NUR 210/NUR210 Exam 3 V3 | Transition
to Practice - Capstone Q&A with Rationale
| Fortis College
1. A nurse manager is discussing the 5 rights of delegation with a newly licensed nurse. Which
of the following should be included as one of the rights?
A. Right person
B. Right cost
C. Right hospital
D. Right documentation
Correct Answer: A
Expert Explanation: The right person is one of the five rights of delegation, ensuring the
task is assigned to someone with the appropriate skills. The other rights include the right
task, right circumstance, right direction/communication, and right supervision/evaluation.
Proper delegation is essential for patient safety and efficient nursing care.
2. Which task can a nurse safely delegate to an unlicensed assistive personnel (UAP)?
A. Measuring and recording intake and output
B. Performing a sterile dressing change
C. Assessing a client’s surgical incision
D. Providing discharge instructions to a client
,Correct Answer: A
Expert Explanation: UAPs are trained to perform non-invasive tasks such as measuring
and recording intake and output. Tasks involving assessment, sterile procedures, and client
education require the professional judgment of a licensed nurse. Nurses remain
accountable for the outcome of any task delegated to assistive personnel.
3. A charge nurse is observing a nurse providing care. Which action by the nurse
demonstrates the ethical principle of autonomy?
A. Supporting a client’s decision to refuse chemotherapy
B. Treating all clients with the same level of respect
C. Reporting a medication error to the supervisor
D. Keeping a promise to return to a client’s room at a specific time
Correct Answer: A
Expert Explanation: Autonomy refers to the right of the client to make their own decisions
regarding their healthcare. Supporting a client’s choice to refuse treatment, even if the
nurse disagrees, is a direct application of this principle. Nurses must ensure that clients are
fully informed before exercising their autonomy.
4. In a disaster situation, which client should be assigned a ‘Red Tag’ (Emergent)?
A. A client with a sucking chest wound
B. A client with a simple fracture of the arm
, C. A client who is unresponsive with no spontaneous respirations
D. A client with minor abrasions and contusions
Correct Answer: A
Expert Explanation: The ‘Red Tag’ is reserved for clients with life-threatening injuries
who have a high probability of survival if treated immediately, such as a sucking chest
wound. Clients who are unresponsive without breathing are typically tagged ‘Black’
(Expectant) in a mass casualty event. This triage system prioritizes the use of limited
resources to save the greatest number of lives.
5. A nurse is caring for four clients. Which client should the nurse assess first?
A. A client who had an abdominal surgery 12 hours ago and reports pain of 6/10
B. A client with a history of heart failure who has developed a new onset of shortness of
breath
C. A client who needs a dressing change for a pressure injury
D. A client scheduled for discharge who is waiting for their prescription
Correct Answer: B
Expert Explanation: The nurse must use the ABC (Airway, Breathing, Circulation)
framework to prioritize care. Shortness of breath indicates a breathing problem that could
quickly become life-threatening, making this client the highest priority. Other tasks, such as
pain management and discharge, are secondary to ensuring respiratory stability.
to Practice - Capstone Q&A with Rationale
| Fortis College
1. A nurse manager is discussing the 5 rights of delegation with a newly licensed nurse. Which
of the following should be included as one of the rights?
A. Right person
B. Right cost
C. Right hospital
D. Right documentation
Correct Answer: A
Expert Explanation: The right person is one of the five rights of delegation, ensuring the
task is assigned to someone with the appropriate skills. The other rights include the right
task, right circumstance, right direction/communication, and right supervision/evaluation.
Proper delegation is essential for patient safety and efficient nursing care.
2. Which task can a nurse safely delegate to an unlicensed assistive personnel (UAP)?
A. Measuring and recording intake and output
B. Performing a sterile dressing change
C. Assessing a client’s surgical incision
D. Providing discharge instructions to a client
,Correct Answer: A
Expert Explanation: UAPs are trained to perform non-invasive tasks such as measuring
and recording intake and output. Tasks involving assessment, sterile procedures, and client
education require the professional judgment of a licensed nurse. Nurses remain
accountable for the outcome of any task delegated to assistive personnel.
3. A charge nurse is observing a nurse providing care. Which action by the nurse
demonstrates the ethical principle of autonomy?
A. Supporting a client’s decision to refuse chemotherapy
B. Treating all clients with the same level of respect
C. Reporting a medication error to the supervisor
D. Keeping a promise to return to a client’s room at a specific time
Correct Answer: A
Expert Explanation: Autonomy refers to the right of the client to make their own decisions
regarding their healthcare. Supporting a client’s choice to refuse treatment, even if the
nurse disagrees, is a direct application of this principle. Nurses must ensure that clients are
fully informed before exercising their autonomy.
4. In a disaster situation, which client should be assigned a ‘Red Tag’ (Emergent)?
A. A client with a sucking chest wound
B. A client with a simple fracture of the arm
, C. A client who is unresponsive with no spontaneous respirations
D. A client with minor abrasions and contusions
Correct Answer: A
Expert Explanation: The ‘Red Tag’ is reserved for clients with life-threatening injuries
who have a high probability of survival if treated immediately, such as a sucking chest
wound. Clients who are unresponsive without breathing are typically tagged ‘Black’
(Expectant) in a mass casualty event. This triage system prioritizes the use of limited
resources to save the greatest number of lives.
5. A nurse is caring for four clients. Which client should the nurse assess first?
A. A client who had an abdominal surgery 12 hours ago and reports pain of 6/10
B. A client with a history of heart failure who has developed a new onset of shortness of
breath
C. A client who needs a dressing change for a pressure injury
D. A client scheduled for discharge who is waiting for their prescription
Correct Answer: B
Expert Explanation: The nurse must use the ABC (Airway, Breathing, Circulation)
framework to prioritize care. Shortness of breath indicates a breathing problem that could
quickly become life-threatening, making this client the highest priority. Other tasks, such as
pain management and discharge, are secondary to ensuring respiratory stability.
