NUR155/NUR 155 Final Exam V1 | Critical
Thinking for the Practical Nurse Q&A with
Rationale | Hondros College of Nursing
1. Which phase of the nursing process involves the systematic collection of both subjective
and objective data from a client?
A. Planning
B. Implementation
C. Assessment
D. Evaluation
Correct Answer: C
Rationale: Assessment is the first step of the nursing process and is essential for gathering
data to form a clinical judgment. During this phase, the nurse collects subjective data from
the client’s statements and objective data through observation and physical exam. This
information serves as the foundation for the entire care plan and subsequent nursing
actions.
2. A nurse is prioritizing care for a group of patients. Which client should the nurse see first
according to the ABC prioritization framework?
A. A client with a scheduled dressing change for a leg ulcer.
B. A client reporting a pain level of 5 out of 10 after surgery.
,C. A client who needs discharge instructions for a new medication.
D. A client exhibiting shortness of breath and an oxygen saturation of 88%.
Correct Answer: D
Rationale: The ABC framework stands for Airway, Breathing, and Circulation, which
identifies life-threatening conditions. Shortness of breath and low oxygen saturation
indicate a critical breathing issue that must be addressed immediately to prevent further
deterioration. Other needs, such as pain management or teaching, are important but
secondary to respiratory stability.
3. When a nurse ensures that a patient has all the necessary information to make an
autonomous decision about their care, which ethical principle is being upheld?
A. Beneficence
B. Justice
C. Nonmaleficence
D. Autonomy
Correct Answer: D
Rationale: Autonomy refers to the right of the individual to make their own healthcare
decisions without coercion. The nurse supports this principle by providing comprehensive
education and ensuring the client understands the risks and benefits of various treatments.
Respecting a client’s independence is a fundamental component of patient-centered care
and ethical nursing practice.
, 4. Which of the following is considered subjective data collected during a nursing
assessment?
A. The client’s statement, ‘I feel like my heart is racing.’
B. A blood pressure reading of 140/90 mmHg.
C. An observable rash on the client’s upper chest.
D. A serum potassium level of 3.2 mEq/L.
Correct Answer: A
Rationale: Subjective data consists of information that the client describes or feels, which
cannot be measured by the nurse. In this scenario, the feeling of a racing heart is a
symptom reported by the client rather than a clinical sign. Objective data, conversely,
includes measurable signs like blood pressure and laboratory values.
5. According to Maslow’s Hierarchy of Needs, which patient need should the nurse address
first?
A. Physiological needs such as adequate hydration and nutrition.
B. Safety and security by using bed rails.
C. Self-actualization through spiritual support.
D. Love and belonging through family visitation.
Correct Answer: A
Thinking for the Practical Nurse Q&A with
Rationale | Hondros College of Nursing
1. Which phase of the nursing process involves the systematic collection of both subjective
and objective data from a client?
A. Planning
B. Implementation
C. Assessment
D. Evaluation
Correct Answer: C
Rationale: Assessment is the first step of the nursing process and is essential for gathering
data to form a clinical judgment. During this phase, the nurse collects subjective data from
the client’s statements and objective data through observation and physical exam. This
information serves as the foundation for the entire care plan and subsequent nursing
actions.
2. A nurse is prioritizing care for a group of patients. Which client should the nurse see first
according to the ABC prioritization framework?
A. A client with a scheduled dressing change for a leg ulcer.
B. A client reporting a pain level of 5 out of 10 after surgery.
,C. A client who needs discharge instructions for a new medication.
D. A client exhibiting shortness of breath and an oxygen saturation of 88%.
Correct Answer: D
Rationale: The ABC framework stands for Airway, Breathing, and Circulation, which
identifies life-threatening conditions. Shortness of breath and low oxygen saturation
indicate a critical breathing issue that must be addressed immediately to prevent further
deterioration. Other needs, such as pain management or teaching, are important but
secondary to respiratory stability.
3. When a nurse ensures that a patient has all the necessary information to make an
autonomous decision about their care, which ethical principle is being upheld?
A. Beneficence
B. Justice
C. Nonmaleficence
D. Autonomy
Correct Answer: D
Rationale: Autonomy refers to the right of the individual to make their own healthcare
decisions without coercion. The nurse supports this principle by providing comprehensive
education and ensuring the client understands the risks and benefits of various treatments.
Respecting a client’s independence is a fundamental component of patient-centered care
and ethical nursing practice.
, 4. Which of the following is considered subjective data collected during a nursing
assessment?
A. The client’s statement, ‘I feel like my heart is racing.’
B. A blood pressure reading of 140/90 mmHg.
C. An observable rash on the client’s upper chest.
D. A serum potassium level of 3.2 mEq/L.
Correct Answer: A
Rationale: Subjective data consists of information that the client describes or feels, which
cannot be measured by the nurse. In this scenario, the feeling of a racing heart is a
symptom reported by the client rather than a clinical sign. Objective data, conversely,
includes measurable signs like blood pressure and laboratory values.
5. According to Maslow’s Hierarchy of Needs, which patient need should the nurse address
first?
A. Physiological needs such as adequate hydration and nutrition.
B. Safety and security by using bed rails.
C. Self-actualization through spiritual support.
D. Love and belonging through family visitation.
Correct Answer: A
