NUR 185 Test 1 (HONDROS) Exam
Questions and answers with
rationales 2026
1. A nurse is assessing a client who has just been admitted to the medical-
surgical unit. Which assessment should the nurse perform first?
A. Review the client's dietary preferences
B. Assess airway, breathing, and circulation
C. Obtain the client's complete social history
D. Determine the client's preferred learning style
Answer: B. Assess airway, breathing, and circulation
Rationale:
The ABCs—airway, breathing, and circulation—are immediate priorities
because impairment in any of these systems can rapidly become life-threatening.
Nursing assessment begins with identifying problems that pose the greatest
immediate threat to life. Social history, dietary preferences, and learning style are
important but are lower priorities.
2. Which statement best describes the purpose of a nursing assessment?
A. To establish the medical diagnosis
B. To determine the client's insurance eligibility
C. To collect information about the client's health status
D. To determine which medications the provider will prescribe
Answer: C. To collect information about the client's health status
Rationale:
Nursing assessment involves systematically collecting subjective and objective
information about the client's physical, psychological, social, and functional
status. Nurses use this information to identify nursing problems and develop an
individualized plan of care. Diagnosing medical conditions and prescribing
medications are not within the general nursing scope of practice.
,3. Which finding is considered subjective data?
A. Blood pressure of 148/92 mmHg
B. Temperature of 38.2°C (100.8°F)
C. Client reports, "My pain is an 8 out of 10."
D. Oxygen saturation of 91%
Answer: C. Client reports, "My pain is an 8 out of 10."
Rationale:
Subjective data are information that the client experiences and reports, such as
pain, nausea, dizziness, or anxiety. Objective data are measurable or observable
findings obtained through assessment, such as vital signs, laboratory values,
physical examination findings, and oxygen saturation.
4. A client states, "I have been feeling dizzy whenever I stand up." How
should the nurse classify this information?
A. Objective data
B. Subjective data
C. Diagnostic data
D. Secondary data
Answer: B. Subjective data
Rationale:
The client's description of dizziness is subjective because it represents the client's
personal experience. Although the nurse may later obtain objective evidence such
as orthostatic blood pressure changes, the initial statement itself is subjective
information.
5. Which action demonstrates appropriate use of therapeutic communication?
A. "You shouldn't worry about that."
B. "Everything will be fine."
,C. "Tell me more about what concerns you."
D. "Why did you wait so long to seek treatment?"
Answer: C. "Tell me more about what concerns you."
Rationale:
Open-ended statements encourage the client to express feelings and provide
additional information. Therapeutic communication should be nonjudgmental,
respectful, and client-centered. False reassurance and judgmental "why"
questions can discourage communication.
6. A nurse is interviewing a client who appears anxious. Which response is
most therapeutic?
A. "There is nothing to be anxious about."
B. "You need to calm down."
C. "I notice that you seem anxious. What is concerning you?"
D. "Other clients have much more serious problems."
Answer: C. "I notice that you seem anxious. What is concerning you?"
Rationale:
This response acknowledges the client's observed emotion and invites discussion.
The nurse should avoid minimizing feelings or comparing the client's concerns
with those of other clients.
7. Which question is an example of an open-ended question?
A. "Do you have pain?"
B. "Is your pain sharp?"
C. "Does your pain occur at night?"
D. "Tell me what your pain feels like."
Answer: D. "Tell me what your pain feels like."
Rationale:
Open-ended questions encourage clients to provide detailed responses. Questions
, that can be answered with "yes" or "no" are closed-ended questions and generally
provide less information.
8. A nurse obtains a client's blood pressure as 86/50 mmHg. What should the
nurse do first?
A. Document the finding and continue the assessment
B. Recheck the blood pressure and assess the client
C. Tell the client to drink a glass of water
D. Notify the family
Answer: B. Recheck the blood pressure and assess the client
Rationale:
The blood pressure is significantly low. The nurse should validate the abnormal
finding and immediately assess the client's condition, including symptoms such as
dizziness, weakness, altered mental status, or signs of poor perfusion. Depending
on the client's condition, additional interventions and provider notification may be
necessary.
9. Which vital sign is considered a measurement of respiratory status?
A. Pulse
B. Blood pressure
C. Respiratory rate
D. Temperature
Answer: C. Respiratory rate
Rationale:
Respiratory rate measures the number of breaths taken per minute and provides
information about ventilation. Respiratory assessment should also include rhythm,
depth, effort, and oxygenation when appropriate.
