obstruction), retractions (accessory muscle use indicating
respiratory distress), and oxygen saturation of 89% (below normal 95-100%)
demonstrates compromised breathing and airway patency, representing an immediate
threat to life. This requires immediate intervention before addressing any other patient
needs. Options A, B, and D represent important but non-urgent needs that can be
addressed after life-threatening conditions are stabilized. Maslow's Hierarchy of Needs
also supports this prioritization, as physiological needs (oxygenation) must be met
before safety, comfort, or educational needs.
Q4: Using Maslow's Hierarchy of Needs to prioritize care, which patient need should the
nurse address first?
A. A patient expressing fear about upcoming surgery
B. A patient with a blood glucose level of 45 mg/dL
C. A patient requesting assistance contacting family members
D. A patient who feels isolated from the healthcare team
Correct Answer: B [CORRECT]
Rationale: Maslow's Hierarchy of Needs prioritizes physiological needs (bottom level)
before safety, love/belonging, esteem, and self-actualization needs. A blood glucose
level of 45 mg/dL represents severe hypoglycemia, a life-threatening physiological
imbalance that can lead to seizures, loss of consciousness, or death if untreated. This
physiological need takes absolute priority over emotional needs (fear, isolation) or
, social needs (contacting family), which appear higher in the hierarchy. The nurse must
immediately address the hypoglycemia with appropriate interventions (oral glucose, IV
dextrose if unconscious) before addressing psychosocial concerns. This prioritization
ensures survival needs are met first, consistent with both Maslow's theory and nursing
safety priorities.
Q5: A nurse identifies the nursing diagnosis: "Impaired Skin Integrity related to
immobility and shearing forces as evidenced by stage 2 pressure injury on sacrum."
Which component represents the "related to" factor?
A. Impaired Skin Integrity
B. Stage 2 pressure injury on sacrum
C. Immobility and shearing forces
D. The entire statement
Correct Answer: C [CORRECT]
Rationale: A NANDA-I nursing diagnosis follows the PES format: Problem (P), Etiology
(E), and Signs/Symptoms (S). In this diagnosis, "Impaired Skin Integrity" is the Problem
(P) - the nursing diagnosis label. "Immobility and shearing forces" represents the
Etiology (E) or "related to" factors - the causes or contributing factors that the nurse can
treat through interventions. "Stage 2 pressure injury on sacrum" represents the
Signs/Symptoms (S) or "as evidenced by" - the defining characteristics that support the
diagnosis. Understanding this structure is crucial because nursing interventions must
target the etiology (immobility and shearing forces) to effectively treat the problem, not
just manage the symptoms.
Answers with Complete Solutions | Fundamentals of Nursing
| NCLEX-RN Aligned | Hondros College | Pass Guaranteed -
A+ Graded
Domain 1: Nursing Process & Critical Thinking (15 Questions)
Q1: A 68-year-old patient with COPD is admitted with shortness of breath, oxygen
saturation of 88% on room air, respiratory rate of 28 breaths/min, and anxiety. Which
nursing action demonstrates the first step of the nursing process?
A. Administer oxygen via nasal cannula at 2 L/min
B. Document the patient's respiratory rate and oxygen saturation
C. Diagnose the patient with "Impaired Gas Exchange"
D. Establish a goal for oxygen saturation to remain above 92%
Correct Answer: B [CORRECT]
Rationale: The nursing process follows the ADPIE framework: Assessment, Diagnosis,
Planning, Implementation, and Evaluation. Assessment is always the first step and
involves collecting both subjective and objective data. Documenting the respiratory rate
(28 breaths/min) and oxygen saturation (88%) represents objective data collection,
which is the foundation of assessment. Option A represents Implementation, which
cannot occur before assessment and planning. Option C represents the Diagnosis
phase, which requires assessment data first. Option D represents the Planning phase,
which follows diagnosis. Without proper assessment, all subsequent steps are based
on incomplete or inaccurate information, potentially compromising patient safety.
,Q2: During morning assessment, a nurse collects the following data: "Patient states, 'I
feel dizzy when I stand up'" and "Blood pressure 110/70 mmHg supine, 90/60 mmHg
standing." How should the nurse classify this information?
