BSN465: DECISION MAKING IN NURSING
Final Exam Real Questions, Verified Answers &
Rationale 2026/2027 Updated | Already Graded
A+ | Brand New Alert!!
Question 1:
A nurse notices that a patient has a respiratory rate of 28, SpO2 89% on
room air, and is using accessory muscles. According to Tanner's Clinical
Judgment Model, which phase is the nurse in?
A. Noticing (recognizing cues)
B. Interpreting (making sense of data)
C. Responding (taking action)
D. Reflecting (evaluating outcome)
Rationale: Correct answer: A. Noticing is the phase where the nurse
recognizes cues (tachypnea, hypoxia, accessory muscle use). Interpreting
(B) would be analyzing that these cues indicate respiratory distress.
Responding (C) would be giving oxygen.
Question 2:
A nurse is caring for a patient with chest pain. The EKG shows ST
elevation. The nurse activates the catheterization lab. Which phase of the
NCSBN Clinical Judgment Measurement Model (CJMM) is the nurse
in?
A. Recognize Cues
,
B. Analyze Cues
C. Prioritize Hypotheses
D. Take Actions
Rationale: Correct answer: D. Take Actions is the phase where the nurse
implements interventions (activating the cath lab). Recognize Cues (A)
would be noticing ST elevation. Analyze Cues (B) would be linking ST
elevation to MI. Prioritize Hypotheses (C) would be ranking MI as the
top priority.
Question 3:
A nurse is assigned to care for four patients. Which patient should the
nurse assess first?
A. Patient with COPD who has SpO2 89% on 2L oxygen (stable on
oxygen)
B. Patient with new-onset chest pain and diaphoresis (possible MI)
C. Patient with diabetes requesting a glass of orange juice
(hypoglycemia? stable)
D. Patient with a urinary catheter asking to ambulate (stable)
Rationale: Correct answer: B. Chest pain with diaphoresis could indicate
MI (life-threatening). ABCs: Chest pain (Circulation concern). The
patient with hypoxia on oxygen (A) is stable on supplemental oxygen.
Requests (C, D) are lower priority.
Question 4:
,
A nurse is delegating tasks to a UAP. Which of the following instructions
demonstrates the Right Communication?
A. "Take vital signs and tell me if anything is abnormal."
B. "Take Mrs. Smith's vital signs and report a heart rate above 100, blood
pressure below 90, or respiratory rate above 24."
C. "Take vital signs on all patients."
D. "Take vital signs whenever you have time."
Rationale: Correct answer: B. Right Communication includes clear,
specific instructions with parameters for reporting (HR >100, SBP <90,
RR >24). Vague instructions (A, C, D) are not effective.
Question 5:
A patient with a history of drug-seeking behavior reports severe pain
(10/10) after abdominal surgery. The nurse notices that the patient is
watching TV calmly and laughing. The nurse suspects drug-seeking
behavior. What cognitive bias is most likely affecting the nurse's
decision?
A. Confirmation bias (seeking evidence that confirms suspicion,
ignoring contradictory cues)
B. Anchoring
C. Availability heuristic
D. Overconfidence
Rationale: Correct answer: A. Confirmation bias: the nurse focuses on
evidence that supports suspicion of drug-seeking (patient is laughing)
and ignores evidence that the patient just had surgery (expected pain).
,
Attending to contradictory cues (vital signs, surgical site, objective
findings) is important.
Question 6:
A nurse is using the Levett-Jones Clinical Reasoning Cycle. After
collecting cues (vital signs, labs, history) and processing information,
what is the next step?
A. Take action
B. Identify problems/issues
C. Establish goals
D. Evaluate outcomes
Rationale: Correct answer: B. Clinical Reasoning Cycle steps: 1)
Consider patient situation, 2) Collect cues, 3) Process information, 4)
Identify problems/issues, 5) Establish goals, 6) Take action, 7) Evaluate
outcomes, 8) Reflect. After processing (step 3), identify problems (step
4).
Question 7:
A nurse receives a telephone order from a provider for "Lasix 40mg IV
push now." What is the nurse's priority action?
