BSN 465 Exam 2 V2 | BSN 465 Decision-
making in Nursing | Q&A with Rationale
(BSN465 Exam 2) | Nightingale College
1. A nurse is using Tanner’s Clinical Judgment Model to evaluate a patient with new-onset
chest pain. Which action represents the ‘Noticing’ phase?
A. Assessing the patient’s vital signs and pain level.
B. Administering sublingual nitroglycerin as ordered.
C. Determining that the patient is experiencing a myocardial infarction.
D. Evaluating the effectiveness of the pain medication after 15 minutes.
Correct Answer: A
Rationale: Noticing involves the initial collection of data and recognizing deviations from
the norm. This stage is influenced by the nurse’s expectations and background knowledge.
Without accurate noticing, the nurse cannot proceed to interpret the data correctly.
2. Which ethical principle is a nurse applying when they support a patient’s decision to refuse
a life-saving blood transfusion due to religious beliefs?
A. Autonomy
B. Beneficence
C. Justice
,D. Veracity
Correct Answer: A
Rationale: Autonomy refers to the patient’s right to make their own healthcare decisions.
The nurse’s role is to respect and advocate for the patient’s self-determination even if it
conflicts with clinical advice. This principle is a cornerstone of ethical nursing practice and
patient-centered care.
3. A nurse manager is implementing a new EHR system and identifies staff members who are
resistant to the change. According to Lewin’s Change Theory, which stage is the manager
currently in?
A. Moving
B. Unfreezing
C. Refreezing
D. Transitioning
Correct Answer: B
Rationale: Unfreezing is the stage where the need for change is recognized and old
patterns are challenged. During this phase, the manager must create readiness for change
and address resistance. Successful unfreezing is necessary before new behaviors can be
implemented in the moving stage.
, 4. Which task is most appropriate for a Registered Nurse (RN) to delegate to an Unlicensed
Assistive Personnel (UAP)?
A. Evaluating a patient’s response to an antihypertensive medication.
B. Assisting a stable patient with ambulation in the hallway.
C. Teaching a patient how to perform self-catheterization at home.
D. Completing an admission assessment on a new patient.
Correct Answer: B
Rationale: Assisting with ambulation is a standard, non-invasive task that does not require
clinical judgment. The RN remains responsible for the initial assessment and any complex
teaching or evaluation. Delegation to UAPs should focus on routine tasks that are within
their scope of training.
5. A nurse is caring for four patients. Which patient should the nurse assess first using the
principles of prioritization?
A. A patient with a respiratory rate of 28 and oxygen saturation of 88%.
B. A patient reporting a pain level of 6 out of 10 on a surgical site.
C. A patient with a scheduled dose of IV antibiotics due in 10 minutes.
D. A patient who needs a discharge summary completed for a 2 PM departure.
Correct Answer: A
making in Nursing | Q&A with Rationale
(BSN465 Exam 2) | Nightingale College
1. A nurse is using Tanner’s Clinical Judgment Model to evaluate a patient with new-onset
chest pain. Which action represents the ‘Noticing’ phase?
A. Assessing the patient’s vital signs and pain level.
B. Administering sublingual nitroglycerin as ordered.
C. Determining that the patient is experiencing a myocardial infarction.
D. Evaluating the effectiveness of the pain medication after 15 minutes.
Correct Answer: A
Rationale: Noticing involves the initial collection of data and recognizing deviations from
the norm. This stage is influenced by the nurse’s expectations and background knowledge.
Without accurate noticing, the nurse cannot proceed to interpret the data correctly.
2. Which ethical principle is a nurse applying when they support a patient’s decision to refuse
a life-saving blood transfusion due to religious beliefs?
A. Autonomy
B. Beneficence
C. Justice
,D. Veracity
Correct Answer: A
Rationale: Autonomy refers to the patient’s right to make their own healthcare decisions.
The nurse’s role is to respect and advocate for the patient’s self-determination even if it
conflicts with clinical advice. This principle is a cornerstone of ethical nursing practice and
patient-centered care.
3. A nurse manager is implementing a new EHR system and identifies staff members who are
resistant to the change. According to Lewin’s Change Theory, which stage is the manager
currently in?
A. Moving
B. Unfreezing
C. Refreezing
D. Transitioning
Correct Answer: B
Rationale: Unfreezing is the stage where the need for change is recognized and old
patterns are challenged. During this phase, the manager must create readiness for change
and address resistance. Successful unfreezing is necessary before new behaviors can be
implemented in the moving stage.
, 4. Which task is most appropriate for a Registered Nurse (RN) to delegate to an Unlicensed
Assistive Personnel (UAP)?
A. Evaluating a patient’s response to an antihypertensive medication.
B. Assisting a stable patient with ambulation in the hallway.
C. Teaching a patient how to perform self-catheterization at home.
D. Completing an admission assessment on a new patient.
Correct Answer: B
Rationale: Assisting with ambulation is a standard, non-invasive task that does not require
clinical judgment. The RN remains responsible for the initial assessment and any complex
teaching or evaluation. Delegation to UAPs should focus on routine tasks that are within
their scope of training.
5. A nurse is caring for four patients. Which patient should the nurse assess first using the
principles of prioritization?
A. A patient with a respiratory rate of 28 and oxygen saturation of 88%.
B. A patient reporting a pain level of 6 out of 10 on a surgical site.
C. A patient with a scheduled dose of IV antibiotics due in 10 minutes.
D. A patient who needs a discharge summary completed for a 2 PM departure.
Correct Answer: A
