NUR 160 / NUR 160 Final Exam (Latest )
Fundamental Concepts of Practical Nursing II
Hondros College | Questions and Verified Answers | Grade A
Section 1: Professional Nursing Concepts and Legal/Ethical Issues (Q1-15)
Q1: A practical nurse (LPN) is caring for a post-operative patient who reports increasing pain at the surgical site.
The LPN assesses the incision, documents findings, and administers the prescribed analgesic. Which step of the
nursing process does the assessment of the incision represent?
A. Planning
B. Evaluation
C. Assessment [CORRECT]
D. Implementation
Correct Answer: C
Rationale: Assessment is the first step of the nursing process (ADPIE) and involves collecting both subjective data (the patient
report of pain) and objective data (visual inspection of the incision). Planning involves goal setting, and implementation involves
carrying out interventions such as administering medication. Evaluation measures patient outcomes against established goals,
which occurs after the intervention.
Q2: The RN delegates vital sign measurement and ambulation assistance to an LPN for a stable post-operative
patient. Which of the Five Rights of Delegation is being upheld by assigning a stable patient?
A. Right direction/communication
B. Right circumstance [CORRECT]
C. Right person
D. Right task
Correct Answer: B
Rationale: The Right Circumstance refers to ensuring the patient condition and setting are appropriate for delegation, including
that the patient is stable. The Right Person refers to the competency of the delegatee. The Right Task means the task is within the
delegatee scope. The Right Direction/Communication involves clear instructions, and the Right Supervision/Evaluation ensures
appropriate oversight.
Q3: A patient scheduled for surgery asks the LPN to explain the risks of the procedure. What is the most
appropriate action by the LPN?
A. Explain the risks as described in the consent form
B. Refer the patient to the surgeon or provider for explanation [CORRECT]
C. Provide a written brochure about the procedure and document the teaching
D. Tell the patient that signing the form indicates understanding of risks
Correct Answer: B
Rationale: Informed consent is the responsibility of the provider (physician/surgeon), not the nurse. The nurse witnesses the
signature and ensures the patient appears to understand, but the explanation of risks, benefits, and alternatives must come from
the provider performing the procedure. Referring the patient back to the provider is the correct and legally safe action for the
LPN.
Q4: A patient with a DNR order experiences cardiac arrest. The LPN notes that the family is at the bedside and
becomes emotionally distressed. Which ethical principle best supports respecting the patient DNR wishes despite
1
,family objections?
A. Beneficence
B. Justice
C. Autonomy [CORRECT]
D. Fidelity
Correct Answer: C
Rationale: Autonomy is the ethical principle that respects the patient right to self-determination and supports honoring the
advance directive (DNR) that the patient established while competent. Beneficence means doing good, justice involves fair
treatment, and fidelity refers to loyalty and keeping promises. Autonomy is the foundational principle underlying advance
directives and living wills.
Q5: An LPN witnesses a colleague fail to perform hand hygiene before performing a dressing change. The
colleague states they forgot. Which action by the LPN demonstrates the ethical principle of nonmaleficence?
A. Report the colleague to the charge nurse immediately
B. Remind the colleague to perform hand hygiene before the procedure [CORRECT]
C. Document the incident and complete an incident report
D. Refrain from intervening because it is not the LPN responsibility
Correct Answer: B
Rationale: Nonmaleficence means "do no harm." Reminding the colleague to perform hand hygiene directly prevents potential
harm to the patient from infection. While reporting may eventually be necessary if the behavior continues, the immediate action
to stop the harm is most aligned with nonmaleficence. Documenting without intervening first does not actively prevent harm to the
current patient.
Q6: A patient is admitted with a gunshot wound to the leg. Which action is required of the LPN based on
mandatory reporting laws?
A. Document the wound and notify the charge nurse
B. Report the injury to law enforcement as required by state law [CORRECT]
C. Contact the patient family before making any notifications
D. Provide treatment only and maintain patient confidentiality
Correct Answer: B
Rationale: Gunshot wounds are subject to mandatory reporting in all states. The LPN must ensure the incident is reported to the
appropriate law enforcement authorities. While documentation and notifying the charge nurse are standard nursing actions,
mandatory reporting specifically requires reporting to law enforcement. Patient confidentiality does not override mandatory
reporting obligations for certain injuries and conditions.