A. Administer the medication immediately
B. Read back the order to the provider (read-back) to confirm accuracy
C. Document the order in the MAR
D. Ask the provider to come to the unit
Final Exam Real Questions, Verified Answers &
Rationale 2026/2027 Updated | Already Graded
A+ | Brand New Alert!!
Question 1:
A nurse notices that a patient has a respiratory rate of 28, SpO2 89% on
room air, and is using accessory muscles. According to Tanner's Clinical
Judgment Model, which phase is the nurse in?
A. Noticing (recognizing cues)
B. Interpreting (making sense of data)
C. Responding (taking action)
D. Reflecting (evaluating outcome)
Rationale: Correct answer: A. Noticing is the phase where the nurse
recognizes cues (tachypnea, hypoxia, accessory muscle use). Interpreting
(B) would be analyzing that these cues indicate respiratory distress.
Responding (C) would be giving oxygen.
Question 2:
A nurse is caring for a patient with chest pain. The EKG shows ST
elevation. The nurse activates the catheterization lab. Which phase of the
NCSBN Clinical Judgment Measurement Model (CJMM) is the nurse
in?
A. Recognize Cues
,
B. Analyze Cues
C. Prioritize Hypotheses
D. Take Actions
Rationale: Correct answer: D. Take Actions is the phase where the nurse
implements interventions (activating the cath lab). Recognize Cues (A)
would be noticing ST elevation. Analyze Cues (B) would be linking ST
elevation to MI. Prioritize Hypotheses (C) would be ranking MI as the
top priority.
Question 3:
A nurse is assigned to care for four patients. Which patient should the
nurse assess first?
A. Patient with COPD who has SpO2 89% on 2L oxygen (stable on
oxygen)
B. Patient with new-onset chest pain and diaphoresis (possible MI)
C. Patient with diabetes requesting a glass of orange juice
(hypoglycemia? stable)
D. Patient with a urinary catheter asking to ambulate (stable)
Rationale: Correct answer: B. Chest pain with diaphoresis could indicate
MI (life-threatening). ABCs: Chest pain (Circulation concern). The
patient with hypoxia on oxygen (A) is stable on supplemental oxygen.
Requests (C, D) are lower priority.
Question 4:
,
A nurse is delegating tasks to a UAP. Which of the following instructions
demonstrates the Right Communication?
A. "Take vital signs and tell me if anything is abnormal."
B. "Take Mrs. Smith's vital signs and report a heart rate above 100, blood
pressure below 90, or respiratory rate above 24."
C. "Take vital signs on all patients."
D. "Take vital signs whenever you have time."
Rationale: Correct answer: B. Right Communication includes clear,
specific instructions with parameters for reporting (HR >100, SBP <90,
RR >24). Vague instructions (A, C, D) are not effective.
Question 5:
A patient with a history of drug-seeking behavior reports severe pain
(10/10) after abdominal surgery. The nurse notices that the patient is
watching TV calmly and laughing. The nurse suspects drug-seeking
behavior. What cognitive bias is most likely affecting the nurse's
decision?
A. Confirmation bias (seeking evidence that confirms suspicion,
ignoring contradictory cues)
B. Anchoring
C. Availability heuristic
D. Overconfidence
Rationale: Correct answer: A. Confirmation bias: the nurse focuses on
evidence that supports suspicion of drug-seeking (patient is laughing)
and ignores evidence that the patient just had surgery (expected pain).
,
Attending to contradictory cues (vital signs, surgical site, objective
findings) is important.
Question 6:
A nurse is using the Levett-Jones Clinical Reasoning Cycle. After
collecting cues (vital signs, labs, history) and processing information,
what is the next step?
A. Take action
B. Identify problems/issues
C. Establish goals
D. Evaluate outcomes
Rationale: Correct answer: B. Clinical Reasoning Cycle steps: 1)
Consider patient situation, 2) Collect cues, 3) Process information, 4)
Identify problems/issues, 5) Establish goals, 6) Take action, 7) Evaluate
outcomes, 8) Reflect. After processing (step 3), identify problems (step
4).
Question 7:
A nurse receives a telephone order from a provider for "Lasix 40mg IV
push now." What is the nurse's priority action?
A. Administer the medication immediately
B. Read back the order to the provider (read-back) to confirm accuracy
C. Document the order in the MAR
D. Ask the provider to come to the unit
