ECPI NUR 164 (Chapters 1-8) Exam Actual Exam
2025/2026 | Complete Exam-Style Questions
with Detailed Answers Plus Rationales | 100%
Verified | Guaranteed Pass A+ Graded.
1. A nurse notices a colleague documenting vital signs before actually measuring them. What is the best action?
A) Ignore it to avoid conflict
B) Report to the charge nurse immediately
C) Confront the colleague in the hallway
D) Document the same way to fit in
Answer: B
Rationale: Falsifying records is unethical and illegal; reporting protects patient safety and upholds nursing
standards.
2. A patient post-op refuses to ambulate despite teaching. Which nursing intervention first?
A) Document refusal and notify provider
B) Ask why the patient is refusing
C) Get a prescription for restraints
D) Ambulate patient anyway
Answer: B
Rationale: Exploring reasons for refusal respects autonomy and may reveal fears or correctable barriers.
3. A nurse administers wrong medication but patient is unharmed. What legal concept applies?
A) Assault
B) Battery
1|Page SUCCESS!!!
,C) Negligence
D) Slander
Answer: C
Rationale: Negligence is failure to act as a prudent nurse, even without harm; reporting is mandatory.
4. A client with heart failure reports 3 lb weight gain in one day. Nurse’s priority?
A) Restrict fluids to 500 mL/day
B) Assess lung sounds and edema
C) Encourage walking to increase metabolism
D) Give a stat diuretic before assessment
Answer: B
Rationale: Sudden weight gain suggests fluid overload; respiratory and edema assessment guides next steps.
5. A nurse hears another staff member sharing a patient’s diagnosis in the elevator. What action?
A) Join the conversation to correct details
B) Remind staff that this violates HIPAA
C) Report to security only
D) Document in patient’s chart
Answer: B
Rationale: HIPAA prohibits sharing identifiable health information in public spaces; nurse must correct the
breach.
6. A patient’s advance directive states no CPR. The patient becomes pulseless. What should nurse do?
A) Begin CPR until family arrives
B) Call provider to override directive
2|Page SUCCESS!!!
,C) Respect directive and do not start CPR
D) Give epinephrine but no compressions
Answer: C
Rationale: Legally valid advance directives must be honored; nurse verifies document and follows DNR order.
7. During change-of-shift report, a nurse uses SBAR. What does “B” represent?
A) Background
B) Breathing
C) Baseline
D) Behavior
Answer: A
Rationale: SBAR is Situation, Background, Assessment, Recommendation—standard for handoff communication.
8. A patient with pneumonia has O2 sat 88% on room air. First action?
A) Position supine for perfusion
B) Apply O2 via nasal cannula at 2 L/min
C) Call rapid response team
D) Draw blood for ABG
Answer: B
Rationale: Hypoxemia (SpO2 <90%) requires prompt oxygen therapy; start low flow and reassess.
9. A nurse touches a patient without consent to give an injection. This is:
A) Assault
B) Battery
C) Invasion of privacy
3|Page SUCCESS!!!
, D) Negligence
Answer: B
Rationale: Battery is harmful or offensive touching without consent; assault is threat of touching.
10. A diabetic patient’s blood glucose is 45 mg/dL and patient is drowsy. What should nurse give first?
A) Orange juice orally
B) Glucagon IM
C) 15 g of carbohydrate if awake and swallowing
D) Insulin lispro
Answer: C
Rationale: Conscious but drowsy patient can take oral glucose; never give oral if swallowing impaired.
11. A nurse delegates bathing to an LPN. Who is legally responsible if patient falls during the bath?
A) LPN only
B) Nurse manager
C) Delegating nurse
D) Hospital administration
Answer: C
Rationale: Delegating nurse retains accountability for appropriate delegation and supervision.
12. A patient states, “You’re the worst nurse.” Nurse’s best response?
A) “I’m sorry you feel that way.”
B) “You cannot speak to me like that.”
C) “Tell me what’s upsetting you.”
D) Leave the room silently.
