Complete Exam-Style Questions with Detailed Rationales
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SECTION 1: Management of Care
Q1: A nurse is caring for four clients on a medical-surgical unit. Which task is
appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP)?
A. Assessing a client's pain level 30 minutes after receiving oral analgesia
B. Reinforcing teaching about wound care to a client being discharged today
C. Measuring and recording intake and output for a client with heart failure [CORRECT]
D. Evaluating the effectiveness of a new bowel regimen for a client with constipation
Correct Answer: C
Rationale: Correct because measuring and recording intake and output is within the
UAP's scope of practice and does not require nursing judgment or clinical
decision-making.
Q2: A nurse is delegating client care on a busy medical-surgical unit. Which client is
most appropriate for the licensed practical nurse (LPN) to care for under RN
supervision?
A. A client admitted 2 hours ago with chest pain who requires initial assessment and
teaching
B. A client with a new tracheostomy who needs frequent suctioning and respiratory
assessment
C. A client with stable heart failure who requires routine medication administration and
vital signs [CORRECT]
D. A client with a new diagnosis of diabetes who needs instruction on insulin
self-administration
Correct Answer: C
Rationale: Correct because the LPN can care for stable clients with predictable
outcomes, including routine medication administration and vital signs, under RN
supervision.
,Q3: A client is scheduled for an elective surgical procedure. The nurse verifies that
informed consent has been obtained. Which action by the nurse indicates proper
understanding of informed consent requirements?
A. The nurse witnesses the client signing the consent form after the surgeon has
explained the procedure [CORRECT]
B. The nurse explains the risks and benefits of the procedure to the client when the
surgeon is unavailable
C. The nurse obtains the client's signature on the consent form when the client is
sedated with preoperative medication
D. The nurse asks the client's adult daughter to sign the consent form because the client
speaks limited English
Correct Answer: A
Rationale: Correct because the nurse's role in informed consent is to witness the client's
signature after the surgeon has provided the explanation of risks, benefits, and
alternatives.
Q4: A nurse receives a phone call from a client's spouse requesting information about
the client's laboratory results. The nurse reviews the electronic health record and notes
that the client has not designated the spouse as a person authorized to receive
protected health information. Which action should the nurse take?
A. Provide the laboratory results to the spouse because they are legally married to the
client
B. Refuse to provide any information and immediately terminate the phone call
C. Verify the client's authorization for information release and provide only the
information the client has approved [CORRECT]
D. Tell the spouse to contact the health information management department for a copy
of the entire medical record
Correct Answer: C
Rationale: Correct because HIPAA requires verification of authorization before releasing
protected health information, and the nurse must provide only the information the client
has approved.
Q5: A client with terminal cancer tells the nurse, "I have a living will that states I do not
want to be resuscitated." The client is admitted for symptom management and is
currently alert and oriented. Which action should the nurse take first?
A. Place a copy of the living will in the client's chart and ensure a DNR order is
documented by the provider [CORRECT]
, B. Ask the client to verbally confirm the living will instructions with two witnesses
present
C. Inform the client that the living will is not valid until the client loses decision-making
capacity
D. Contact the hospital ethics committee to review the living will for legal validity
Correct Answer: A
Rationale: Correct because the nurse must ensure advance directives are accessible in
the medical record and that the provider documents corresponding orders to honor the
client's wishes.
Q6: A nurse overhears a physician telling a client that their insurance will not cover an
expensive but necessary treatment. The physician then suggests a less effective
alternative. Which action by the nurse demonstrates client advocacy?
A. Document the conversation in the client's medical record and take no further action
B. Privately discuss the situation with the client, ensuring they understand all treatment
options and their right to appeal insurance decisions [CORRECT]
C. Confront the physician in the hallway and demand that the original treatment be
ordered
D. Contact the insurance company directly to argue for coverage of the expensive
treatment
Correct Answer: B
Rationale: Correct because client advocacy involves ensuring the client understands all
options and rights, including the right to appeal insurance decisions and seek second
opinions.
Q7: A nurse in the emergency department is caring for four clients. Which client should
the nurse assess first?
A. A client with a sprained ankle who reports pain rated 4/10 and is waiting for x-ray
results
B. A client with abdominal pain who is stable, has received pain medication, and is
waiting for CT scan results
C. A client with a headache who is alert and oriented, with vital signs within normal
limits
D. A client with chest pain who is diaphoretic, has a blood pressure of 88/50 mmHg, and
reports crushing substernal pain [CORRECT]
Correct Answer: D