Q7: An LPN is caring for a patient who has a physical restraint applied. Which statement by the LPN indicates
correct understanding of restraint documentation requirements?
A. I will document restraint assessment findings every 2 hours
B. I will document the restraint application and reassess every 15-30 minutes [CORRECT]
C. I will document restraint use once per shift
D. I will document only when the restraint is removed
Correct Answer: B
Rationale: Restraint documentation requires continuous monitoring and reassessment at regular intervals, typically every 15-30
minutes depending on facility policy. This includes assessing circulation, sensation, range of motion, and the patient physical and
emotional status. Every-2-hour documentation is insufficient. Documentation must occur at each reassessment interval, not just
once per shift.
Q8: Which scenario best demonstrates negligence rather than malpractice?
A. An LPN administers insulin without checking the blood glucose level, causing hypoglycemia
2
, B. A nurse fails to raise the side rails for a confused patient, who falls and sustains a fracture
[CORRECT]
C. An RN performs a procedure outside her scope of practice, causing patient harm
D. A nurse deliberately withholds a prescribed medication from a patient
Correct Answer: B
Rationale: Negligence is the unintentional failure to use reasonable care, resulting in harm. Failing to raise side rails for a
fall-risk patient is an unintentional omission of a standard safety measure. Malpractice is a subtype of negligence that is specific
to professional practice and requires establishing breach of duty, causation, and damages within the professional role. Deliberate
withholding of medication is an intentional act, not negligence.
Q9: A nurse is caring for a patient who refuses a blood transfusion based on religious beliefs. The patient is
competent and the spouse insists the transfusion be given. What should the nurse do?
A. Consult the hospital ethics committee and follow the patient wishes [CORRECT]
B. Administer the transfusion because the spouse has legal authority
C. Contact the provider to obtain a court order for the transfusion
D. Document the refusal and ask the spouse to sign a release of liability
Correct Answer: A
Rationale: A competent patient has the right to refuse treatment based on the ethical principle of autonomy. The spouse does not
have the authority to override a competent patient decision. The nurse should respect the patient refusal and consult the ethics
committee if there is a dispute. Court orders are generally sought only when the patient lacks decision-making capacity.
Q10: Which of the following is the correct sequence of the nursing process?
A. Assessment, Diagnosis, Planning, Implementation, Evaluation [CORRECT]
B. Assessment, Planning, Diagnosis, Implementation, Evaluation
C. Diagnosis, Assessment, Planning, Implementation, Evaluation
D. Planning, Assessment, Diagnosis, Implementation, Evaluation
Correct Answer: A
Rationale: The correct sequence of the nursing process is ADPIE: Assessment (collecting data), Diagnosis (formulating nursing
diagnoses), Planning (setting goals and outcomes), Implementation (carrying out interventions), and Evaluation (assessing
whether outcomes were met). Assessment must always come first because data collection informs the diagnosis and all subsequent
steps.
Q11: An LPN is discussing patient care with a UAP. Which task is appropriate for the LPN to delegate to the
UAP?
A. Assessing a patient wound for signs of infection
B. Administering oral medications to stable patients
C. Measuring and recording intake and output [CORRECT]
D. Providing wound care for a stage 2 pressure ulcer
Correct Answer: C
Rationale: LPNs can delegate basic tasks such as measuring and recording intake and output, vital signs, and ADLs to UAPs.
Assessments, medication administration, and wound care require nursing education and licensure and cannot be delegated to
UAPs. The LPN maintains accountability for the delegated task and must provide appropriate direction and supervision.
Q12: A patient has a valid Durable Power of Attorney for Healthcare (DPOA-HC) designating their daughter as
the agent. The patient is now unconscious. The daughter requests a treatment that contradicts the patient
previously expressed wishes. What should guide the decision?
