NUR155/NUR 155 Exam 2 V2 | Critical
Thinking for the Practical Nurse Q&A with
Rationale | Hondros College of Nursing
1. A nurse is collecting data from a client who reports feeling short of breath. Which of the
following is an example of objective data?
A. The client’s statement that they feel ‘anxious’.
B. The client’s report of a history of asthma.
C. The client’s description of chest tightness.
D. A respiratory rate of 28 breaths per minute.
Correct Answer: D
Rationale: Objective data are observable and measurable signs that can be verified by the
nurse. A respiratory rate is a specific measurement that can be seen and counted.
Subjective data, such as feelings of anxiety or chest tightness, are what the patient tells the
nurse.
2. A practical nurse is prioritizing care for four clients. Which client should the nurse see first?
A. A client reporting new onset of substernal chest pain.
B. A client who needs a scheduled dressing change.
C. A client requesting a PRN medication for mild back pain.
D. A client with a blood glucose of 110 mg/dL.
,Correct Answer: A
Rationale: According to the ABC (Airway, Breathing, Circulation) framework, chest pain is
a priority because it may indicate a circulatory emergency. Substernal pain requires
immediate assessment to rule out myocardial infarction. The other tasks are either routine
or involve non-urgent physical needs.
3. Which phase of the nursing process involves the nurse determining if the client’s goals
have been met?
A. Assessment
B. Planning
C. Evaluation
D. Implementation
Correct Answer: C
Rationale: Evaluation is the final step where the nurse compares the client’s current status
with the desired outcomes. This step determines if the plan of care was effective or needs
revision. Without evaluation, the nurse cannot know if the interventions improved the
client’s condition.
4. The nurse is practicing within the scope of the Nurse Practice Act. Which ethical principle is
demonstrated when the nurse keeps a promise to return to a client’s room in 10 minutes?
A. Beneficence
B. Autonomy
, C. Justice
D. Fidelity
Correct Answer: D
Rationale: Fidelity refers to the obligation to be faithful to commitments and promises. By
returning as promised, the nurse builds trust and maintains the professional relationship.
This is a core component of ethical nursing practice and critical thinking.
5. A nurse is caring for an older adult client who is at risk for falls. Which of the following is
the priority nursing action?
A. Teaching the client how to use the call light.
B. Identifying the client’s fall risk using a standardized scale.
C. Placing the bed in the lowest position.
D. Applying a bed alarm as per facility protocol.
Correct Answer: B
Rationale: The first step in any nursing action is assessment or data collection. Identifying
the specific level of risk allows the nurse to tailor interventions appropriately. Once the risk
is identified, secondary safety measures like call light teaching or low beds can be
implemented.
Thinking for the Practical Nurse Q&A with
Rationale | Hondros College of Nursing
1. A nurse is collecting data from a client who reports feeling short of breath. Which of the
following is an example of objective data?
A. The client’s statement that they feel ‘anxious’.
B. The client’s report of a history of asthma.
C. The client’s description of chest tightness.
D. A respiratory rate of 28 breaths per minute.
Correct Answer: D
Rationale: Objective data are observable and measurable signs that can be verified by the
nurse. A respiratory rate is a specific measurement that can be seen and counted.
Subjective data, such as feelings of anxiety or chest tightness, are what the patient tells the
nurse.
2. A practical nurse is prioritizing care for four clients. Which client should the nurse see first?
A. A client reporting new onset of substernal chest pain.
B. A client who needs a scheduled dressing change.
C. A client requesting a PRN medication for mild back pain.
D. A client with a blood glucose of 110 mg/dL.
,Correct Answer: A
Rationale: According to the ABC (Airway, Breathing, Circulation) framework, chest pain is
a priority because it may indicate a circulatory emergency. Substernal pain requires
immediate assessment to rule out myocardial infarction. The other tasks are either routine
or involve non-urgent physical needs.
3. Which phase of the nursing process involves the nurse determining if the client’s goals
have been met?
A. Assessment
B. Planning
C. Evaluation
D. Implementation
Correct Answer: C
Rationale: Evaluation is the final step where the nurse compares the client’s current status
with the desired outcomes. This step determines if the plan of care was effective or needs
revision. Without evaluation, the nurse cannot know if the interventions improved the
client’s condition.
4. The nurse is practicing within the scope of the Nurse Practice Act. Which ethical principle is
demonstrated when the nurse keeps a promise to return to a client’s room in 10 minutes?
A. Beneficence
B. Autonomy
, C. Justice
D. Fidelity
Correct Answer: D
Rationale: Fidelity refers to the obligation to be faithful to commitments and promises. By
returning as promised, the nurse builds trust and maintains the professional relationship.
This is a core component of ethical nursing practice and critical thinking.
5. A nurse is caring for an older adult client who is at risk for falls. Which of the following is
the priority nursing action?
A. Teaching the client how to use the call light.
B. Identifying the client’s fall risk using a standardized scale.
C. Placing the bed in the lowest position.
D. Applying a bed alarm as per facility protocol.
Correct Answer: B
Rationale: The first step in any nursing action is assessment or data collection. Identifying
the specific level of risk allows the nurse to tailor interventions appropriately. Once the risk
is identified, secondary safety measures like call light teaching or low beds can be
implemented.
