NUR 210/NUR210 Exam 4 V3 | Transition
to Practice - Capstone Q&A with Rationale
| Fortis College
1. A nurse is preparing to delegate tasks to an unlicensed assistive personnel (UAP). Which of
the following tasks is most appropriate to delegate to the UAP?
A. Obtaining vital signs on a client returning from surgery.
B. Administering oral medications to a stable client.
C. Assessing a new admission’s skin integrity.
D. Teaching a client how to use an incentive spirometer.
Correct Answer: A
Expert Explanation: The nurse can delegate data collection such as vital signs for stable
clients to the UAP. Assessment, medication administration, and teaching are nursing
responsibilities that require clinical judgment and cannot be delegated. Delegating
appropriately ensures that the RN can focus on complex tasks that require professional
nursing skills.
2. Which clinical scenario should the nurse prioritize first when beginning the shift?
A. A client with a history of heart failure requesting a routine diuretic.
B. A client who is 1 day post-op and reporting 4/10 pain.
C. A client with diabetes whose morning blood glucose was 140 mg/dL.
,D. A client with pneumonia who has a new onset of confusion and restlessness.
Correct Answer: D
Expert Explanation: The nurse must prioritize the client with new onset confusion and
restlessness as these are early signs of hypoxia. Using the ABC (Airway, Breathing,
Circulation) framework, respiratory distress or neurological changes take precedence over
stable pain or routine care. Timely intervention in such cases prevents further
physiological deterioration and potential failure to rescue.
3. A nurse is caring for a client who refuses a life-saving blood transfusion due to religious
beliefs. What is the nurse’s best action in accordance with ethical principles?
A. Administer the blood while the patient is sleeping to save their life.
B. Request a psychiatric consultation to evaluate the client’s competence.
C. Ask the family to convince the client to accept the treatment.
D. Respect the client’s decision and document the refusal in the record.
Correct Answer: D
Expert Explanation: The principle of autonomy dictates that a competent adult has the
right to refuse medical treatment, even if it is life-saving. The nurse must respect this right
and ensure the client is fully informed of the risks associated with refusal. Ethical practice
in nursing requires balancing beneficence with the legal right of the individual to self-
determine their care.
, 4. A nurse is caring for a client who is scheduled for surgery. The client tells the nurse, ‘I don’t
really understand what the doctor is going to do.’ Which action should the nurse take?
A. Explain the surgical procedure in detail to the client.
B. Notify the surgeon that the client needs further explanation of the procedure.
C. Proceed with the preoperative checklist and have the client sign the form.
D. Give the client a pamphlet about the surgery and ask if they have questions.
Correct Answer: B
Expert Explanation: The surgeon is legally responsible for providing the primary
explanation of the risks and benefits of the surgery. The nurse’s role in informed consent is
to witness the signature and advocate for the client if understanding is lacking. Proceeding
without ensuring the client understands the procedure violates the standards of informed
consent and patient advocacy.
5. In the event of a mass casualty incident, which client should the nurse tag with a red
(immediate) triage tag?
A. A client with a closed fracture of the tibia.
B. A client with minor abrasions and anxiety.
C. A client who is pulseless and non-breathing with a massive head injury.
D. A client with a sucking chest wound and difficulty breathing.
Correct Answer: D
to Practice - Capstone Q&A with Rationale
| Fortis College
1. A nurse is preparing to delegate tasks to an unlicensed assistive personnel (UAP). Which of
the following tasks is most appropriate to delegate to the UAP?
A. Obtaining vital signs on a client returning from surgery.
B. Administering oral medications to a stable client.
C. Assessing a new admission’s skin integrity.
D. Teaching a client how to use an incentive spirometer.
Correct Answer: A
Expert Explanation: The nurse can delegate data collection such as vital signs for stable
clients to the UAP. Assessment, medication administration, and teaching are nursing
responsibilities that require clinical judgment and cannot be delegated. Delegating
appropriately ensures that the RN can focus on complex tasks that require professional
nursing skills.
2. Which clinical scenario should the nurse prioritize first when beginning the shift?
A. A client with a history of heart failure requesting a routine diuretic.
B. A client who is 1 day post-op and reporting 4/10 pain.
C. A client with diabetes whose morning blood glucose was 140 mg/dL.
,D. A client with pneumonia who has a new onset of confusion and restlessness.
Correct Answer: D
Expert Explanation: The nurse must prioritize the client with new onset confusion and
restlessness as these are early signs of hypoxia. Using the ABC (Airway, Breathing,
Circulation) framework, respiratory distress or neurological changes take precedence over
stable pain or routine care. Timely intervention in such cases prevents further
physiological deterioration and potential failure to rescue.
3. A nurse is caring for a client who refuses a life-saving blood transfusion due to religious
beliefs. What is the nurse’s best action in accordance with ethical principles?
A. Administer the blood while the patient is sleeping to save their life.
B. Request a psychiatric consultation to evaluate the client’s competence.
C. Ask the family to convince the client to accept the treatment.
D. Respect the client’s decision and document the refusal in the record.
Correct Answer: D
Expert Explanation: The principle of autonomy dictates that a competent adult has the
right to refuse medical treatment, even if it is life-saving. The nurse must respect this right
and ensure the client is fully informed of the risks associated with refusal. Ethical practice
in nursing requires balancing beneficence with the legal right of the individual to self-
determine their care.
, 4. A nurse is caring for a client who is scheduled for surgery. The client tells the nurse, ‘I don’t
really understand what the doctor is going to do.’ Which action should the nurse take?
A. Explain the surgical procedure in detail to the client.
B. Notify the surgeon that the client needs further explanation of the procedure.
C. Proceed with the preoperative checklist and have the client sign the form.
D. Give the client a pamphlet about the surgery and ask if they have questions.
Correct Answer: B
Expert Explanation: The surgeon is legally responsible for providing the primary
explanation of the risks and benefits of the surgery. The nurse’s role in informed consent is
to witness the signature and advocate for the client if understanding is lacking. Proceeding
without ensuring the client understands the procedure violates the standards of informed
consent and patient advocacy.
5. In the event of a mass casualty incident, which client should the nurse tag with a red
(immediate) triage tag?
A. A client with a closed fracture of the tibia.
B. A client with minor abrasions and anxiety.
C. A client who is pulseless and non-breathing with a massive head injury.
D. A client with a sucking chest wound and difficulty breathing.
Correct Answer: D