A. The daughter decision as the designated DPOA-HC agent
B. The patient previously expressed wishes when competent [CORRECT]
C. The attending physician personal opinion
3
Fundamental Concepts of Practical Nursing II
Hondros College | Questions and Verified Answers | Grade A
Section 1: Professional Nursing Concepts and Legal/Ethical Issues (Q1-15)
Q1: A practical nurse (LPN) is caring for a post-operative patient who reports increasing pain at the surgical site.
The LPN assesses the incision, documents findings, and administers the prescribed analgesic. Which step of the
nursing process does the assessment of the incision represent?
A. Planning
B. Evaluation
C. Assessment [CORRECT]
D. Implementation
Correct Answer: C
Rationale: Assessment is the first step of the nursing process (ADPIE) and involves collecting both subjective data (the patient
report of pain) and objective data (visual inspection of the incision). Planning involves goal setting, and implementation involves
carrying out interventions such as administering medication. Evaluation measures patient outcomes against established goals,
which occurs after the intervention.
Q2: The RN delegates vital sign measurement and ambulation assistance to an LPN for a stable post-operative
patient. Which of the Five Rights of Delegation is being upheld by assigning a stable patient?
A. Right direction/communication
B. Right circumstance [CORRECT]
C. Right person
D. Right task
Correct Answer: B
Rationale: The Right Circumstance refers to ensuring the patient condition and setting are appropriate for delegation, including
that the patient is stable. The Right Person refers to the competency of the delegatee. The Right Task means the task is within the
delegatee scope. The Right Direction/Communication involves clear instructions, and the Right Supervision/Evaluation ensures
appropriate oversight.
Q3: A patient scheduled for surgery asks the LPN to explain the risks of the procedure. What is the most
appropriate action by the LPN?
A. Explain the risks as described in the consent form
B. Refer the patient to the surgeon or provider for explanation [CORRECT]
C. Provide a written brochure about the procedure and document the teaching
D. Tell the patient that signing the form indicates understanding of risks
Correct Answer: B
Rationale: Informed consent is the responsibility of the provider (physician/surgeon), not the nurse. The nurse witnesses the
signature and ensures the patient appears to understand, but the explanation of risks, benefits, and alternatives must come from
the provider performing the procedure. Referring the patient back to the provider is the correct and legally safe action for the
LPN.
Q4: A patient with a DNR order experiences cardiac arrest. The LPN notes that the family is at the bedside and
becomes emotionally distressed. Which ethical principle best supports respecting the patient DNR wishes despite
1
,family objections?
A. Beneficence
B. Justice
C. Autonomy [CORRECT]
D. Fidelity
Correct Answer: C
Rationale: Autonomy is the ethical principle that respects the patient right to self-determination and supports honoring the
advance directive (DNR) that the patient established while competent. Beneficence means doing good, justice involves fair
treatment, and fidelity refers to loyalty and keeping promises. Autonomy is the foundational principle underlying advance
directives and living wills.
Q5: An LPN witnesses a colleague fail to perform hand hygiene before performing a dressing change. The
colleague states they forgot. Which action by the LPN demonstrates the ethical principle of nonmaleficence?
A. Report the colleague to the charge nurse immediately
B. Remind the colleague to perform hand hygiene before the procedure [CORRECT]
C. Document the incident and complete an incident report
D. Refrain from intervening because it is not the LPN responsibility
Correct Answer: B
Rationale: Nonmaleficence means "do no harm." Reminding the colleague to perform hand hygiene directly prevents potential
harm to the patient from infection. While reporting may eventually be necessary if the behavior continues, the immediate action
to stop the harm is most aligned with nonmaleficence. Documenting without intervening first does not actively prevent harm to the
current patient.
Q6: A patient is admitted with a gunshot wound to the leg. Which action is required of the LPN based on
mandatory reporting laws?
A. Document the wound and notify the charge nurse
B. Report the injury to law enforcement as required by state law [CORRECT]
C. Contact the patient family before making any notifications
D. Provide treatment only and maintain patient confidentiality
Correct Answer: B
Rationale: Gunshot wounds are subject to mandatory reporting in all states. The LPN must ensure the incident is reported to the
appropriate law enforcement authorities. While documentation and notifying the charge nurse are standard nursing actions,
mandatory reporting specifically requires reporting to law enforcement. Patient confidentiality does not override mandatory
reporting obligations for certain injuries and conditions.