4|Page SUCCESS!!!
2025/2026 | Complete Exam-Style Questions
with Detailed Answers Plus Rationales | 100%
Verified | Guaranteed Pass A+ Graded.
1. A nurse notices a colleague documenting vital signs before actually measuring them. What is the best action?
A) Ignore it to avoid conflict
B) Report to the charge nurse immediately
C) Confront the colleague in the hallway
D) Document the same way to fit in
Answer: B
Rationale: Falsifying records is unethical and illegal; reporting protects patient safety and upholds nursing
standards.
2. A patient post-op refuses to ambulate despite teaching. Which nursing intervention first?
A) Document refusal and notify provider
B) Ask why the patient is refusing
C) Get a prescription for restraints
D) Ambulate patient anyway
Answer: B
Rationale: Exploring reasons for refusal respects autonomy and may reveal fears or correctable barriers.
3. A nurse administers wrong medication but patient is unharmed. What legal concept applies?
A) Assault
B) Battery
1|Page SUCCESS!!!
,C) Negligence
D) Slander
Answer: C
Rationale: Negligence is failure to act as a prudent nurse, even without harm; reporting is mandatory.
4. A client with heart failure reports 3 lb weight gain in one day. Nurse’s priority?
A) Restrict fluids to 500 mL/day
B) Assess lung sounds and edema
C) Encourage walking to increase metabolism
D) Give a stat diuretic before assessment
Answer: B
Rationale: Sudden weight gain suggests fluid overload; respiratory and edema assessment guides next steps.
5. A nurse hears another staff member sharing a patient’s diagnosis in the elevator. What action?
A) Join the conversation to correct details
B) Remind staff that this violates HIPAA
C) Report to security only
D) Document in patient’s chart
Answer: B
Rationale: HIPAA prohibits sharing identifiable health information in public spaces; nurse must correct the
breach.
6. A patient’s advance directive states no CPR. The patient becomes pulseless. What should nurse do?
A) Begin CPR until family arrives
B) Call provider to override directive
2|Page SUCCESS!!!
,C) Respect directive and do not start CPR
D) Give epinephrine but no compressions
Answer: C
Rationale: Legally valid advance directives must be honored; nurse verifies document and follows DNR order.
7. During change-of-shift report, a nurse uses SBAR. What does “B” represent?
A) Background
B) Breathing
C) Baseline
D) Behavior
Answer: A
Rationale: SBAR is Situation, Background, Assessment, Recommendation—standard for handoff communication.
8. A patient with pneumonia has O2 sat 88% on room air. First action?
A) Position supine for perfusion
B) Apply O2 via nasal cannula at 2 L/min
C) Call rapid response team
D) Draw blood for ABG
Answer: B
Rationale: Hypoxemia (SpO2 <90%) requires prompt oxygen therapy; start low flow and reassess.
9. A nurse touches a patient without consent to give an injection. This is:
A) Assault
B) Battery
C) Invasion of privacy
3|Page SUCCESS!!!
, D) Negligence
Answer: B
Rationale: Battery is harmful or offensive touching without consent; assault is threat of touching.
10. A diabetic patient’s blood glucose is 45 mg/dL and patient is drowsy. What should nurse give first?
A) Orange juice orally
B) Glucagon IM
C) 15 g of carbohydrate if awake and swallowing
D) Insulin lispro
Answer: C
Rationale: Conscious but drowsy patient can take oral glucose; never give oral if swallowing impaired.
11. A nurse delegates bathing to an LPN. Who is legally responsible if patient falls during the bath?
A) LPN only
B) Nurse manager
C) Delegating nurse
D) Hospital administration
Answer: C
Rationale: Delegating nurse retains accountability for appropriate delegation and supervision.
12. A patient states, “You’re the worst nurse.” Nurse’s best response?
A) “I’m sorry you feel that way.”
B) “You cannot speak to me like that.”
C) “Tell me what’s upsetting you.”
D) Leave the room silently.
4|Page SUCCESS!!!
