NUR155/NUR 155 Exam 3 V3 | Critical
Thinking for the Practical Nurse Q&A with
Rationale | Hondros College of Nursing
1. A nurse is prioritizing care for four patients who just received hand-off report. Which
patient should the nurse assess first?
A. A patient with a blood pressure of 110/70 mmHg and mild nausea.
B. A patient who needs a dressing change for a clean surgical incision.
C. A patient reporting sharp chest pain radiating to the left jaw.
D. A patient requesting a PRN medication for a chronic headache.
Correct Answer: C
Rationale: According to the ABC (Airway, Breathing, Circulation) framework, chest pain
radiating to the jaw is a classic sign of myocardial infarction, which is a life-threatening
circulatory emergency. Assessing this patient immediately takes precedence over routine
care or stable vital signs. This reflects the nurse’s ability to prioritize based on
physiological stability.
2. During the assessment phase of the nursing process, which of the following is considered
subjective data?
A. The patient’s temperature is 101.2 degrees Fahrenheit.
B. The patient’s surgical site is red and swollen.
,C. The patient states, ‘I feel very dizzy when I stand up.’
D. The nurse observes the patient grimacing while moving.
Correct Answer: C
Rationale: Subjective data consists of information that the patient describes or feels, which
cannot be measured directly by the nurse. A statement about dizziness is a personal
sensation reported by the client. In contrast, temperature, redness, and grimacing are
objective findings that the nurse can see or measure.
3. The nurse is preparing to delegate tasks to an unlicensed assistive personnel (UAP). Which
task is appropriate to delegate?
A. Evaluating a patient’s response to a new pain medication.
B. Teaching a patient how to use an incentive spirometer.
C. Assisting a stable patient with ambulation to the bathroom.
D. Performing the initial admission assessment on a new patient.
Correct Answer: C
Rationale: Delegation to a UAP must involve tasks that are routine, non-invasive, and do
not require clinical judgment. Assisting a stable patient with activities of daily living, such
as ambulation, is within the UAP’s scope. Evaluation, teaching, and assessment require the
professional judgment and knowledge of a licensed nurse.
, 4. A nurse uses the SBAR tool to communicate with a physician. What does the ‘R’ in SBAR
stand for?
A. Review
B. Rationale
C. Recommendation
D. Reaction
Correct Answer: C
Rationale: The SBAR acronym stands for Situation, Background, Assessment, and
Recommendation. This structured communication tool ensures that critical information is
conveyed clearly and efficiently between healthcare professionals. Using SBAR helps
reduce communication errors and improves patient safety outcomes.
5. Which step of the nursing process involves comparing the patient’s current health status
with the desired outcomes defined in the planning phase?
A. Implementation
B. Evaluation
C. Diagnosis
D. Assessment
Correct Answer: B
Thinking for the Practical Nurse Q&A with
Rationale | Hondros College of Nursing
1. A nurse is prioritizing care for four patients who just received hand-off report. Which
patient should the nurse assess first?
A. A patient with a blood pressure of 110/70 mmHg and mild nausea.
B. A patient who needs a dressing change for a clean surgical incision.
C. A patient reporting sharp chest pain radiating to the left jaw.
D. A patient requesting a PRN medication for a chronic headache.
Correct Answer: C
Rationale: According to the ABC (Airway, Breathing, Circulation) framework, chest pain
radiating to the jaw is a classic sign of myocardial infarction, which is a life-threatening
circulatory emergency. Assessing this patient immediately takes precedence over routine
care or stable vital signs. This reflects the nurse’s ability to prioritize based on
physiological stability.
2. During the assessment phase of the nursing process, which of the following is considered
subjective data?
A. The patient’s temperature is 101.2 degrees Fahrenheit.
B. The patient’s surgical site is red and swollen.
,C. The patient states, ‘I feel very dizzy when I stand up.’
D. The nurse observes the patient grimacing while moving.
Correct Answer: C
Rationale: Subjective data consists of information that the patient describes or feels, which
cannot be measured directly by the nurse. A statement about dizziness is a personal
sensation reported by the client. In contrast, temperature, redness, and grimacing are
objective findings that the nurse can see or measure.
3. The nurse is preparing to delegate tasks to an unlicensed assistive personnel (UAP). Which
task is appropriate to delegate?
A. Evaluating a patient’s response to a new pain medication.
B. Teaching a patient how to use an incentive spirometer.
C. Assisting a stable patient with ambulation to the bathroom.
D. Performing the initial admission assessment on a new patient.
Correct Answer: C
Rationale: Delegation to a UAP must involve tasks that are routine, non-invasive, and do
not require clinical judgment. Assisting a stable patient with activities of daily living, such
as ambulation, is within the UAP’s scope. Evaluation, teaching, and assessment require the
professional judgment and knowledge of a licensed nurse.
, 4. A nurse uses the SBAR tool to communicate with a physician. What does the ‘R’ in SBAR
stand for?
A. Review
B. Rationale
C. Recommendation
D. Reaction
Correct Answer: C
Rationale: The SBAR acronym stands for Situation, Background, Assessment, and
Recommendation. This structured communication tool ensures that critical information is
conveyed clearly and efficiently between healthcare professionals. Using SBAR helps
reduce communication errors and improves patient safety outcomes.
5. Which step of the nursing process involves comparing the patient’s current health status
with the desired outcomes defined in the planning phase?
A. Implementation
B. Evaluation
C. Diagnosis
D. Assessment
Correct Answer: B