Questions and answers with
rationales 2026
1. A nurse is assessing a client who has just been admitted to the medical-
surgical unit. Which assessment should the nurse perform first?
A. Review the client's dietary preferences
B. Assess airway, breathing, and circulation
C. Obtain the client's complete social history
D. Determine the client's preferred learning style
Answer: B. Assess airway, breathing, and circulation
Rationale:
The ABCs—airway, breathing, and circulation—are immediate priorities
because impairment in any of these systems can rapidly become life-threatening.
Nursing assessment begins with identifying problems that pose the greatest
immediate threat to life. Social history, dietary preferences, and learning style are
important but are lower priorities.
2. Which statement best describes the purpose of a nursing assessment?
A. To establish the medical diagnosis
B. To determine the client's insurance eligibility
C. To collect information about the client's health status
D. To determine which medications the provider will prescribe
Answer: C. To collect information about the client's health status
Rationale:
Nursing assessment involves systematically collecting subjective and objective
information about the client's physical, psychological, social, and functional
status. Nurses use this information to identify nursing problems and develop an
individualized plan of care. Diagnosing medical conditions and prescribing
medications are not within the general nursing scope of practice.
,3. Which finding is considered subjective data?
A. Blood pressure of 148/92 mmHg
B. Temperature of 38.2°C (100.8°F)
C. Client reports, "My pain is an 8 out of 10."
D. Oxygen saturation of 91%
Answer: C. Client reports, "My pain is an 8 out of 10."
Rationale:
Subjective data are information that the client experiences and reports, such as
pain, nausea, dizziness, or anxiety. Objective data are measurable or observable
findings obtained through assessment, such as vital signs, laboratory values,
physical examination findings, and oxygen saturation.
4. A client states, "I have been feeling dizzy whenever I stand up." How
should the nurse classify this information?
A. Objective data
B. Subjective data
C. Diagnostic data
D. Secondary data
Answer: B. Subjective data
Rationale:
The client's description of dizziness is subjective because it represents the client's
personal experience. Although the nurse may later obtain objective evidence such
as orthostatic blood pressure changes, the initial statement itself is subjective
information.
5. Which action demonstrates appropriate use of therapeutic communication?
A. "You shouldn't worry about that."
B. "Everything will be fine."
,C. "Tell me more about what concerns you."
D. "Why did you wait so long to seek treatment?"
Answer: C. "Tell me more about what concerns you."
Rationale:
Open-ended statements encourage the client to express feelings and provide
additional information. Therapeutic communication should be nonjudgmental,
respectful, and client-centered. False reassurance and judgmental "why"
questions can discourage communication.
6. A nurse is interviewing a client who appears anxious. Which response is
most therapeutic?
A. "There is nothing to be anxious about."
B. "You need to calm down."
C. "I notice that you seem anxious. What is concerning you?"
D. "Other clients have much more serious problems."
Answer: C. "I notice that you seem anxious. What is concerning you?"
Rationale:
This response acknowledges the client's observed emotion and invites discussion.
The nurse should avoid minimizing feelings or comparing the client's concerns
with those of other clients.
7. Which question is an example of an open-ended question?
A. "Do you have pain?"
B. "Is your pain sharp?"
C. "Does your pain occur at night?"
D. "Tell me what your pain feels like."
Answer: D. "Tell me what your pain feels like."
Rationale:
Open-ended questions encourage clients to provide detailed responses. Questions
, that can be answered with "yes" or "no" are closed-ended questions and generally
provide less information.
8. A nurse obtains a client's blood pressure as 86/50 mmHg. What should the
nurse do first?
A. Document the finding and continue the assessment
B. Recheck the blood pressure and assess the client
C. Tell the client to drink a glass of water
D. Notify the family
Answer: B. Recheck the blood pressure and assess the client
Rationale:
The blood pressure is significantly low. The nurse should validate the abnormal
finding and immediately assess the client's condition, including symptoms such as
dizziness, weakness, altered mental status, or signs of poor perfusion. Depending
on the client's condition, additional interventions and provider notification may be
necessary.
9. Which vital sign is considered a measurement of respiratory status?
A. Pulse
B. Blood pressure
C. Respiratory rate
D. Temperature
Answer: C. Respiratory rate
Rationale:
Respiratory rate measures the number of breaths taken per minute and provides
information about ventilation. Respiratory assessment should also include rhythm,
depth, effort, and oxygenation when appropriate.
