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,page2
,Question 1
A charge nurse is making client assignments on a medical-surgical unit. Which client
should the charge nurse assign to an LPN/LVN?
A) A client with acute respiratory distress requiring frequent suctioning of a tracheostomy
B) A client with a new colostomy who needs discharge teaching about pouch care
C) A client with stable diabetes mellitus requiring daily subcutaneous insulin injections
D) A client with unstable angina awaiting transfer to the cardiac catheterization lab
Answer: C
LPN/LVNs can administer medications (including subcut insulin) to stable clients with
predictable outcomes . The client with acute respiratory distress (A) requires RN
assessment and complex airway management; discharge teaching (B) requires RN-level
evaluation and teaching; unstable angina (D) requires RN assessment and monitoring for
changes in status. LPNs cannot perform initial assessments, discharge teaching, or care for
unstable patients.
Question 2
A nurse manager is reviewing the five rights of delegation with the nursing staff. Which of
the following is NOT one of the five rights?
A) Right task
B) Right license
C) Right person
D) Right circumstances
Answer: B
The five rights of delegation are: right task, right circumstance, right person, right
direction/communication, and right supervision/evaluation . "Right license" is not one of the
five rights; instead, the RN must ensure the person (delegatee) has the appropriate skill and
training (scope of practice) to perform the task.
Question 3
A registered nurse (RN) is delegating tasks to an assistive personnel (AP). Which of the
following tasks is appropriate to delegate?
A) Assessing a client's ability to swallow after a stroke
B) Administering a tube feeding to a client with a PEG tube
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, C) Performing a sterile dressing change on a surgical wound
D) Ambulating a client with a hip prosthesis using a gait belt
Answer: D
Ambulating a stable client with a gait belt is within the scope of AP after proper training .
Assessment of swallow (A) requires nursing judgment; tube feedings (B) require nursing
knowledge (verifying placement, checking residuals); sterile dressing changes (C) require
sterile technique and assessment. APs can ambulate stable, predictable clients.
Question 4
A nurse is caring for a client who refuses a prescribed blood transfusion due to religious
beliefs (Jehovah's Witness). Which of the following actions should the nurse take?
A) Administer the transfusion because it is life-saving
B) Notify the provider to obtain a court order for transfusion
C) Respect the client's refusal and notify the provider to discuss alternative treatments
D) Ask the client's family to convince the client to accept the transfusion
Answer: C
Autonomy requires respecting the client's right to refuse treatment, even if it may lead to
death . The nurse should respect the client's refusal, notify the provider, and explore
alternative treatments (erythropoiesis-stimulating agents, iron, blood conservation
strategies). Court orders are generally not obtained for competent adults' religious refusals.
Question 5
A nurse is preparing a client for surgery. The client has signed the informed consent form,
but the nurse notes that the client is sedated and drowsy. What is the appropriate action?
A) Proceed with the surgery; the consent was already signed
B) Have the client's family member sign the consent form
C) Notify the provider that the client is sedated and that the consent should be re-obtained
when the client is alert
D) Administer the preoperative medications and proceed
Answer: C
Informed consent must be obtained from a competent, informed client who has not been
sedated . If the client is sedated when consent was signed, the consent may be invalid. The
provider should be notified, and consent should be re-obtained when the client is alert. The
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,page2
,Question 1
A charge nurse is making client assignments on a medical-surgical unit. Which client
should the charge nurse assign to an LPN/LVN?
A) A client with acute respiratory distress requiring frequent suctioning of a tracheostomy
B) A client with a new colostomy who needs discharge teaching about pouch care
C) A client with stable diabetes mellitus requiring daily subcutaneous insulin injections
D) A client with unstable angina awaiting transfer to the cardiac catheterization lab
Answer: C
LPN/LVNs can administer medications (including subcut insulin) to stable clients with
predictable outcomes . The client with acute respiratory distress (A) requires RN
assessment and complex airway management; discharge teaching (B) requires RN-level
evaluation and teaching; unstable angina (D) requires RN assessment and monitoring for
changes in status. LPNs cannot perform initial assessments, discharge teaching, or care for
unstable patients.
Question 2
A nurse manager is reviewing the five rights of delegation with the nursing staff. Which of
the following is NOT one of the five rights?
A) Right task
B) Right license
C) Right person
D) Right circumstances
Answer: B
The five rights of delegation are: right task, right circumstance, right person, right
direction/communication, and right supervision/evaluation . "Right license" is not one of the
five rights; instead, the RN must ensure the person (delegatee) has the appropriate skill and
training (scope of practice) to perform the task.
Question 3
A registered nurse (RN) is delegating tasks to an assistive personnel (AP). Which of the
following tasks is appropriate to delegate?
A) Assessing a client's ability to swallow after a stroke
B) Administering a tube feeding to a client with a PEG tube
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, C) Performing a sterile dressing change on a surgical wound
D) Ambulating a client with a hip prosthesis using a gait belt
Answer: D
Ambulating a stable client with a gait belt is within the scope of AP after proper training .
Assessment of swallow (A) requires nursing judgment; tube feedings (B) require nursing
knowledge (verifying placement, checking residuals); sterile dressing changes (C) require
sterile technique and assessment. APs can ambulate stable, predictable clients.
Question 4
A nurse is caring for a client who refuses a prescribed blood transfusion due to religious
beliefs (Jehovah's Witness). Which of the following actions should the nurse take?
A) Administer the transfusion because it is life-saving
B) Notify the provider to obtain a court order for transfusion
C) Respect the client's refusal and notify the provider to discuss alternative treatments
D) Ask the client's family to convince the client to accept the transfusion
Answer: C
Autonomy requires respecting the client's right to refuse treatment, even if it may lead to
death . The nurse should respect the client's refusal, notify the provider, and explore
alternative treatments (erythropoiesis-stimulating agents, iron, blood conservation
strategies). Court orders are generally not obtained for competent adults' religious refusals.
Question 5
A nurse is preparing a client for surgery. The client has signed the informed consent form,
but the nurse notes that the client is sedated and drowsy. What is the appropriate action?
A) Proceed with the surgery; the consent was already signed
B) Have the client's family member sign the consent form
C) Notify the provider that the client is sedated and that the consent should be re-obtained
when the client is alert
D) Administer the preoperative medications and proceed
Answer: C
Informed consent must be obtained from a competent, informed client who has not been
sedated . If the client is sedated when consent was signed, the consent may be invalid. The
provider should be notified, and consent should be re-obtained when the client is alert. The
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