NUR155/NUR 155 Exam 3 V2 | Critical
Thinking for the Practical Nurse Q&A with
Rationale | Hondros College of Nursing
1. A nurse is reviewing the plan of care for a client who has a history of falls. Which of the
following is the priority action for the nurse to include?
A. Monitor the client every 2 hours.
B. Ensure the client is wearing non-skid footwear.
C. Place a ‘fall risk’ sign on the client’s door.
D. Provide the client with a bedside commode.
Correct Answer: B
Rationale: Safety is the priority intervention when managing a patient with a history of
falls. Ensuring the client has non-skid footwear provides immediate traction and reduces
the risk of slipping during ambulation. This action addresses the physical hazard directly
and is a fundamental component of a fall prevention protocol.
2. When applying the nursing process, which of the following activities should the nurse
perform during the assessment phase?
A. Formulating a nursing diagnosis.
B. Collecting and organizing client data.
C. Setting measurable client goals.
,D. Determining if the client met the outcomes.
Correct Answer: B
Rationale: The assessment phase is the first step of the nursing process and involves
systematic data collection. The nurse gathers both subjective and objective data to
establish a database about the client’s health status. This information is essential for
developing a valid nursing diagnosis and a personalized plan of care.
3. A nurse is caring for a client who is postoperative. The nurse notices the client’s surgical
dressing is saturated with bright red blood. Which of the following actions should the nurse
take first?
A. Document the findings in the medical record.
B. Notify the surgeon immediately.
C. Apply a pressure dressing over the site.
D. Check the client’s blood pressure and pulse.
Correct Answer: D
Rationale: According to the nursing process, the nurse must assess the client’s
physiological stability before performing an intervention. Vital signs provide critical
information regarding the extent of blood loss and potential shock. Once the nurse has
assessed the client’s status, they can then apply pressure or notify the provider as needed.
4. Which of the following describes the ethical principle of ‘Nonmaleficence’?
A. The duty to do good for others.
, B. The right of the client to make their own decisions.
C. The duty to avoid doing harm.
D. The obligation to be fair to all people.
Correct Answer: C
Rationale: Nonmaleficence is the ethical requirement for healthcare providers to ‘do no
harm’ to their patients. This involves protecting clients from danger and avoiding
procedures that have unnecessary risks. It is a foundational concept in nursing ethics that
guides decision-making in complex clinical scenarios.
5. A nurse is using the SBAR communication tool to report a change in a client’s condition.
Which of the following information should the nurse include in the ‘Background’ section?
A. The reason for the client’s admission and medical history.
B. The nurse’s recommendation for a change in treatment.
C. The client’s current vital signs.
D. The client’s current primary problem.
Correct Answer: A
Rationale: The Background component of SBAR provides the context for the current
situation. It includes relevant history, such as the admission diagnosis, date of admission,
and pertinent medical history. This allows the receiver of the information to understand
the circumstances leading up to the current issue.
Thinking for the Practical Nurse Q&A with
Rationale | Hondros College of Nursing
1. A nurse is reviewing the plan of care for a client who has a history of falls. Which of the
following is the priority action for the nurse to include?
A. Monitor the client every 2 hours.
B. Ensure the client is wearing non-skid footwear.
C. Place a ‘fall risk’ sign on the client’s door.
D. Provide the client with a bedside commode.
Correct Answer: B
Rationale: Safety is the priority intervention when managing a patient with a history of
falls. Ensuring the client has non-skid footwear provides immediate traction and reduces
the risk of slipping during ambulation. This action addresses the physical hazard directly
and is a fundamental component of a fall prevention protocol.
2. When applying the nursing process, which of the following activities should the nurse
perform during the assessment phase?
A. Formulating a nursing diagnosis.
B. Collecting and organizing client data.
C. Setting measurable client goals.
,D. Determining if the client met the outcomes.
Correct Answer: B
Rationale: The assessment phase is the first step of the nursing process and involves
systematic data collection. The nurse gathers both subjective and objective data to
establish a database about the client’s health status. This information is essential for
developing a valid nursing diagnosis and a personalized plan of care.
3. A nurse is caring for a client who is postoperative. The nurse notices the client’s surgical
dressing is saturated with bright red blood. Which of the following actions should the nurse
take first?
A. Document the findings in the medical record.
B. Notify the surgeon immediately.
C. Apply a pressure dressing over the site.
D. Check the client’s blood pressure and pulse.
Correct Answer: D
Rationale: According to the nursing process, the nurse must assess the client’s
physiological stability before performing an intervention. Vital signs provide critical
information regarding the extent of blood loss and potential shock. Once the nurse has
assessed the client’s status, they can then apply pressure or notify the provider as needed.
4. Which of the following describes the ethical principle of ‘Nonmaleficence’?
A. The duty to do good for others.
, B. The right of the client to make their own decisions.
C. The duty to avoid doing harm.
D. The obligation to be fair to all people.
Correct Answer: C
Rationale: Nonmaleficence is the ethical requirement for healthcare providers to ‘do no
harm’ to their patients. This involves protecting clients from danger and avoiding
procedures that have unnecessary risks. It is a foundational concept in nursing ethics that
guides decision-making in complex clinical scenarios.
5. A nurse is using the SBAR communication tool to report a change in a client’s condition.
Which of the following information should the nurse include in the ‘Background’ section?
A. The reason for the client’s admission and medical history.
B. The nurse’s recommendation for a change in treatment.
C. The client’s current vital signs.
D. The client’s current primary problem.
Correct Answer: A
Rationale: The Background component of SBAR provides the context for the current
situation. It includes relevant history, such as the admission diagnosis, date of admission,
and pertinent medical history. This allows the receiver of the information to understand
the circumstances leading up to the current issue.
