NUR 210/NUR210 Exam 2 V3 | 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 intervention?
A. The nurse documents care as it is completed throughout the shift.
B. The nurse completes all high-priority tasks before moving to lower-priority tasks.
C. The nurse waits until the end of the shift to document all patient care activities.
D. The nurse creates a list of tasks and checks them off as they are finished.
Correct Answer: C
Expert Explanation: Documentation should be performed as soon as possible after a task
is completed to ensure accuracy and prevent errors. Waiting until the end of the shift
increases the risk of forgetting important clinical data or missing significant changes in
patient status. Real-time documentation is a core competency for transition to practice and
ensures patient safety through accurate communication.
2. A nurse is caring for a group of patients and needs to delegate tasks to an unlicensed
assistive personnel (UAP). Which task is most appropriate to delegate?
A. Collecting a clean-catch urine specimen from a patient.
B. Assisting a stable patient with ambulation for the first time post-surgery.
,C. Evaluating the effectiveness of pain medication administered 30 minutes ago.
D. Updating a patient’s care plan regarding nutritional requirements.
Correct Answer: A
Expert Explanation: Delegating the collection of a urine specimen is appropriate because
it is a routine, non-invasive procedure that does not require clinical judgment. Assessment,
evaluation, and care planning are professional nursing responsibilities that cannot be
delegated to assistive personnel. The nurse remains accountable for the outcome of the
delegated task and must ensure the UAP is competent to perform it.
3. According to Lewin’s Change Theory, which stage involves the nurse manager helping staff
members integrate a new EBP protocol into their daily routines?
A. Unfreezing
B. Moving
C. Refreezing
D. Assessment
Correct Answer: C
Expert Explanation: The refreezing stage occurs when the new behavior or process
becomes the new norm and is integrated into the system’s culture. In this phase, the
manager provides support and reinforcement to ensure the change persists over time. This
is distinct from the unfreezing stage, which involves creating readiness for change, and the
moving stage, which is the implementation phase.
, 4. A nurse is assigned to four patients. Which patient should the nurse assess first?
A. A patient with a history of heart failure who has 2+ pitting edema in the lower
extremities.
B. A patient with asthma who has a respiratory rate of 28/min and is using accessory
muscles.
C. A patient who is 2 days postoperative following a hip replacement and reports pain of
6/10.
D. A patient receiving IV antibiotics who has a small amount of redness at the insertion site.
Correct Answer: B
Expert Explanation: Using the ABC (Airway, Breathing, Circulation) framework, the
patient with asthma exhibiting tachypnea and accessory muscle use is the highest priority.
These signs indicate potential respiratory distress or impending failure, requiring
immediate intervention. The other patients are stable or present with expected findings
that do not pose an immediate threat to life.
5. Which ethical principle is being upheld when a nurse provides a patient with the
information needed to make an informed decision about their treatment?
A. Justice
B. Autonomy
C. Nonmaleficence
D. Fidelity
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 intervention?
A. The nurse documents care as it is completed throughout the shift.
B. The nurse completes all high-priority tasks before moving to lower-priority tasks.
C. The nurse waits until the end of the shift to document all patient care activities.
D. The nurse creates a list of tasks and checks them off as they are finished.
Correct Answer: C
Expert Explanation: Documentation should be performed as soon as possible after a task
is completed to ensure accuracy and prevent errors. Waiting until the end of the shift
increases the risk of forgetting important clinical data or missing significant changes in
patient status. Real-time documentation is a core competency for transition to practice and
ensures patient safety through accurate communication.
2. A nurse is caring for a group of patients and needs to delegate tasks to an unlicensed
assistive personnel (UAP). Which task is most appropriate to delegate?
A. Collecting a clean-catch urine specimen from a patient.
B. Assisting a stable patient with ambulation for the first time post-surgery.
,C. Evaluating the effectiveness of pain medication administered 30 minutes ago.
D. Updating a patient’s care plan regarding nutritional requirements.
Correct Answer: A
Expert Explanation: Delegating the collection of a urine specimen is appropriate because
it is a routine, non-invasive procedure that does not require clinical judgment. Assessment,
evaluation, and care planning are professional nursing responsibilities that cannot be
delegated to assistive personnel. The nurse remains accountable for the outcome of the
delegated task and must ensure the UAP is competent to perform it.
3. According to Lewin’s Change Theory, which stage involves the nurse manager helping staff
members integrate a new EBP protocol into their daily routines?
A. Unfreezing
B. Moving
C. Refreezing
D. Assessment
Correct Answer: C
Expert Explanation: The refreezing stage occurs when the new behavior or process
becomes the new norm and is integrated into the system’s culture. In this phase, the
manager provides support and reinforcement to ensure the change persists over time. This
is distinct from the unfreezing stage, which involves creating readiness for change, and the
moving stage, which is the implementation phase.
, 4. A nurse is assigned to four patients. Which patient should the nurse assess first?
A. A patient with a history of heart failure who has 2+ pitting edema in the lower
extremities.
B. A patient with asthma who has a respiratory rate of 28/min and is using accessory
muscles.
C. A patient who is 2 days postoperative following a hip replacement and reports pain of
6/10.
D. A patient receiving IV antibiotics who has a small amount of redness at the insertion site.
Correct Answer: B
Expert Explanation: Using the ABC (Airway, Breathing, Circulation) framework, the
patient with asthma exhibiting tachypnea and accessory muscle use is the highest priority.
These signs indicate potential respiratory distress or impending failure, requiring
immediate intervention. The other patients are stable or present with expected findings
that do not pose an immediate threat to life.
5. Which ethical principle is being upheld when a nurse provides a patient with the
information needed to make an informed decision about their treatment?
A. Justice
B. Autonomy
C. Nonmaleficence
D. Fidelity
