NUR155/NUR 155 Exam 2 V3 | Critical
Thinking for the Practical Nurse Q&A with
Rationale | Hondros College of Nursing
1. A Licensed Practical Nurse (LPN) is assisting with the development of a care plan for a
patient with heart failure. Which step of the nursing process is the nurse participating in
when identifying patient outcomes?
A. Assessment
B. Evaluation
C. Implementation
D. Planning
Correct Answer: D
Rationale: The planning phase of the nursing process involves setting priorities and
establishing measurable goals or outcomes. The LPN contributes to this phase by
collaborating with the Registered Nurse to ensure the plan is realistic for the patient. This
step follows the assessment and diagnosis phases and precedes the actual delivery of care.
2. Which clinical finding should the nurse prioritize first when using the ABC framework for
prioritization?
A. Blood pressure of 100/60 mmHg
B. Oxygen saturation of 88% on room air
,C. Heart rate of 110 beats per minute
D. Stridor noted upon inspiration
Correct Answer: D
Rationale: According to the ABC (Airway, Breathing, Circulation) framework, airway issues
are the highest priority. Stridor indicates a potential upper airway obstruction, which is an
immediate life-threatening emergency. Oxygen saturation and blood pressure are
important, but the airway must be patent before breathing or circulation can be addressed.
3. The nurse is caring for a group of patients. Which patient should the nurse see first based
on Maslow’s Hierarchy of Needs?
A. A patient reporting level 8/10 abdominal pain
B. A patient requesting a chaplain visit
C. A patient who is feeling lonely and wants to talk
D. A patient asking about their discharge medications
Correct Answer: A
Rationale: Maslow’s Hierarchy of Needs identifies physiological needs, such as pain relief
and comfort, as the most basic and urgent level. Severe pain can interfere with physical
stability and must be addressed before higher-level needs like belonging or self-
actualization. Providing timely analgesia is a priority nursing intervention for physiological
stability.
, 4. An LPN is collecting data from a patient who reports feeling ‘dizzy and lightheaded.’ How
should the nurse classify this type of data?
A. Objective data
B. Subjective data
C. Secondary data
D. External data
Correct Answer: B
Rationale: Subjective data consists of information that the patient expresses or feels,
which cannot be directly measured by the nurse. Symptoms like dizziness, pain, or anxiety
are categorized as subjective because they are personal perceptions. Objective data, in
contrast, are measurable signs such as blood pressure or lung sounds.
5. Which action by the nurse demonstrates the ethical principle of autonomy?
A. Keeping a promise to return to the patient’s room in 10 minutes
B. Giving a prescribed pain medication to a patient in distress
C. Ensuring the patient signs the consent form after a full explanation
D. Treating all patients equally regardless of their insurance status
Correct Answer: C
Rationale: Autonomy refers to the right of the patient to make their own decisions
regarding their healthcare. By ensuring the patient is fully informed before signing a
Thinking for the Practical Nurse Q&A with
Rationale | Hondros College of Nursing
1. A Licensed Practical Nurse (LPN) is assisting with the development of a care plan for a
patient with heart failure. Which step of the nursing process is the nurse participating in
when identifying patient outcomes?
A. Assessment
B. Evaluation
C. Implementation
D. Planning
Correct Answer: D
Rationale: The planning phase of the nursing process involves setting priorities and
establishing measurable goals or outcomes. The LPN contributes to this phase by
collaborating with the Registered Nurse to ensure the plan is realistic for the patient. This
step follows the assessment and diagnosis phases and precedes the actual delivery of care.
2. Which clinical finding should the nurse prioritize first when using the ABC framework for
prioritization?
A. Blood pressure of 100/60 mmHg
B. Oxygen saturation of 88% on room air
,C. Heart rate of 110 beats per minute
D. Stridor noted upon inspiration
Correct Answer: D
Rationale: According to the ABC (Airway, Breathing, Circulation) framework, airway issues
are the highest priority. Stridor indicates a potential upper airway obstruction, which is an
immediate life-threatening emergency. Oxygen saturation and blood pressure are
important, but the airway must be patent before breathing or circulation can be addressed.
3. The nurse is caring for a group of patients. Which patient should the nurse see first based
on Maslow’s Hierarchy of Needs?
A. A patient reporting level 8/10 abdominal pain
B. A patient requesting a chaplain visit
C. A patient who is feeling lonely and wants to talk
D. A patient asking about their discharge medications
Correct Answer: A
Rationale: Maslow’s Hierarchy of Needs identifies physiological needs, such as pain relief
and comfort, as the most basic and urgent level. Severe pain can interfere with physical
stability and must be addressed before higher-level needs like belonging or self-
actualization. Providing timely analgesia is a priority nursing intervention for physiological
stability.
, 4. An LPN is collecting data from a patient who reports feeling ‘dizzy and lightheaded.’ How
should the nurse classify this type of data?
A. Objective data
B. Subjective data
C. Secondary data
D. External data
Correct Answer: B
Rationale: Subjective data consists of information that the patient expresses or feels,
which cannot be directly measured by the nurse. Symptoms like dizziness, pain, or anxiety
are categorized as subjective because they are personal perceptions. Objective data, in
contrast, are measurable signs such as blood pressure or lung sounds.
5. Which action by the nurse demonstrates the ethical principle of autonomy?
A. Keeping a promise to return to the patient’s room in 10 minutes
B. Giving a prescribed pain medication to a patient in distress
C. Ensuring the patient signs the consent form after a full explanation
D. Treating all patients equally regardless of their insurance status
Correct Answer: C
Rationale: Autonomy refers to the right of the patient to make their own decisions
regarding their healthcare. By ensuring the patient is fully informed before signing a