A. Both are objective data
B. Both are subjective data
C. The statement is subjective; the blood pressure readings are objective
D. The statement is objective; the blood pressure readings are subjective
Correct Answer: C [CORRECT]
Rationale: Subjective data consists of information perceived by the patient and cannot
be measured or observed by others, such as feelings, sensations, or symptoms reported
by the patient ("I feel dizzy"). Objective data consists of observable, measurable
information obtained through physical examination, laboratory tests, or diagnostic
procedures (blood pressure readings of 110/70 supine and 90/60 standing). This
orthostatic blood pressure change objectively confirms the patient's subjective
complaint of dizziness, demonstrating how subjective and objective data work together
to provide a complete clinical picture. The other options incorrectly classify these data
types.
Q3: A nurse is caring for four patients. Which patient requires immediate priority
intervention using the ABC (Airway, Breathing, Circulation) framework?
A. A post-operative patient requesting pain medication for a 4/10 pain level
B. A patient with newly diagnosed diabetes asking for dietary education
C. A patient with stridor, retractions, and oxygen saturation of 89%
D. A patient scheduled for discharge who needs medication instructions
,Correct Answer: C [CORRECT]
Rationale: The ABC framework prioritizes life-threatening conditions in order of urgency:
Airway, Breathing, and Circulation. The patient with stridor (high-pitched sound
indicating upper airway obstruction), retractions (accessory muscle use indicating
respiratory distress), and oxygen saturation of 89% (below normal 95-100%)
demonstrates compromised breathing and airway patency, representing an immediate
threat to life. This requires immediate intervention before addressing any other patient
needs. Options A, B, and D represent important but non-urgent needs that can be
addressed after life-threatening conditions are stabilized. Maslow's Hierarchy of Needs
also supports this prioritization, as physiological needs (oxygenation) must be met
before safety, comfort, or educational needs.
Q4: Using Maslow's Hierarchy of Needs to prioritize care, which patient need should the
nurse address first?
A. A patient expressing fear about upcoming surgery
B. A patient with a blood glucose level of 45 mg/dL
C. A patient requesting assistance contacting family members
D. A patient who feels isolated from the healthcare team
Correct Answer: B [CORRECT]
Rationale: Maslow's Hierarchy of Needs prioritizes physiological needs (bottom level)
before safety, love/belonging, esteem, and self-actualization needs. A blood glucose
level of 45 mg/dL represents severe hypoglycemia, a life-threatening physiological
imbalance that can lead to seizures, loss of consciousness, or death if untreated. This
physiological need takes absolute priority over emotional needs (fear, isolation) or
, social needs (contacting family), which appear higher in the hierarchy. The nurse must
immediately address the hypoglycemia with appropriate interventions (oral glucose, IV
dextrose if unconscious) before addressing psychosocial concerns. This prioritization
ensures survival needs are met first, consistent with both Maslow's theory and nursing
safety priorities.
Q5: A nurse identifies the nursing diagnosis: "Impaired Skin Integrity related to
immobility and shearing forces as evidenced by stage 2 pressure injury on sacrum."
Which component represents the "related to" factor?
A. Impaired Skin Integrity
B. Stage 2 pressure injury on sacrum
C. Immobility and shearing forces
D. The entire statement
Correct Answer: C [CORRECT]
Rationale: A NANDA-I nursing diagnosis follows the PES format: Problem (P), Etiology
(E), and Signs/Symptoms (S). In this diagnosis, "Impaired Skin Integrity" is the Problem
(P) - the nursing diagnosis label. "Immobility and shearing forces" represents the
Etiology (E) or "related to" factors - the causes or contributing factors that the nurse can
treat through interventions. "Stage 2 pressure injury on sacrum" represents the
Signs/Symptoms (S) or "as evidenced by" - the defining characteristics that support the
diagnosis. Understanding this structure is crucial because nursing interventions must
target the etiology (immobility and shearing forces) to effectively treat the problem, not
just manage the symptoms.
