NUR155/NUR 155 Exam 2 V1 | Critical
Thinking for the Practical Nurse Q&A with
Rationale | Hondros College of Nursing
1. Which phase of the nursing process involves the nurse determining if the client’s goals and
outcomes have been achieved?
A. Assessment
B. Evaluation
C. Implementation
D. Planning
Correct Answer: B
Rationale: Evaluation is the final step where the nurse compares the client’s current status
with the desired outcomes. This process allows the nurse to determine the effectiveness of
the nursing care plan. If outcomes are not met, the nurse must reassess and modify the plan
accordingly.
2. A nurse is caring for multiple clients. Using Maslow’s Hierarchy of Needs, which client
should the nurse see first?
A. A client experiencing difficulty breathing
B. A client requesting pain medication for a chronic condition
C. A client who is crying because they are lonely
,D. A client who needs assistance with discharge paperwork
Correct Answer: A
Rationale: Physiological needs, such as airway and breathing, are the highest priority
according to Maslow’s Hierarchy of Needs. Survival needs must be addressed before
higher-level needs like belonging or self-esteem can be considered. Ensuring a patent
airway is critical for maintaining life and preventing further complications.
3. When using the SBAR communication tool, which information is included in the ‘B’
(Background) section?
A. The nurse’s recommendation for care
B. The nurse’s name and unit location
C. Current vital signs and assessment findings
D. The client’s admitting diagnosis and relevant history
Correct Answer: D
Rationale: The Background portion of SBAR provides the context for the current situation
by detailing the medical history and reason for admission. This helps the receiver
understand the patient’s baseline and clinical trajectory. Clear background information
prevents medical errors and ensures continuity of care during transitions.
4. An LPN is delegating tasks to a Unlicensed Assistive Personnel (UAP). Which task is
appropriate for the UAP?
A. Feeding a stable client who has no swallowing precautions
, B. Assessing a new admission’s skin integrity
C. Educating a client on how to use an incentive spirometer
D. Adjusting the flow rate of an intravenous infusion
Correct Answer: A
Rationale: Feeding a stable client is a routine task that does not require clinical judgment
or specialized nursing knowledge. According to the five rights of delegation, tasks assigned
to UAPs must be predictable and low-risk. Assessment, education, and medication
management are responsibilities that must remain with the licensed nurse.
5. A nurse documents ‘The client is uncooperative and rude.’ This documentation is an
example of:
A. Judgmental language
B. Subjective data
C. Objective data
D. Evidence-based practice
Correct Answer: A
Rationale: Nursing documentation should be objective, factual, and free from personal bias
or labels. Using words like ‘uncooperative’ or ‘rude’ represents the nurse’s interpretation
rather than observable behaviors. Instead, the nurse should describe the specific actions or
quotes that led to that impression to maintain professional standards.
Thinking for the Practical Nurse Q&A with
Rationale | Hondros College of Nursing
1. Which phase of the nursing process involves the nurse determining if the client’s goals and
outcomes have been achieved?
A. Assessment
B. Evaluation
C. Implementation
D. Planning
Correct Answer: B
Rationale: Evaluation is the final step where the nurse compares the client’s current status
with the desired outcomes. This process allows the nurse to determine the effectiveness of
the nursing care plan. If outcomes are not met, the nurse must reassess and modify the plan
accordingly.
2. A nurse is caring for multiple clients. Using Maslow’s Hierarchy of Needs, which client
should the nurse see first?
A. A client experiencing difficulty breathing
B. A client requesting pain medication for a chronic condition
C. A client who is crying because they are lonely
,D. A client who needs assistance with discharge paperwork
Correct Answer: A
Rationale: Physiological needs, such as airway and breathing, are the highest priority
according to Maslow’s Hierarchy of Needs. Survival needs must be addressed before
higher-level needs like belonging or self-esteem can be considered. Ensuring a patent
airway is critical for maintaining life and preventing further complications.
3. When using the SBAR communication tool, which information is included in the ‘B’
(Background) section?
A. The nurse’s recommendation for care
B. The nurse’s name and unit location
C. Current vital signs and assessment findings
D. The client’s admitting diagnosis and relevant history
Correct Answer: D
Rationale: The Background portion of SBAR provides the context for the current situation
by detailing the medical history and reason for admission. This helps the receiver
understand the patient’s baseline and clinical trajectory. Clear background information
prevents medical errors and ensures continuity of care during transitions.
4. An LPN is delegating tasks to a Unlicensed Assistive Personnel (UAP). Which task is
appropriate for the UAP?
A. Feeding a stable client who has no swallowing precautions
, B. Assessing a new admission’s skin integrity
C. Educating a client on how to use an incentive spirometer
D. Adjusting the flow rate of an intravenous infusion
Correct Answer: A
Rationale: Feeding a stable client is a routine task that does not require clinical judgment
or specialized nursing knowledge. According to the five rights of delegation, tasks assigned
to UAPs must be predictable and low-risk. Assessment, education, and medication
management are responsibilities that must remain with the licensed nurse.
5. A nurse documents ‘The client is uncooperative and rude.’ This documentation is an
example of:
A. Judgmental language
B. Subjective data
C. Objective data
D. Evidence-based practice
Correct Answer: A
Rationale: Nursing documentation should be objective, factual, and free from personal bias
or labels. Using words like ‘uncooperative’ or ‘rude’ represents the nurse’s interpretation
rather than observable behaviors. Instead, the nurse should describe the specific actions or
quotes that led to that impression to maintain professional standards.
