VATI GREENLIGHT LEADERSHIP, DELEGATION, & ETHICAL
NURSING EXAM (RN) QUESTIONS WITH 100% C0RRECT
ANSWERS AND RATIONALE
1. A charge nurse is making client assignments for a medical-surgical unit. Which
of the following clients should the charge nurse assign to a newly licensed
registered nurse (RN) who is completing orientation?
A client who is 1 hour postoperative following a laryngectomy with a
tracheostomy
A client who has diabetes mellitus and requires teaching about insulin
administration
A client who has active tuberculosis requiring airborne precautions
A client who is unstable with a blood pressure of 80/50 mm Hg
Correct Answer: A client who has diabetes mellitus and requires teaching about
insulin administration
Rationale: A newly licensed nurse should be assigned stable clients with
predictable outcomes. Teaching about insulin administration is appropriate.
Unstable or complex clients should be assigned to experienced nurses.
2. A nurse manager is reviewing delegation principles with a group of staff
nurses. Which of the following tasks is appropriate for the nurse to delegate to
an assistive personnel (AP)?
Measuring the client's blood pressure
Assessing a client's level of pain
Evaluating the effectiveness of pain medication
,Teaching a client how to use an incentive spirometer
Correct Answer: Measuring the client's blood pressure
Rationale: Obtaining vital signs is within the AP's scope of practice. Assessment,
evaluation, and teaching require licensed nursing judgment and cannot be
delegated.
3. A nurse on a medical-surgical unit has received change-of-shift report. Which
of the following clients should the nurse assess first?
A client who has chronic obstructive pulmonary disease with an oxygen saturation
of 89% on room air
A client who has diabetes mellitus with a blood glucose level of 180 mg/dL
A client who has a hip fracture requesting pain medication
A client who has a urinary tract infection with a temperature of 38.0°C (100.4°F)
Correct Answer: A client who has chronic obstructive pulmonary disease with an
oxygen saturation of 89% on room air
Rationale: An oxygen saturation of 89% indicates hypoxemia, which is life-
threatening. This client requires immediate assessment and intervention.
4. A nurse is preparing to administer a blood transfusion to a client. Which of
the following actions is most important for the nurse to take to prevent a
transfusion reaction?
Verify the client's identity using two unique identifiers
Prime the blood tubing with dextrose 5% in water
Warm the blood unit to body temperature before administration
Administer the blood over 15 minutes
Correct Answer: Verify the client's identity using two unique identifiers
,Rationale: The most important step in preventing transfusion reactions is ensuring
the right blood is given to the right client by verifying identity with two identifiers
(name, date of birth, medical record number).
5. A nurse manager is discussing informed consent with a group of newly
licensed nurses. Which of the following statements should the nurse manager
include?
The nurse is responsible for obtaining the client's informed consent
The provider is responsible for explaining the procedure and its risks to the client
A client can sign informed consent even if under the influence of sedating
medications
A parent cannot sign consent for their minor child
Correct Answer: The provider is responsible for explaining the procedure and its
risks to the client
Rationale: The provider (physician, surgeon) is legally responsible for obtaining
informed consent by explaining the procedure, risks, benefits, and alternatives.
The nurse witnesses the signature and confirms understanding.
6. A nurse is caring for a client who refuses to take a prescribed medication.
Which of the following actions should the nurse take first?
Document the client's refusal in the medical record
Notify the provider of the client's refusal
Ask the client to explain the reason for refusing the medication
Administer the medication by another route without the client's knowledge
Correct Answer: Ask the client to explain the reason for refusing the medication
Rationale: The nurse should first explore the reason for refusal (e.g., side effects,
cost, fear) to address any misconceptions or concerns before notifying the
provider.
, 7. A charge nurse is observing a staff nurse insert a urinary catheter. Which of
the following actions by the staff nurse requires intervention?
Using sterile gloves and a sterile catheter
Maintaining the catheter drainage bag below the level of the bladder
Securing the catheter to the client's thigh with tape
Opening the sterile kit before applying sterile gloves
Correct Answer: Opening the sterile kit before applying sterile gloves
Rationale: The outer wrapper of a sterile kit can be opened before applying sterile
gloves, but the inner sterile drape and contents should be opened after sterile
gloves are applied. This action may be correct if done properly.
8. A nurse is caring for a client who has a do-not-resuscitate (DNR) order in
place. The client experiences cardiac arrest. Which of the following actions
should the nurse take?
Initiate CPR and call a code blue
Respect the DNR order and allow natural death
Call the provider for permission to withhold CPR
Ask the family whether they want CPR performed
Correct Answer: Respect the DNR order and allow natural death
Rationale: A DNR order means no resuscitation should be attempted. The nurse
should provide comfort care and support the client and family but should not
initiate CPR.
9. A nurse manager is reviewing the rights of delegation. Which of the following
is considered the right task for delegation to an assistive personnel (AP)?
