Complete Exam-Style Questions with Detailed Rationales |
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Section A, Question 1 (Cognitive Level: Applying | Type: Multiple Choice)
A nurse on a medical-surgical unit has received shift report. Which task is appropriate
for the nurse to delegate to an experienced unlicensed assistive personnel (UAP)?
A. Assess a postoperative client's surgical incision for signs of infection
B. Obtain a set of vital signs on a client admitted 2 hours ago for observation
C. Evaluate the effectiveness of pain medication administered 1 hour prior
D. Educate a newly diagnosed diabetic client about blood glucose monitoring
Correct Answer: B
Rationale: The RN must perform assessments, evaluations, and teaching; obtaining
routine vital signs on a stable client is within the UAP scope. A is incorrect because
assessment of incisions requires nursing judgment and is an RN responsibility. C is
incorrect because evaluating medication effectiveness requires clinical analysis and is
an RN task. D is incorrect because client education requires professional nursing
knowledge and cannot be delegated to a UAP.
Section A, Question 2 (Cognitive Level: Analyzing | Type: Multiple Choice)
A charge nurse is reviewing assignments for the shift. Which client should the nurse
assign to the licensed practical nurse (LPN)?
A. A client 1 hour post-op from an exploratory laparotomy with a PCA pump
B. A client with a new diagnosis of heart failure requiring discharge teaching
C. A client with stable Crohn's disease requiring a scheduled enteral feeding
D. A client with a new chest tube requiring sterile dressing changes
Correct Answer: C
,Rationale: LPNs can care for stable clients with predictable outcomes, including
scheduled feedings; they cannot perform initial teaching, manage PCA pumps, or
perform sterile dressing changes on new chest tubes. A is incorrect because PCA pump
management and immediate post-op assessment require RN-level monitoring and
judgment. B is incorrect because discharge teaching for a new diagnosis requires
RN-level education and evaluation. D is incorrect because sterile dressing changes for a
new chest tube require RN assessment and intervention.
Section A, Question 3 (Cognitive Level: Applying | Type: Multiple Choice)
The nurse is caring for four clients. Which task can the nurse delegate to a UAP?
A. Feed a client with a history of aspiration who requires chin-tuck positioning
B. Ambulate a client whose most recent blood pressure was 88/52 mm Hg
C. Bathe a client who is 1 day post-op after total hip arthroplasty and is stable
D. Perform a sterile dressing change on a client with a stage 2 pressure injury
Correct Answer: C
Rationale: Bathing a stable postoperative client is within UAP scope; feeding at-risk
clients, ambulating unstable clients, and sterile procedures require nursing judgment. A
is incorrect because clients with aspiration risk require nursing assessment and
intervention during meals. B is incorrect because a client with hypotension is unstable
and requires RN assessment before ambulation. D is incorrect because sterile dressing
changes require sterile technique and nursing judgment.
Section A, Question 4 (Cognitive Level: Analyzing | Type: Multiple Choice)
A nurse is supervising a UAP who is providing care for multiple clients. The nurse
observes the UAP performing a task that is outside the UAP's scope of practice. Which
action by the nurse demonstrates appropriate supervision?
A. Complete an incident report after the shift ends
B. Redirect the UAP immediately and provide on-the-spot education
C. Document the observation in the UAP's personnel file
D. Allow the UAP to finish, then discuss the concern at the next staff meeting
Correct Answer: B
,Rationale: Appropriate supervision requires immediate intervention to ensure client
safety and real-time education; delaying action jeopardizes safety. A is incorrect
because incident reports address events, not ongoing unsafe practice requiring
immediate correction. C is incorrect because personnel documentation is a managerial
function, not the immediate clinical priority. D is incorrect because allowing unsafe
practice to continue places the client at risk and violates the nurse's duty to supervise.
Section A, Question 5 (Cognitive Level: Evaluating | Type: Multi-Select)
A nurse is evaluating the performance of a newly hired UAP. Which observations by the
nurse indicate that the UAP understands the five rights of delegation? Select all that
apply.
A. The UAP asks for clarification of the task before beginning
B. The UAP reports back to the nurse after completing the task
C. The UAP accepts a task to administer a client's oral medications
D. The UAP verifies the correct client using two identifiers
E. The UAP declines to perform a task outside the training scope
Correct Answer: A, B, D, E
Rationale: The five rights of delegation include right task, right circumstance, right
person, right direction/communication, and right supervision; asking for clarification,
reporting back, verifying identity, and declining unsafe tasks demonstrate
understanding. A is correct because seeking clarification demonstrates right
direction/communication. B is correct because reporting completion demonstrates
right supervision/communication. D is correct because verifying two identifiers
demonstrates right person. E is correct because declining tasks outside scope
demonstrates right task and right person. C is incorrect because medication
administration is outside the UAP scope and violates the right task.
Section A, Question 6 (Cognitive Level: Analyzing | Type: Multiple Choice)
The nurse enters a client's room and finds the client cyanotic, with no audible
respirations and no palpable pulse. Which action should the nurse take first?
A. Call for the rapid response team
B. Begin cardiopulmonary resuscitation (CPR)
, C. Administer a bolus of intravenous epinephrine
D. Obtain a set of vital signs and document the findings
Correct Answer: B
Rationale: The ABCs (airway, breathing, circulation) prioritize immediate CPR for a
pulseless, apneic client; all other actions follow initiation of CPR. A is incorrect because
calling for help should occur simultaneously if another person is present, but the nurse
must initiate CPR immediately if alone with the client. C is incorrect because medication
administration requires a provider order and is not the first action. D is incorrect
because assessment and documentation delay life-saving intervention.
Section A, Question 7 (Cognitive Level: Analyzing | Type: Multiple Choice)
A nurse is caring for four clients on a busy medical unit. Which client should the nurse
assess first?
A. A client with pneumonia whose oxygen saturation is 92% on 2 L/min nasal cannula
B. A client with heart failure who reports a 2 lb weight gain since yesterday
C. A client with a new ileostomy who reports abdominal cramping and no output for 6
hours
D. A client with diabetes whose blood glucose is 186 mg/dL 1 hour after a meal
Correct Answer: C
Rationale: Acute abdominal cramping with no ostomy output suggests obstruction or
complications, representing an unstable, high-priority condition requiring immediate
assessment. A is incorrect because 92% on low-flow oxygen is stable and expected for
a client with pneumonia. B is incorrect because a 2 lb weight gain is a chronic
management issue, not an acute emergency. D is incorrect because 186 mg/dL 1 hour
postprandial is within acceptable parameters and does not require immediate
intervention.
Section A, Question 8 (Cognitive Level: Applying | Type: Multiple Choice)
A nurse is receiving report on four postoperative clients. Which client should the nurse
prioritize for assessment?
A. A client who is 4 hours post-op and has a respiratory rate of 18/min
B. A client who is 2 hours post-op and has a blood pressure of 148/88 mm Hg