NCLEX HURST REVIEW Qbank/Customize Quiz - Leadership
Which tasks would be appropriate for the nurse to delegate to an unlicensed assistive personnel
(UAP)?
Select all that apply
1. Prepare a client's room for return from surgery.
2. Observe for pain relief in a client after receiving acetaminophen with codeine.
3. Assist a client with perineal care after having diarrhea.
4. Clean nares around a client's nasogastric (NG) tube.
5. Pour a can of tube feeding into a client's percutaneous endoscopic gastrostomy (PEG). - 1., 3,
& 4. Correct. These are appropriate tasks for an UAP to complete. The UAP can provide hygiene
needs to a client such as perineal care and cleaning of the nares. Also, making a surgical bed for
the client returning from surgery is a basic procedure.
2. Incorrect. The UAP cannot assess or evaluate or even monitor the effectiveness of pain
medication. That is what you are asking the UAP to do here. The client has received a narcotic
and you have asked the UAP to evaluate the effectiveness of the medication.
5. Incorrect. Administering tube feeding into a PEG tube is beyond the scope of practice for the
UAP. This is a procedure which requires a licensed personnel. Catheter placement must be
confirmed, client identity checked, tube site flushed with water or sterile water and flow rate
determined.
What action should the nurse take after mistakenly administering the wrong medication?
Select all that apply
1. Notify the nursing supervisor.
2. Inform the primary healthcare provider.
3. Complete an incident (variance) report.
4. Document client assessment and response to medication.
5. Document medication error and incident (variance) report in nurse's notes. - 1., 2., 3., & 4.
Correct: Nurses must immediately report all client care issues, concerns or problems to the
supervising nurse, the primary healthcare provider and/or the performance improvement or risk
management department. A written report of the incident is completed by the nurse and turned
into the appropriate person (generally the performance improvement department).
Documentation of what occurred, and the client's assessment is required in the nurse's notes.
5. Incorrect: Do not document that an error was made or that an incident (variance) report was
completed. Document what medication was given, the client's assessment, the notification of the
nursing supervisor, and primary healthcare provider, and any prescriptions received.
The nurse is caring for four clients. Which client should the nurse see first?
1. The client hospitalized with dehydration related to diarrhea.
2. The seizure client who is currently in the postictal phase.
3. The post-op client who received Morphine 4 mg IV 15 minutes ago.
,4. The client who is due pre-op medication now. - 3. Correct: This client is at risk for respiratory
depression caused by morphine and should be assessed. Remember airway, breathing and
circulation (ABCs). Decreased or suppressed respiration are priority.
1. Incorrect: Dehydration can produce postural hypotension, fever, confusion, agitation and if it
develops quickly or is severe, coma and seizure may occur. Decreased respiratory rate would be
priority.
2. Incorrect: Postictal is the phase after the seizure where they are drowsy, lethargic, and possibly
asleep. Make sure the client is safe and in the recovery position. Client would need to be seen
soon, but again, decreased respirations takes priority.
4. Incorrect: Decreased or suppressed respirations would be priority over the client needing pre-
op medications.
Following a large hurricane, multiple clients arrive at the emergency room for treatment. The
charge nurse must triage and assign clients to appropriate staff. Which clients could be assigned
to an LPN?
Select all that apply
1. Child with superficial burns on both upper arms.
2. Adolescent with bruising to left upper quadrant.
3. Crying toddler missing both upper front teeth.
4. Adult reporting headache and blurred vision.
5. Elderly adult reporting nausea and heartburn. - 1. & 3. Correct: An LPN should be assigned
clients with predictable outcomes. Even though the client is a child, superficial burns require
only dry sterile dressings and possibly oral pain medication, both tasks which are within the
scope of practice for an LPN. The crying toddler has missing front teeth, but there is no
indication this was the result of the hurricane. However, providing care for missing teeth would
also be within the LPN scope of practice.
2. Incorrect: Bruising of the left upper quadrant is often indicative of a ruptured spleen and
internal bleeding. This adolescent will require further tests, such as CT scan, and possibly
emergency surgery. Because of the complexity of the situation, an RN should be assigned this
client.
4. Incorrect: Since these clients were injured during the hurricane, the charge nurse must assume
the worst. This client is reporting headache and diplopia; therefore, a safe nurse would consider
the possibility of head trauma with brain swelling accounting for the blurred vision. Such
potential makes this client serious to critical, and as such, should be assigned to an RN for on-
going neurologic assessment.
5. Incorrect: While the trauma of a hurricane could adversely affect the digestive system, the
charge nurse would assume the worst and suspect the likelihood the client is having a myocardial
infarction. Only an RN can complete the appropriate assessment, testing, and other needs
expected with an M.I. client.
