NUR 210/NUR210 Exam 3 V2 | Transition
to Practice - Capstone Q&A with Rationale
| Fortis College
1. A nurse manager is evaluating the time management skills of a newly licensed nurse.
Which action by the new nurse indicates a need for further teaching?
A. Documenting client care at the end of the shift for all assigned clients.
B. Grouping activities that are in the same location to save time.
C. Creating a list of prioritized tasks at the beginning of the shift.
D. Delegating appropriate tasks to assistive personnel to focus on assessments.
Correct Answer: A
Expert Explanation: Documenting at the end of the shift is considered ‘block charting’ and
is inefficient because it increases the risk of errors and omissions. The nurse should
document care as soon as possible after it is provided to maintain accuracy and clinical
relevance. Effective time management involves real-time documentation to ensure the
healthcare team has current information.
2. A nurse is preparing to delegate tasks to an Unlicensed Assistive Personnel (UAP). Which
task is appropriate for the nurse to delegate?
A. Evaluating the effectiveness of a client’s pain medication.
B. Performing a sterile dressing change on a post-operative wound.
,C. Teaching a client how to use an incentive spirometer.
D. Ambulating a stable client who is two days post-surgery.
Correct Answer: D
Expert Explanation: Ambulating a stable client is within the scope of practice for a UAP as
it does not require clinical judgment or assessment. Assessment, evaluation, and teaching
are nursing responsibilities that cannot be delegated to unlicensed staff. The nurse must
always verify that the client is stable before delegating mobility tasks.
3. A charge nurse is observing a staff nurse who is performing a dressing change for a client
with a central venous catheter. Which action by the staff nurse requires intervention?
A. Performing hand hygiene before and after the procedure.
B. Asking the client to wear a mask during the dressing change.
C. Cleaning the insertion site with chlorhexidine using a back-and-forth motion.
D. Applying a clean, non-sterile glove to remove the old dressing.
Correct Answer: B
Expert Explanation: While the nurse should wear a mask, it is standard practice for the
client to turn their head away from the site rather than wear a mask, unless the client is
actively coughing or unable to comply. The nurse must maintain a sterile field for the
application of the new dressing to prevent bloodstream infections. The use of chlorhexidine
with a back-and-forth motion is the correct technique for skin antisepsis at a central line
site.
, 4. A nurse is caring for a client who is scheduled for an elective surgery. The client states, ‘I
am not sure I want to go through with this procedure.’ Which is the appropriate nursing
response?
A. ‘Tell me more about your concerns regarding the surgery.’
B. ‘Don’t worry, the surgeon performing your procedure is the best in the hospital.’
C. ‘You should talk to your family before making a final decision.’
D. ‘If you cancel now, you might have to wait months for another opening.’
Correct Answer: A
Expert Explanation: This response uses an open-ended therapeutic communication
technique to encourage the client to express their feelings and concerns. The nurse’s role is
to facilitate the client’s decision-making process without providing personal bias or false
reassurance. Understanding the client’s perspective is essential for advocacy and informed
consent.
5. In the event of a mass casualty incident, which color tag should a nurse assign to a client
with a simple fracture and minor lacerations?
A. Red
B. Yellow
C. Green
D. Black
to Practice - Capstone Q&A with Rationale
| Fortis College
1. A nurse manager is evaluating the time management skills of a newly licensed nurse.
Which action by the new nurse indicates a need for further teaching?
A. Documenting client care at the end of the shift for all assigned clients.
B. Grouping activities that are in the same location to save time.
C. Creating a list of prioritized tasks at the beginning of the shift.
D. Delegating appropriate tasks to assistive personnel to focus on assessments.
Correct Answer: A
Expert Explanation: Documenting at the end of the shift is considered ‘block charting’ and
is inefficient because it increases the risk of errors and omissions. The nurse should
document care as soon as possible after it is provided to maintain accuracy and clinical
relevance. Effective time management involves real-time documentation to ensure the
healthcare team has current information.
2. A nurse is preparing to delegate tasks to an Unlicensed Assistive Personnel (UAP). Which
task is appropriate for the nurse to delegate?
A. Evaluating the effectiveness of a client’s pain medication.
B. Performing a sterile dressing change on a post-operative wound.
,C. Teaching a client how to use an incentive spirometer.
D. Ambulating a stable client who is two days post-surgery.
Correct Answer: D
Expert Explanation: Ambulating a stable client is within the scope of practice for a UAP as
it does not require clinical judgment or assessment. Assessment, evaluation, and teaching
are nursing responsibilities that cannot be delegated to unlicensed staff. The nurse must
always verify that the client is stable before delegating mobility tasks.
3. A charge nurse is observing a staff nurse who is performing a dressing change for a client
with a central venous catheter. Which action by the staff nurse requires intervention?
A. Performing hand hygiene before and after the procedure.
B. Asking the client to wear a mask during the dressing change.
C. Cleaning the insertion site with chlorhexidine using a back-and-forth motion.
D. Applying a clean, non-sterile glove to remove the old dressing.
Correct Answer: B
Expert Explanation: While the nurse should wear a mask, it is standard practice for the
client to turn their head away from the site rather than wear a mask, unless the client is
actively coughing or unable to comply. The nurse must maintain a sterile field for the
application of the new dressing to prevent bloodstream infections. The use of chlorhexidine
with a back-and-forth motion is the correct technique for skin antisepsis at a central line
site.
, 4. A nurse is caring for a client who is scheduled for an elective surgery. The client states, ‘I
am not sure I want to go through with this procedure.’ Which is the appropriate nursing
response?
A. ‘Tell me more about your concerns regarding the surgery.’
B. ‘Don’t worry, the surgeon performing your procedure is the best in the hospital.’
C. ‘You should talk to your family before making a final decision.’
D. ‘If you cancel now, you might have to wait months for another opening.’
Correct Answer: A
Expert Explanation: This response uses an open-ended therapeutic communication
technique to encourage the client to express their feelings and concerns. The nurse’s role is
to facilitate the client’s decision-making process without providing personal bias or false
reassurance. Understanding the client’s perspective is essential for advocacy and informed
consent.
5. In the event of a mass casualty incident, which color tag should a nurse assign to a client
with a simple fracture and minor lacerations?
A. Red
B. Yellow
C. Green
D. Black
