NUR 210/NUR210 Final Exam 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 appropriate for the nurse to delegate?
A. Obtaining a clean-catch urine specimen from a client who is stable.
B. Assisting a client with a new diagnosis of diabetes to select menu items.
C. Evaluating the effectiveness of pain medication administered 30 minutes ago.
D. Performing the initial admission assessment on a client arriving from the ER.
Correct Answer: A
Expert Explanation: Obtaining a urine specimen from a stable client is a routine technical
task that falls within the scope of practice for a UAP. Evaluation, assessment, and education
are responsibilities that must be performed by the registered nurse. The nurse must always
ensure the client is stable before delegating any care tasks to unlicensed personnel.
2. A charge nurse is managing conflict between two staff nurses regarding the holiday
schedule. Which of the following actions should the charge nurse take first?
A. Report the conflict to the nurse manager for immediate disciplinary action.
B. Identify the root cause of the conflict by gathering more information.
C. Ask the staff nurses to meet privately to discuss their differences.
,D. Reassign the nurses to different shifts to avoid further interaction.
Correct Answer: B
Expert Explanation: The first step in the conflict resolution process is to assess the
situation and identify the source of the disagreement. This follows the nursing process of
assessment before intervention. By gathering data, the charge nurse can determine if the
conflict is based on a misunderstanding or a substantive issue.
3. A nurse is caring for four clients. Which client should the nurse assess first?
A. A client with pneumonia who has a new onset of confusion and restlessness.
B. A client who is 2 hours post-operative and reports a pain level of 8/10.
C. A client with a chest tube who has 50 mL of drainage in the last hour.
D. A client receiving a blood transfusion who has a temperature of 99.2 F.
Correct Answer: A
Expert Explanation: A new onset of confusion and restlessness is a classic sign of hypoxia,
which takes priority using the ABC (Airway, Breathing, Circulation) framework. While pain
and drainage are important, they are not immediately life-threatening compared to
potential respiratory failure. The nurse must prioritize the client with the most urgent
physiological need.
4. A nurse is witnessing a client sign an informed consent form for a surgical procedure.
Which of the following is the nurse’s primary responsibility?
A. Explaining the risks and benefits of the surgery to the client.
, B. Ensuring the client understands the alternatives to the procedure.
C. Obtaining the consent if the surgeon is unavailable to do so.
D. Verifying that the signature on the form is the client’s signature.
Correct Answer: D
Expert Explanation: The nurse’s role in witnessing informed consent is strictly to verify
that the client is competent, giving consent voluntarily, and that the signature is authentic.
It is the surgeon’s responsibility to explain the procedure, risks, benefits, and alternatives.
If the client has questions about the surgery itself, the nurse must notify the surgeon to
return and provide further explanation.
5. A nurse manager is implementing a new quality improvement initiative. Which of the
following is the first step in the quality improvement process?
A. Identify a specific clinical issue or problem to be addressed.
B. Establish a benchmark for the desired outcome.
C. Develop a plan for corrective action based on results.
D. Collect data to determine the current level of performance.
Correct Answer: A
Expert Explanation: The quality improvement process begins with identifying the
problem or the area that needs improvement. Once the problem is identified, the team can
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 appropriate for the nurse to delegate?
A. Obtaining a clean-catch urine specimen from a client who is stable.
B. Assisting a client with a new diagnosis of diabetes to select menu items.
C. Evaluating the effectiveness of pain medication administered 30 minutes ago.
D. Performing the initial admission assessment on a client arriving from the ER.
Correct Answer: A
Expert Explanation: Obtaining a urine specimen from a stable client is a routine technical
task that falls within the scope of practice for a UAP. Evaluation, assessment, and education
are responsibilities that must be performed by the registered nurse. The nurse must always
ensure the client is stable before delegating any care tasks to unlicensed personnel.
2. A charge nurse is managing conflict between two staff nurses regarding the holiday
schedule. Which of the following actions should the charge nurse take first?
A. Report the conflict to the nurse manager for immediate disciplinary action.
B. Identify the root cause of the conflict by gathering more information.
C. Ask the staff nurses to meet privately to discuss their differences.
,D. Reassign the nurses to different shifts to avoid further interaction.
Correct Answer: B
Expert Explanation: The first step in the conflict resolution process is to assess the
situation and identify the source of the disagreement. This follows the nursing process of
assessment before intervention. By gathering data, the charge nurse can determine if the
conflict is based on a misunderstanding or a substantive issue.
3. A nurse is caring for four clients. Which client should the nurse assess first?
A. A client with pneumonia who has a new onset of confusion and restlessness.
B. A client who is 2 hours post-operative and reports a pain level of 8/10.
C. A client with a chest tube who has 50 mL of drainage in the last hour.
D. A client receiving a blood transfusion who has a temperature of 99.2 F.
Correct Answer: A
Expert Explanation: A new onset of confusion and restlessness is a classic sign of hypoxia,
which takes priority using the ABC (Airway, Breathing, Circulation) framework. While pain
and drainage are important, they are not immediately life-threatening compared to
potential respiratory failure. The nurse must prioritize the client with the most urgent
physiological need.
4. A nurse is witnessing a client sign an informed consent form for a surgical procedure.
Which of the following is the nurse’s primary responsibility?
A. Explaining the risks and benefits of the surgery to the client.
, B. Ensuring the client understands the alternatives to the procedure.
C. Obtaining the consent if the surgeon is unavailable to do so.
D. Verifying that the signature on the form is the client’s signature.
Correct Answer: D
Expert Explanation: The nurse’s role in witnessing informed consent is strictly to verify
that the client is competent, giving consent voluntarily, and that the signature is authentic.
It is the surgeon’s responsibility to explain the procedure, risks, benefits, and alternatives.
If the client has questions about the surgery itself, the nurse must notify the surgeon to
return and provide further explanation.
5. A nurse manager is implementing a new quality improvement initiative. Which of the
following is the first step in the quality improvement process?
A. Identify a specific clinical issue or problem to be addressed.
B. Establish a benchmark for the desired outcome.
C. Develop a plan for corrective action based on results.
D. Collect data to determine the current level of performance.
Correct Answer: A
Expert Explanation: The quality improvement process begins with identifying the
problem or the area that needs improvement. Once the problem is identified, the team can
