BSN 465 Exam 2 V1 | BSN 465 Decision-
making in Nursing | Q&A with Rationale
(BSN465 Exam 2) | Nightingale College
1. A nurse is using Tanner’s Model of Clinical Judgment. Which action by the nurse represents
the ‘Noticing’ phase?
A. Analyzing the patient’s lab values to determine the cause of fatigue.
B. Reflecting on how the patient responded to a specific intervention.
C. Administering a PRN dose of albuterol to a patient with wheezing.
D. Observing that a patient is breathing more rapidly than during the previous shift.
Correct Answer: D
Rationale: Noticing involves the nurse’s initial perception of the clinical situation based on
their knowledge and experience. In this scenario, recognizing a change in respiratory rate
is a key observation that triggers further assessment. This phase is critical because it
determines what information the nurse will focus on for subsequent decision-making.
2. Which ethical principle is the nurse primarily advocating for when ensuring a patient has
signed an informed consent form before surgery?
A. Autonomy
B. Justice
C. Beneficence
,D. Non-maleficence
Correct Answer: A
Rationale: Autonomy refers to the patient’s right to make their own decisions regarding
their healthcare without external influence. Informed consent is a legal and ethical
requirement that validates the patient’s self-determination. By verifying consent, the nurse
ensures the patient fully understands the risks and benefits before proceeding.
3. A charge nurse is delegating tasks to a Licensed Practical Nurse (LPN). Which task is within
the LPN’s scope of practice?
A. Developing the initial nursing care plan for a new admission.
B. Performing a comprehensive admission assessment on a complex patient.
C. Administering a routine intramuscular injection of an antibiotic.
D. Providing discharge teaching to a patient after a major surgery.
Correct Answer: C
Rationale: Administering routine medications such as IM injections is a core competency
for LPNs under RN supervision. LPNs generally cannot perform initial assessments,
develop care plans, or handle primary discharge teaching. These complex tasks require the
advanced clinical judgment and synthesis of data reserved for the Registered Nurse.
4. Using Maslow’s Hierarchy of Needs, which patient should the nurse prioritize first?
A. A patient requesting a chaplain for spiritual distress.
, B. A patient who is experiencing difficulty breathing and has low oxygen saturation.
C. A patient reporting a pain level of 6/10 after a knee replacement.
D. A patient who is lonely and wants to talk about their family.
Correct Answer: B
Rationale: Physiological needs, such as airway and breathing, are at the base of Maslow’s
hierarchy and must be addressed first. A patient with respiratory distress is at immediate
risk of physiological collapse, which takes precedence over pain or psychosocial needs.
Prioritizing these basic needs is essential for maintaining life and stabilizing the patient.
5. A nurse reflects on a previous medication error to identify what went wrong and how to
prevent it in the future. This is an example of:
A. Reflection-in-action
B. Diagnostic reasoning
C. Critical thinking disposition
D. Reflection-on-action
Correct Answer: D
Rationale: Reflection-on-action occurs after a clinical event has concluded and involves
evaluating the outcomes and decisions made. This process allows the nurse to integrate
new knowledge and improve future practice. It differs from reflection-in-action, which
happens during the event itself to adjust interventions in real-time.
making in Nursing | Q&A with Rationale
(BSN465 Exam 2) | Nightingale College
1. A nurse is using Tanner’s Model of Clinical Judgment. Which action by the nurse represents
the ‘Noticing’ phase?
A. Analyzing the patient’s lab values to determine the cause of fatigue.
B. Reflecting on how the patient responded to a specific intervention.
C. Administering a PRN dose of albuterol to a patient with wheezing.
D. Observing that a patient is breathing more rapidly than during the previous shift.
Correct Answer: D
Rationale: Noticing involves the nurse’s initial perception of the clinical situation based on
their knowledge and experience. In this scenario, recognizing a change in respiratory rate
is a key observation that triggers further assessment. This phase is critical because it
determines what information the nurse will focus on for subsequent decision-making.
2. Which ethical principle is the nurse primarily advocating for when ensuring a patient has
signed an informed consent form before surgery?
A. Autonomy
B. Justice
C. Beneficence
,D. Non-maleficence
Correct Answer: A
Rationale: Autonomy refers to the patient’s right to make their own decisions regarding
their healthcare without external influence. Informed consent is a legal and ethical
requirement that validates the patient’s self-determination. By verifying consent, the nurse
ensures the patient fully understands the risks and benefits before proceeding.
3. A charge nurse is delegating tasks to a Licensed Practical Nurse (LPN). Which task is within
the LPN’s scope of practice?
A. Developing the initial nursing care plan for a new admission.
B. Performing a comprehensive admission assessment on a complex patient.
C. Administering a routine intramuscular injection of an antibiotic.
D. Providing discharge teaching to a patient after a major surgery.
Correct Answer: C
Rationale: Administering routine medications such as IM injections is a core competency
for LPNs under RN supervision. LPNs generally cannot perform initial assessments,
develop care plans, or handle primary discharge teaching. These complex tasks require the
advanced clinical judgment and synthesis of data reserved for the Registered Nurse.
4. Using Maslow’s Hierarchy of Needs, which patient should the nurse prioritize first?
A. A patient requesting a chaplain for spiritual distress.
, B. A patient who is experiencing difficulty breathing and has low oxygen saturation.
C. A patient reporting a pain level of 6/10 after a knee replacement.
D. A patient who is lonely and wants to talk about their family.
Correct Answer: B
Rationale: Physiological needs, such as airway and breathing, are at the base of Maslow’s
hierarchy and must be addressed first. A patient with respiratory distress is at immediate
risk of physiological collapse, which takes precedence over pain or psychosocial needs.
Prioritizing these basic needs is essential for maintaining life and stabilizing the patient.
5. A nurse reflects on a previous medication error to identify what went wrong and how to
prevent it in the future. This is an example of:
A. Reflection-in-action
B. Diagnostic reasoning
C. Critical thinking disposition
D. Reflection-on-action
Correct Answer: D
Rationale: Reflection-on-action occurs after a clinical event has concluded and involves
evaluating the outcomes and decisions made. This process allows the nurse to integrate
new knowledge and improve future practice. It differs from reflection-in-action, which
happens during the event itself to adjust interventions in real-time.