Q7: An LPN is caring for a patient who has a physical restraint applied. Which statement by the LPN indicates
correct understanding of restraint documentation requirements?
A. I will document restraint assessment findings every 2 hours
B. I will document the restraint application and reassess every 15-30 minutes [CORRECT]
C. I will document restraint use once per shift
D. I will document only when the restraint is removed
Correct Answer: B
Rationale: Restraint documentation requires continuous monitoring and reassessment at regular intervals, typically every 15-30
minutes depending on facility policy. This includes assessing circulation, sensation, range of motion, and the patient physical and
emotional status. Every-2-hour documentation is insufficient. Documentation must occur at each reassessment interval, not just
once per shift.
Q8: Which scenario best demonstrates negligence rather than malpractice?
A. An LPN administers insulin without checking the blood glucose level, causing hypoglycemia
2
, B. A nurse fails to raise the side rails for a confused patient, who falls and sustains a fracture
[CORRECT]
C. An RN performs a procedure outside her scope of practice, causing patient harm
D. A nurse deliberately withholds a prescribed medication from a patient
Correct Answer: B
Rationale: Negligence is the unintentional failure to use reasonable care, resulting in harm. Failing to raise side rails for a
fall-risk patient is an unintentional omission of a standard safety measure. Malpractice is a subtype of negligence that is specific
to professional practice and requires establishing breach of duty, causation, and damages within the professional role. Deliberate
withholding of medication is an intentional act, not negligence.
Q9: A nurse is caring for a patient who refuses a blood transfusion based on religious beliefs. The patient is
competent and the spouse insists the transfusion be given. What should the nurse do?
A. Consult the hospital ethics committee and follow the patient wishes [CORRECT]
B. Administer the transfusion because the spouse has legal authority
C. Contact the provider to obtain a court order for the transfusion
D. Document the refusal and ask the spouse to sign a release of liability
Correct Answer: A
Rationale: A competent patient has the right to refuse treatment based on the ethical principle of autonomy. The spouse does not
have the authority to override a competent patient decision. The nurse should respect the patient refusal and consult the ethics
committee if there is a dispute. Court orders are generally sought only when the patient lacks decision-making capacity.
Q10: Which of the following is the correct sequence of the nursing process?
A. Assessment, Diagnosis, Planning, Implementation, Evaluation [CORRECT]
B. Assessment, Planning, Diagnosis, Implementation, Evaluation
C. Diagnosis, Assessment, Planning, Implementation, Evaluation
D. Planning, Assessment, Diagnosis, Implementation, Evaluation
Correct Answer: A
Rationale: The correct sequence of the nursing process is ADPIE: Assessment (collecting data), Diagnosis (formulating nursing
diagnoses), Planning (setting goals and outcomes), Implementation (carrying out interventions), and Evaluation (assessing
whether outcomes were met). Assessment must always come first because data collection informs the diagnosis and all subsequent
steps.
Q11: An LPN is discussing patient care with a UAP. Which task is appropriate for the LPN to delegate to the
UAP?
A. Assessing a patient wound for signs of infection
B. Administering oral medications to stable patients
C. Measuring and recording intake and output [CORRECT]
D. Providing wound care for a stage 2 pressure ulcer
Correct Answer: C
Rationale: LPNs can delegate basic tasks such as measuring and recording intake and output, vital signs, and ADLs to UAPs.
Assessments, medication administration, and wound care require nursing education and licensure and cannot be delegated to
UAPs. The LPN maintains accountability for the delegated task and must provide appropriate direction and supervision.
Q12: A patient has a valid Durable Power of Attorney for Healthcare (DPOA-HC) designating their daughter as
the agent. The patient is now unconscious. The daughter requests a treatment that contradicts the patient
previously expressed wishes. What should guide the decision?
A. The daughter decision as the designated DPOA-HC agent
B. The patient previously expressed wishes when competent [CORRECT]
C. The attending physician personal opinion
3