, An LPN/VN has been floated to the emergency room following a chemical plant explosion.
What task would be best to assign to the LPN/LVN?
1. Identify and assess each incoming client.
2. Triage and assign color-coded tags to each client.
3. Gather and apply dressings to open wounds.
4. Initiate oxygen and IV lines as needed. - 3. Correct: An LPN/LVN's scope of practice includes
tasks such as wound care. Covering open wounds will help to decrease bacterial exposure until
the registered nurse or primary healthcare provider can assess and treat each wound. If the LPN
notes any serious bleeding situations, it would need reported immediately to the RN.
1. Incorrect: Although it will be crucial to identify each incoming client, the LPN/LVN's scope
of practice does not include assessment. That task would require an RN or primary healthcare
provider.
2. Incorrect: In a mass casualty situation, triage allows the nurse or primary healthcare provider
to quickly determine which clients are critical versus those stable enough to wait. Because this
involves assessment, an LPN/LVN would not be assigned this task.
4. Incorrect: Initiating intravenous lines is not within the scope of the LPN/LVN. Additionally,
the decision to apply oxygen involves assessment of the respiratory system, which also is not
within the LPN/LVN's scope of practice.
The charge nurse identifies that three admissions were received during the night shift, one nurse
has called in sick, and the clients on the unit have high acuity levels. What action should the
nurse implement first to ensure client safety?
1. Take report on the most critical clients first.
2. Encourage the staff to help each other.
3. Assign one additional client to each nurse.
4. Call the nursing supervisor to request additional staff immediately. - 4. Correct: The hospital
nurse to client staffing ratio should reflect the complexity of nursing care for high acuity clients.
The nurse should call for immediate help so that a safe care environment is maintained for all
clients. The charge nurse should notify the nursing supervisor who will seek additional staff. The
nursing supervisor may be able to assist with client care until another nurse can come in to work.
1. Incorrect: The critical clients are important, but all clients must be considered. The charge
nurse must evaluate each client's status and needs to assign the appropriate staff to care for them.
The safety of each client must be reviewed.
2. Incorrect: The charge nurse may encourage the staff to work together. This is a positive action
but the priority for the charge nurse is to ask for additional staff to maintain safe nursing care.
3. Incorrect: Each nurse may have to increase his/her client load until adequate staffing can be
obtained. However, calling the nursing supervisor to request help is the first action.
Which tasks would be appropriate for the nurse to delegate to an unlicensed assistive personnel
(UAP)?
Select all that apply
1. Prepare a client's room for return from surgery.
2. Observe for pain relief in a client after receiving acetaminophen with codeine.
3. Assist a client with perineal care after having diarrhea.
4. Clean nares around a client's nasogastric (NG) tube.
5. Pour a can of tube feeding into a client's percutaneous endoscopic gastrostomy (PEG). - 1., 3,
& 4. Correct. These are appropriate tasks for an UAP to complete. The UAP can provide hygiene
needs to a client such as perineal care and cleaning of the nares. Also, making a surgical bed for
the client returning from surgery is a basic procedure.
2. Incorrect. The UAP cannot assess or evaluate or even monitor the effectiveness of pain
medication. That is what you are asking the UAP to do here. The client has received a narcotic
and you have asked the UAP to evaluate the effectiveness of the medication.
5. Incorrect. Administering tube feeding into a PEG tube is beyond the scope of practice for the
UAP. This is a procedure which requires a licensed personnel. Catheter placement must be
confirmed, client identity checked, tube site flushed with water or sterile water and flow rate
determined.
What action should the nurse take after mistakenly administering the wrong medication?
Select all that apply
1. Notify the nursing supervisor.
2. Inform the primary healthcare provider.
3. Complete an incident (variance) report.
4. Document client assessment and response to medication.
5. Document medication error and incident (variance) report in nurse's notes. - 1., 2., 3., & 4.
Correct: Nurses must immediately report all client care issues, concerns or problems to the
supervising nurse, the primary healthcare provider and/or the performance improvement or risk
management department. A written report of the incident is completed by the nurse and turned
into the appropriate person (generally the performance improvement department).
Documentation of what occurred, and the client's assessment is required in the nurse's notes.
5. Incorrect: Do not document that an error was made or that an incident (variance) report was
completed. Document what medication was given, the client's assessment, the notification of the
nursing supervisor, and primary healthcare provider, and any prescriptions received.
The nurse is caring for four clients. Which client should the nurse see first?
1. The client hospitalized with dehydration related to diarrhea.
2. The seizure client who is currently in the postictal phase.
3. The post-op client who received Morphine 4 mg IV 15 minutes ago.
,4. The client who is due pre-op medication now. - 3. Correct: This client is at risk for respiratory
depression caused by morphine and should be assessed. Remember airway, breathing and
circulation (ABCs). Decreased or suppressed respiration are priority.
