NURS 330CAPSTONE EXAM 2CLINICAL JUDGMENT] QUESTIONS AND CORRECT ANSWERS
(VERIFIED ANSWERS) PLUS RATIONALES 2026 Q&A |LATEST EXAM UPDATE 2026/2027.
SECTION ONE: QUESTIONS 1–100
A nurse is caring for a patient who develops sudden dyspnea and tachycardia. Which action
demonstrates the highest level of clinical judgment?
A. Document the assessment findings in the EHR.
B. Initiate oxygen therapy and notify the rapid response team.
C. Ask the patient if they are feeling anxious.
D. Wait 15 minutes to see if the symptoms subside.
🟢B
🔴 RATIONALE: Clinical judgment requires prioritizing patient safety through immediate
intervention for signs of physiological instability, such as sudden dyspnea.
A nurse observes a colleague failing to perform hand hygiene before entering a patient's room.
What is the most professional initial action?
A. Report the colleague to the state board.
B. Ignore the incident to maintain unit harmony.
C. Remind the colleague privately about unit infection control policies.
D. Document the incident in the patient's chart.
🟢C
🔴 RATIONALE: Professional standards dictate addressing safety concerns directly and
professionally, prioritizing the patient's health while maintaining collegial respect.
Which ethical principle is upheld when a nurse refuses to administer a medication that the patient
states they are allergic to, despite a provider's order?
A. Autonomy
B. Justice
,C. Nonmaleficence
D. Fidelity
🟢C
🔴 RATIONALE: Nonmaleficence is the obligation to do no harm, which is fulfilled by preventing a
known allergic reaction.
A patient with dementia experiences sundowning. Which intervention is most appropriate?
A. Increase lighting in the evening.
B. Administer PRN restraints.
C. Keep the room dark and quiet.
D. Limit daytime activity.
🟢A
🔴 RATIONALE: Increasing lighting and maintaining a consistent routine are evidence-based
practices to manage symptoms of sundowning.
When prioritizing care for four patients, which patient should the nurse see first?
A. A patient requesting discharge paperwork.
B. A patient reporting 3/10 incisional pain.
C. A patient with a blood pressure of 180/110 mm Hg complaining of a headache.
D. A patient scheduled for an afternoon dressing change.
🟢C
🔴 RATIONALE: A high blood pressure reading accompanied by a headache indicates a potential
hypertensive emergency, requiring immediate assessment.
A nurse is teaching a patient about informed consent. Which statement indicates the patient
understands?
A. The nurse is responsible for explaining the procedure details.
,B. Consent can be withdrawn by the patient at any time.
C. Signing the form means the patient must proceed.
D. The provider is only responsible for the surgical site.
🟢B
🔴 RATIONALE: Informed consent is an ongoing process, and the patient retains the right to
revoke consent at any stage.
Which documentation style is most appropriate for legal compliance and clinical accuracy?
A. Concise, objective, and timely.
B. Detailed with subjective feelings.
C. General summaries of the shift.
D. Omission of unexpected events.
🟢A
🔴 RATIONALE: Medical documentation must be objective, factual, and recorded in real-time to
ensure legal defensibility and continuity of care.
A patient is non-adherent with insulin therapy. What is the nurse's priority?
A. Tell the patient they will lose their sight.
B. Assess the patient's understanding and barriers to adherence.
C. Contact the provider to discontinue the insulin.
D. Have the family manage the injections.
🟢B
🔴 RATIONALE: Effective clinical judgment involves assessing the root cause of non-adherence
before intervening to improve patient outcomes.
Which action demonstrates the nurse's role in patient advocacy?
A. Discussing the patient’s diagnosis with their neighbor.
, B. Ensuring the patient’s preferences are communicated to the healthcare team.
C. Performing only the tasks ordered by the physician.
D. Avoiding controversial discussions with the patient.
🟢B
🔴 RATIONALE: Advocacy involves ensuring the patient's voice and choices are represented in
the care planning process.
A patient becomes aggressive during care. What is the nurse's primary goal?
A. Maintain safety for the patient and staff.
B. Physically restrain the patient.
C. Call security immediately.
D. Discontinue all nursing care.
🟢A
🔴 RATIONALE: Safety is the priority; de-escalation techniques are the first line of defense in
managing aggressive behavior.
What is the primary purpose of the Nursing Process?
A. To provide a framework for systematic, individualized care.
B. To reduce the time spent in documentation.
C. To limit the scope of nursing practice.
D. To replace the need for critical thinking.
🟢A
🔴 RATIONALE: The nursing process (ADPIE) serves as a structured approach to clinical
decision-making.
A nurse is delegating tasks to a UAP. Which task is appropriate to delegate?
