Exam 2 NUR 115 ncelx style questions
A nurse is caring for four patients. Which patient should the nurse assess first based on
Maslow's hierarchy?
A. A patient who is crying because of loneliness after a divorce
B. A patient who has an oxygen saturation of 82% on room air
C. A patient who states, "I feel ugly after my mastectomy"
D. A patient who is asking for a referral to a church leader for spiritual guidance
Answer: B
Rationale: Airway/breathing/circulation (ABC) and physiological needs come first.
Oxygenation is life-threatening if not addressed immediately.
A nurse tells a patient, "If you don't take this medication, I will have to put you in
restraints." This is an example of:
A. Battery
B. Assault
C. False imprisonment
D. Negligence
Answer: B
Rationale: Assault is a verbal or implied threat of harm. Battery is actual physical contact
without consent.
Which situation would be considered malpractice?
A. Forgetting to raise side rails for a confused patient
B. Administering the wrong medication that causes the patient to have a seizure
C. Failing to provide a bed bath to a dependent patient
D. Discussing a patient's diagnosis with coworkers in the cafeteria
Answer: B
Rationale: Malpractice is professional negligence that causes harm. Giving the wrong
medication with injury meets that definition.
Which statement by the nurse demonstrates correct charting by exception?
A. "Patient ambulated with a steady gait, no assistance required."
B. "Patient is alert, oriented ×3, denies pain, no acute distress."
C. "All assessments are within normal limits, unless otherwise noted."
D. "Patient verbalized feeling anxious about upcoming procedure."
, Answer: C
Rationale: Charting by exception documents only abnormal findings; otherwise,
standards/flowsheets assume WNL.
A 16-year-old patient arrives in the emergency department for appendectomy. The nurse
should obtain consent from:
A. The patient
B. The surgeon
C. The patient's parent or guardian
D. The hospital administrator
Answer: C
Rationale: Minors cannot legally sign informed consent unless emancipated, married, or in
special circumstances (STIs, pregnancy, etc.). Parent/guardian provides consent.
Which patient statement requires further teaching about a durable power of attorney for
healthcare (DPOA-HC)?
A. "This person can make medical decisions for me if I can't speak."
B. "It is valid throughout the United States."
C. "My DPOA can manage my finances when I'm in the hospital."
D. "It goes into effect only if I lose decision-making capacity."
Answer: C
Rationale: DPOA for healthcare applies only to medical decisions, not finances.
Which nurse's action best demonstrates comportment?
A. Remains up to date on evidence-based practice
B. Addresses coworkers respectfully, even during conflict
C. Attends continuing education conferences regularly
D. Reads medical journals weekly
Answer: B
Rationale: Comportment = dignity, civility, accountability, and respect in interactions.
The nurse collects subjective and objective data from the patient and family. Which step of
the nursing process is this?
A. Diagnosis
B. Planning
A nurse is caring for four patients. Which patient should the nurse assess first based on
Maslow's hierarchy?
A. A patient who is crying because of loneliness after a divorce
B. A patient who has an oxygen saturation of 82% on room air
C. A patient who states, "I feel ugly after my mastectomy"
D. A patient who is asking for a referral to a church leader for spiritual guidance
Answer: B
Rationale: Airway/breathing/circulation (ABC) and physiological needs come first.
Oxygenation is life-threatening if not addressed immediately.
A nurse tells a patient, "If you don't take this medication, I will have to put you in
restraints." This is an example of:
A. Battery
B. Assault
C. False imprisonment
D. Negligence
Answer: B
Rationale: Assault is a verbal or implied threat of harm. Battery is actual physical contact
without consent.
Which situation would be considered malpractice?
A. Forgetting to raise side rails for a confused patient
B. Administering the wrong medication that causes the patient to have a seizure
C. Failing to provide a bed bath to a dependent patient
D. Discussing a patient's diagnosis with coworkers in the cafeteria
Answer: B
Rationale: Malpractice is professional negligence that causes harm. Giving the wrong
medication with injury meets that definition.
Which statement by the nurse demonstrates correct charting by exception?
A. "Patient ambulated with a steady gait, no assistance required."
B. "Patient is alert, oriented ×3, denies pain, no acute distress."
C. "All assessments are within normal limits, unless otherwise noted."
D. "Patient verbalized feeling anxious about upcoming procedure."
, Answer: C
Rationale: Charting by exception documents only abnormal findings; otherwise,
standards/flowsheets assume WNL.
A 16-year-old patient arrives in the emergency department for appendectomy. The nurse
should obtain consent from:
A. The patient
B. The surgeon
C. The patient's parent or guardian
D. The hospital administrator
Answer: C
Rationale: Minors cannot legally sign informed consent unless emancipated, married, or in
special circumstances (STIs, pregnancy, etc.). Parent/guardian provides consent.
Which patient statement requires further teaching about a durable power of attorney for
healthcare (DPOA-HC)?
A. "This person can make medical decisions for me if I can't speak."
B. "It is valid throughout the United States."
C. "My DPOA can manage my finances when I'm in the hospital."
D. "It goes into effect only if I lose decision-making capacity."
Answer: C
Rationale: DPOA for healthcare applies only to medical decisions, not finances.
Which nurse's action best demonstrates comportment?
A. Remains up to date on evidence-based practice
B. Addresses coworkers respectfully, even during conflict
C. Attends continuing education conferences regularly
D. Reads medical journals weekly
Answer: B
Rationale: Comportment = dignity, civility, accountability, and respect in interactions.
The nurse collects subjective and objective data from the patient and family. Which step of
the nursing process is this?
A. Diagnosis
B. Planning