1. Incorrect: Dehydration can produce postural hypotension, fever, confusion, agitation and if it
develops quickly or is severe, coma and seizure may occur. Decreased respiratory rate would be
priority.
2. Incorrect: Postictal is the phase after the seizure where they are drowsy, lethargic, and possibly
asleep. Make sure the client is safe and in the recovery position. Client would need to be seen
soon, but again, decreased respirations takes priority.
4. Incorrect: Decreased or suppressed respirations would be priority over the client needing pre-
op medications.
Following a large hurricane, multiple clients arrive at the emergency room for treatment. The
charge nurse must triage and assign clients to appropriate staff. Which clients could be assigned
to an LPN?
Select all that apply
1. Child with superficial burns on both upper arms.
2. Adolescent with bruising to left upper quadrant.
3. Crying toddler missing both upper front teeth.
4. Adult reporting headache and blurred vision.
5. Elderly adult reporting nausea and heartburn. - 1. & 3. Correct: An LPN should be assigned
clients with predictable outcomes. Even though the client is a child, superficial burns require
only dry sterile dressings and possibly oral pain medication, both tasks which are within the
scope of practice for an LPN. The crying toddler has missing front teeth, but there is no
indication this was the result of the hurricane. However, providing care for missing teeth would
also be within the LPN scope of practice.
2. Incorrect: Bruising of the left upper quadrant is often indicative of a ruptured spleen and
internal bleeding. This adolescent will require further tests, such as CT scan, and possibly
emergency surgery. Because of the complexity of the situation, an RN should be assigned this
client.
4. Incorrect: Since these clients were injured during the hurricane, the charge nurse must assume
the worst. This client is reporting headache and diplopia; therefore, a safe nurse would consider
the possibility of head trauma with brain swelling accounting for the blurred vision. Such
potential makes this client serious to critical, and as such, should be assigned to an RN for on-
going neurologic assessment.
5. Incorrect: While the trauma of a hurricane could adversely affect the digestive system, the
charge nurse would assume the worst and suspect the likelihood the client is having a myocardial
infarction. Only an RN can complete the appropriate assessment, testing, and other needs
expected with an M.I. client.
, An LPN/VN has been floated to the emergency room following a chemical plant explosion.
What task would be best to assign to the LPN/LVN?
1. Identify and assess each incoming client.
2. Triage and assign color-coded tags to each client.
3. Gather and apply dressings to open wounds.
4. Initiate oxygen and IV lines as needed. - 3. Correct: An LPN/LVN's scope of practice includes
tasks such as wound care. Covering open wounds will help to decrease bacterial exposure until
the registered nurse or primary healthcare provider can assess and treat each wound. If the LPN
notes any serious bleeding situations, it would need reported immediately to the RN.
1. Incorrect: Although it will be crucial to identify each incoming client, the LPN/LVN's scope
of practice does not include assessment. That task would require an RN or primary healthcare
provider.
2. Incorrect: In a mass casualty situation, triage allows the nurse or primary healthcare provider
to quickly determine which clients are critical versus those stable enough to wait. Because this
involves assessment, an LPN/LVN would not be assigned this task.
4. Incorrect: Initiating intravenous lines is not within the scope of the LPN/LVN. Additionally,
the decision to apply oxygen involves assessment of the respiratory system, which also is not
within the LPN/LVN's scope of practice.
The charge nurse identifies that three admissions were received during the night shift, one nurse
has called in sick, and the clients on the unit have high acuity levels. What action should the
nurse implement first to ensure client safety?
1. Take report on the most critical clients first.
2. Encourage the staff to help each other.
3. Assign one additional client to each nurse.
4. Call the nursing supervisor to request additional staff immediately. - 4. Correct: The hospital
nurse to client staffing ratio should reflect the complexity of nursing care for high acuity clients.
The nurse should call for immediate help so that a safe care environment is maintained for all
clients. The charge nurse should notify the nursing supervisor who will seek additional staff. The
nursing supervisor may be able to assist with client care until another nurse can come in to work.
1. Incorrect: The critical clients are important, but all clients must be considered. The charge
nurse must evaluate each client's status and needs to assign the appropriate staff to care for them.
The safety of each client must be reviewed.
2. Incorrect: The charge nurse may encourage the staff to work together. This is a positive action
but the priority for the charge nurse is to ask for additional staff to maintain safe nursing care.
3. Incorrect: Each nurse may have to increase his/her client load until adequate staffing can be
obtained. However, calling the nursing supervisor to request help is the first action.