Administering oral medications to a stable client
Performing a sterile dressing change
Assisting a client with bathing and grooming
NURSING EXAM (RN) QUESTIONS WITH 100% C0RRECT
ANSWERS AND RATIONALE
1. A charge nurse is making client assignments for a medical-surgical unit. Which
of the following clients should the charge nurse assign to a newly licensed
registered nurse (RN) who is completing orientation?
A client who is 1 hour postoperative following a laryngectomy with a
tracheostomy
A client who has diabetes mellitus and requires teaching about insulin
administration
A client who has active tuberculosis requiring airborne precautions
A client who is unstable with a blood pressure of 80/50 mm Hg
Correct Answer: A client who has diabetes mellitus and requires teaching about
insulin administration
Rationale: A newly licensed nurse should be assigned stable clients with
predictable outcomes. Teaching about insulin administration is appropriate.
Unstable or complex clients should be assigned to experienced nurses.
2. A nurse manager is reviewing delegation principles with a group of staff
nurses. Which of the following tasks is appropriate for the nurse to delegate to
an assistive personnel (AP)?
Measuring the client's blood pressure
Assessing a client's level of pain
Evaluating the effectiveness of pain medication
,Teaching a client how to use an incentive spirometer
Correct Answer: Measuring the client's blood pressure
Rationale: Obtaining vital signs is within the AP's scope of practice. Assessment,
evaluation, and teaching require licensed nursing judgment and cannot be
delegated.
3. A nurse on a medical-surgical unit has received change-of-shift report. Which
of the following clients should the nurse assess first?
A client who has chronic obstructive pulmonary disease with an oxygen saturation
of 89% on room air
A client who has diabetes mellitus with a blood glucose level of 180 mg/dL
A client who has a hip fracture requesting pain medication
A client who has a urinary tract infection with a temperature of 38.0°C (100.4°F)
Correct Answer: A client who has chronic obstructive pulmonary disease with an
oxygen saturation of 89% on room air
Rationale: An oxygen saturation of 89% indicates hypoxemia, which is life-
threatening. This client requires immediate assessment and intervention.
4. A nurse is preparing to administer a blood transfusion to a client. Which of
the following actions is most important for the nurse to take to prevent a
transfusion reaction?
Verify the client's identity using two unique identifiers
Prime the blood tubing with dextrose 5% in water
Warm the blood unit to body temperature before administration
Administer the blood over 15 minutes
Correct Answer: Verify the client's identity using two unique identifiers
,Rationale: The most important step in preventing transfusion reactions is ensuring
the right blood is given to the right client by verifying identity with two identifiers
(name, date of birth, medical record number).
5. A nurse manager is discussing informed consent with a group of newly
licensed nurses. Which of the following statements should the nurse manager
include?
The nurse is responsible for obtaining the client's informed consent
The provider is responsible for explaining the procedure and its risks to the client
A client can sign informed consent even if under the influence of sedating
medications
A parent cannot sign consent for their minor child
Correct Answer: The provider is responsible for explaining the procedure and its
risks to the client
Rationale: The provider (physician, surgeon) is legally responsible for obtaining
informed consent by explaining the procedure, risks, benefits, and alternatives.
The nurse witnesses the signature and confirms understanding.
6. A nurse is caring for a client who refuses to take a prescribed medication.
Which of the following actions should the nurse take first?
Document the client's refusal in the medical record
Notify the provider of the client's refusal
Ask the client to explain the reason for refusing the medication
Administer the medication by another route without the client's knowledge
Correct Answer: Ask the client to explain the reason for refusing the medication
Rationale: The nurse should first explore the reason for refusal (e.g., side effects,
cost, fear) to address any misconceptions or concerns before notifying the
provider.
, 7. A charge nurse is observing a staff nurse insert a urinary catheter. Which of
the following actions by the staff nurse requires intervention?
Using sterile gloves and a sterile catheter
Maintaining the catheter drainage bag below the level of the bladder
Securing the catheter to the client's thigh with tape
Opening the sterile kit before applying sterile gloves
Correct Answer: Opening the sterile kit before applying sterile gloves
Rationale: The outer wrapper of a sterile kit can be opened before applying sterile
gloves, but the inner sterile drape and contents should be opened after sterile
gloves are applied. This action may be correct if done properly.
8. A nurse is caring for a client who has a do-not-resuscitate (DNR) order in
place. The client experiences cardiac arrest. Which of the following actions
should the nurse take?
Initiate CPR and call a code blue
Respect the DNR order and allow natural death
Call the provider for permission to withhold CPR
Ask the family whether they want CPR performed
Correct Answer: Respect the DNR order and allow natural death
Rationale: A DNR order means no resuscitation should be attempted. The nurse
should provide comfort care and support the client and family but should not
initiate CPR.
9. A nurse manager is reviewing the rights of delegation. Which of the following
is considered the right task for delegation to an assistive personnel (AP)?
Administering oral medications to a stable client
Performing a sterile dressing change
Assisting a client with bathing and grooming
