BSN 465 Exam 1 V1 | BSN 465 Decision-
making in Nursing | Q&A with Rationale
(BSN465 Exam 1) | Nightingale College
1. A nurse is caring for a group of clients on a medical-surgical unit. Which client should the
nurse prioritize for assessment first?
A. A client with a history of COPD who has an oxygen saturation of 91% on room air.
B. A client who is 2 hours post-operative following a cholecystectomy and reporting
nausea.
C. A client receiving a blood transfusion who has a temperature increase of 0.5 degrees
Fahrenheit.
D. A client with a deep vein thrombosis who is reporting sudden shortness of breath and
chest pain.
Correct Answer: D
Rationale: The client reporting sudden shortness of breath and chest pain may be
experiencing a pulmonary embolism, which is a life-threatening complication of deep vein
thrombosis. This situation requires immediate assessment and intervention according to
the ABC (Airway, Breathing, Circulation) priority framework. The other clients are stable or
experiencing expected post-operative symptoms that do not take precedence over an acute
respiratory emergency.
,2. A charge nurse is delegating tasks to an unlicensed assistive personnel (UAP). Which task is
appropriate for the nurse to delegate?
A. Evaluating a client’s response to pain medication.
B. Assisting a stable client with ambulation to the bathroom.
C. Performing an initial skin assessment on a newly admitted client.
D. Providing discharge instructions to a client following a minor procedure.
Correct Answer: B
Rationale: Assisting a stable client with activities of daily living, such as ambulation, falls
within the scope of practice for a UAP. Evaluation, assessment, and teaching are tasks that
require clinical judgment and must be performed by a licensed nurse. The nurse remains
accountable for the task and must ensure the UAP is competent to perform it.
3. Which component of the clinical judgment model involves the nurse collecting data and
identifying initial cues about a client’s condition?
A. Interpreting
B. Reflecting
C. Responding
D. Noticing
Correct Answer: D
,Rationale: Noticing is the first phase of Tanner’s Clinical Judgment Model where the nurse
gathers data from various sources to form a grasp of the situation. This involves
recognizing patterns and identifying deviations from the expected baseline for a specific
patient. Without accurate noticing, the subsequent steps of interpreting and responding
would be based on flawed information.
4. A nurse is faced with an ethical dilemma regarding a client’s refusal of life-saving
treatment. Which ethical principle supports the client’s right to make this decision?
A. Beneficence
B. Justice
C. Nonmaleficence
D. Autonomy
Correct Answer: D
Rationale: Autonomy refers to the right of the individual to make their own choices
regarding their healthcare, even if the nurse or physician disagrees. The nurse’s role is to
ensure the client is fully informed of the consequences of their decision before it is
finalized. This principle is foundational to patient-centered care and legal requirements for
informed consent.
5. A nurse manager is implementing a new EHR system and expects resistance from staff.
Which leadership style is most effective for encouraging collaboration during this change?
A. Autocratic
, B. Laissez-faire
C. Democratic
D. Transactional
Correct Answer: C
Rationale: The democratic leadership style encourages group discussion and decision-
making, which helps build consensus and reduces resistance to change. By involving staff in
the transition to a new EHR system, the manager fosters a sense of ownership and
accountability. This approach is highly effective for long-term organizational changes
compared to top-down autocratic methods.
6. During a multidisciplinary team meeting, the nurse uses SBAR to communicate a client’s
declining status. What does the ‘R’ in SBAR stand for?
A. Recommendation
B. Response
C. Rationale
D. Review
Correct Answer: A
Rationale: The ‘R’ in SBAR stands for Recommendation, where the nurse suggests a
specific action or intervention to address the client’s current situation. This tool provides a
structured communication framework to ensure all critical information is transferred
making in Nursing | Q&A with Rationale
(BSN465 Exam 1) | Nightingale College
1. A nurse is caring for a group of clients on a medical-surgical unit. Which client should the
nurse prioritize for assessment first?
A. A client with a history of COPD who has an oxygen saturation of 91% on room air.
B. A client who is 2 hours post-operative following a cholecystectomy and reporting
nausea.
C. A client receiving a blood transfusion who has a temperature increase of 0.5 degrees
Fahrenheit.
D. A client with a deep vein thrombosis who is reporting sudden shortness of breath and
chest pain.
Correct Answer: D
Rationale: The client reporting sudden shortness of breath and chest pain may be
experiencing a pulmonary embolism, which is a life-threatening complication of deep vein
thrombosis. This situation requires immediate assessment and intervention according to
the ABC (Airway, Breathing, Circulation) priority framework. The other clients are stable or
experiencing expected post-operative symptoms that do not take precedence over an acute
respiratory emergency.
,2. A charge nurse is delegating tasks to an unlicensed assistive personnel (UAP). Which task is
appropriate for the nurse to delegate?
A. Evaluating a client’s response to pain medication.
B. Assisting a stable client with ambulation to the bathroom.
C. Performing an initial skin assessment on a newly admitted client.
D. Providing discharge instructions to a client following a minor procedure.
Correct Answer: B
Rationale: Assisting a stable client with activities of daily living, such as ambulation, falls
within the scope of practice for a UAP. Evaluation, assessment, and teaching are tasks that
require clinical judgment and must be performed by a licensed nurse. The nurse remains
accountable for the task and must ensure the UAP is competent to perform it.
3. Which component of the clinical judgment model involves the nurse collecting data and
identifying initial cues about a client’s condition?
A. Interpreting
B. Reflecting
C. Responding
D. Noticing
Correct Answer: D
,Rationale: Noticing is the first phase of Tanner’s Clinical Judgment Model where the nurse
gathers data from various sources to form a grasp of the situation. This involves
recognizing patterns and identifying deviations from the expected baseline for a specific
patient. Without accurate noticing, the subsequent steps of interpreting and responding
would be based on flawed information.
4. A nurse is faced with an ethical dilemma regarding a client’s refusal of life-saving
treatment. Which ethical principle supports the client’s right to make this decision?
A. Beneficence
B. Justice
C. Nonmaleficence
D. Autonomy
Correct Answer: D
Rationale: Autonomy refers to the right of the individual to make their own choices
regarding their healthcare, even if the nurse or physician disagrees. The nurse’s role is to
ensure the client is fully informed of the consequences of their decision before it is
finalized. This principle is foundational to patient-centered care and legal requirements for
informed consent.
5. A nurse manager is implementing a new EHR system and expects resistance from staff.
Which leadership style is most effective for encouraging collaboration during this change?
A. Autocratic
, B. Laissez-faire
C. Democratic
D. Transactional
Correct Answer: C
Rationale: The democratic leadership style encourages group discussion and decision-
making, which helps build consensus and reduces resistance to change. By involving staff in
the transition to a new EHR system, the manager fosters a sense of ownership and
accountability. This approach is highly effective for long-term organizational changes
compared to top-down autocratic methods.
6. During a multidisciplinary team meeting, the nurse uses SBAR to communicate a client’s
declining status. What does the ‘R’ in SBAR stand for?
A. Recommendation
B. Response
C. Rationale
D. Review
Correct Answer: A
Rationale: The ‘R’ in SBAR stands for Recommendation, where the nurse suggests a
specific action or intervention to address the client’s current situation. This tool provides a
structured communication framework to ensure all critical information is transferred