A. Assessing vital signs on a stable patient.
(VERIFIED ANSWERS) PLUS RATIONALES 2026 Q&A |LATEST EXAM UPDATE 2026/2027.
SECTION ONE: QUESTIONS 1–100
A nurse is caring for a patient who develops sudden dyspnea and tachycardia. Which action
demonstrates the highest level of clinical judgment?
A. Document the assessment findings in the EHR.
B. Initiate oxygen therapy and notify the rapid response team.
C. Ask the patient if they are feeling anxious.
D. Wait 15 minutes to see if the symptoms subside.
🟢B
🔴 RATIONALE: Clinical judgment requires prioritizing patient safety through immediate
intervention for signs of physiological instability, such as sudden dyspnea.
A nurse observes a colleague failing to perform hand hygiene before entering a patient's room.
What is the most professional initial action?
A. Report the colleague to the state board.
B. Ignore the incident to maintain unit harmony.
C. Remind the colleague privately about unit infection control policies.
D. Document the incident in the patient's chart.
🟢C
🔴 RATIONALE: Professional standards dictate addressing safety concerns directly and
professionally, prioritizing the patient's health while maintaining collegial respect.
Which ethical principle is upheld when a nurse refuses to administer a medication that the patient
states they are allergic to, despite a provider's order?
A. Autonomy
B. Justice
,C. Nonmaleficence
D. Fidelity
🟢C
🔴 RATIONALE: Nonmaleficence is the obligation to do no harm, which is fulfilled by preventing a
known allergic reaction.
A patient with dementia experiences sundowning. Which intervention is most appropriate?
A. Increase lighting in the evening.
B. Administer PRN restraints.
C. Keep the room dark and quiet.
D. Limit daytime activity.
🟢A
🔴 RATIONALE: Increasing lighting and maintaining a consistent routine are evidence-based
practices to manage symptoms of sundowning.
When prioritizing care for four patients, which patient should the nurse see first?
A. A patient requesting discharge paperwork.
B. A patient reporting 3/10 incisional pain.
C. A patient with a blood pressure of 180/110 mm Hg complaining of a headache.
D. A patient scheduled for an afternoon dressing change.
🟢C
🔴 RATIONALE: A high blood pressure reading accompanied by a headache indicates a potential
hypertensive emergency, requiring immediate assessment.
A nurse is teaching a patient about informed consent. Which statement indicates the patient
understands?
A. The nurse is responsible for explaining the procedure details.
,B. Consent can be withdrawn by the patient at any time.
C. Signing the form means the patient must proceed.
D. The provider is only responsible for the surgical site.
🟢B
🔴 RATIONALE: Informed consent is an ongoing process, and the patient retains the right to
revoke consent at any stage.
Which documentation style is most appropriate for legal compliance and clinical accuracy?
A. Concise, objective, and timely.
B. Detailed with subjective feelings.
C. General summaries of the shift.
D. Omission of unexpected events.
🟢A
🔴 RATIONALE: Medical documentation must be objective, factual, and recorded in real-time to
ensure legal defensibility and continuity of care.
A patient is non-adherent with insulin therapy. What is the nurse's priority?
A. Tell the patient they will lose their sight.
B. Assess the patient's understanding and barriers to adherence.
C. Contact the provider to discontinue the insulin.
D. Have the family manage the injections.
🟢B
🔴 RATIONALE: Effective clinical judgment involves assessing the root cause of non-adherence
before intervening to improve patient outcomes.
Which action demonstrates the nurse's role in patient advocacy?
A. Discussing the patient’s diagnosis with their neighbor.
, B. Ensuring the patient’s preferences are communicated to the healthcare team.
C. Performing only the tasks ordered by the physician.
D. Avoiding controversial discussions with the patient.
🟢B
🔴 RATIONALE: Advocacy involves ensuring the patient's voice and choices are represented in
the care planning process.
A patient becomes aggressive during care. What is the nurse's primary goal?
A. Maintain safety for the patient and staff.
B. Physically restrain the patient.
C. Call security immediately.
D. Discontinue all nursing care.
🟢A
🔴 RATIONALE: Safety is the priority; de-escalation techniques are the first line of defense in
managing aggressive behavior.
What is the primary purpose of the Nursing Process?
A. To provide a framework for systematic, individualized care.
B. To reduce the time spent in documentation.
C. To limit the scope of nursing practice.
D. To replace the need for critical thinking.
🟢A
🔴 RATIONALE: The nursing process (ADPIE) serves as a structured approach to clinical
decision-making.
A nurse is delegating tasks to a UAP. Which task is appropriate to delegate?
A. Assessing vital signs on a stable patient.
