,Diagnostic Test
Read the question, and then choose the most correct answer.
Safe and Effective Care Environment—
Management of Care
1. The nurse is delegating tasks to an unlicensed assistive
personnel (UAP). Which client task should the nurse delegate
to the UAP?
A. a client whose IV infiltrated and needs replacing
B. a client on BiPAP who needs arterial blood gases
(ABGs) drawn
C. a client with mild dementia who needs assistance with
her food tray
D. a client who needs a wet-to-dry dressing change on an
abdominal incision
2. A nurse is preparing a client scheduled for a right mastectomy.
Which statement indicates the need for further intervention?
A. The client refuses to sign the blood consent since she
is a Jehovah’s Witness.
B. The client identifies the right breast as the surgical site
for a right mastectomy.
C. The client signs the consent form with an X, which is
witnessed by two licensed personnel.
, D. The client expresses doubt over her decision and asks
the nurse to explain more about the procedure.
3. An external weather disaster has flooded the emergency
department with several new clients. Which client should the
nurse see first ?
A. the client complaining of chest pain and nausea who is
diaphoretic
B. the client with a simple fracture of the radius from a fall
on a staircase
C. the client complaining of slight redness and itching at
the IV site in his hand
D. the client presenting with a sprained ankle from a tree
branch falling on him
4. A nurse is working with an unlicensed assistive personnel
(UAP) to perform a bed bath on a client. The nurse notes the
smell of alcohol on the UAP’s breath. Which is the priority
nursing action?
A. Work closely with the UAP during the shift and observe
for any signs of impairment.
B. Complete the bed bath without comment. The unit is
already short one staff member.
C. Offer chewing gum to the UAP. Since she does not give
medications, she can do her job as she does not
appear impaired.
D. Call for another nurse to complete the bath and
immediately report the UAP to the charge nurse or unit
manager.
5. The nurse has received report on the assigned night-shift
clients. Which client should the nurse see first ?
A. a mildly confused client due for a dressing change on a
diabetic ulcer to the heel
, B. an elderly, stable client who just returned from an MRI
to rule out a kidney mass
C. a client whose IV pump has started beeping, indicating
that the antibiotic has completed infusing
D. a client complaining of sudden warmth and pain at an
appendectomy incision site 48 hours after surgery
6. The nurse is working triage in the ED when four clients present
at the same time. Which client should be seen first ?
A. a 45-year-old female on oral contraceptives with
unusually heavy menstrual bleeding
B. a 24-year-old with a dog bite to the leg from the family
dog who is current on rabies shots
C. an irritable 4-month-old with a petechial rash, nuchal
rigidity, and temperature of 103.4°F
D. a 16-year-old football player with a twisted ankle who
has no deformity and a pedal pulse
7. The nurse is caring for clients on a medical-surgical floor.
Which tasks related to pain management can be delegated to
unlicensed assistive personnel (UAP)? Select all that apply.
A. assessing the pain level on a scale of 1 – 10
B. reminding clients to report pain immediately
C. reporting facial grimacing in unresponsive clients
D. asking clients directly, “Are you having any pain right
now?”
E. giving acetaminophen (Tylenol) after the nurse obtains
the medication but is interrupted to attend a code blue
before she administers it
8. A newly graduated nurse is working in the pediatric unit. Which
client assignment is most appropriate for this nurse?
A. a 2-year-old with hemophilia A who has suddenly
become less responsive
Read the question, and then choose the most correct answer.
Safe and Effective Care Environment—
Management of Care
1. The nurse is delegating tasks to an unlicensed assistive
personnel (UAP). Which client task should the nurse delegate
to the UAP?
A. a client whose IV infiltrated and needs replacing
B. a client on BiPAP who needs arterial blood gases
(ABGs) drawn
C. a client with mild dementia who needs assistance with
her food tray
D. a client who needs a wet-to-dry dressing change on an
abdominal incision
2. A nurse is preparing a client scheduled for a right mastectomy.
Which statement indicates the need for further intervention?
A. The client refuses to sign the blood consent since she
is a Jehovah’s Witness.
B. The client identifies the right breast as the surgical site
for a right mastectomy.
C. The client signs the consent form with an X, which is
witnessed by two licensed personnel.
, D. The client expresses doubt over her decision and asks
the nurse to explain more about the procedure.
3. An external weather disaster has flooded the emergency
department with several new clients. Which client should the
nurse see first ?
A. the client complaining of chest pain and nausea who is
diaphoretic
B. the client with a simple fracture of the radius from a fall
on a staircase
C. the client complaining of slight redness and itching at
the IV site in his hand
D. the client presenting with a sprained ankle from a tree
branch falling on him
4. A nurse is working with an unlicensed assistive personnel
(UAP) to perform a bed bath on a client. The nurse notes the
smell of alcohol on the UAP’s breath. Which is the priority
nursing action?
A. Work closely with the UAP during the shift and observe
for any signs of impairment.
B. Complete the bed bath without comment. The unit is
already short one staff member.
C. Offer chewing gum to the UAP. Since she does not give
medications, she can do her job as she does not
appear impaired.
D. Call for another nurse to complete the bath and
immediately report the UAP to the charge nurse or unit
manager.
5. The nurse has received report on the assigned night-shift
clients. Which client should the nurse see first ?
A. a mildly confused client due for a dressing change on a
diabetic ulcer to the heel
, B. an elderly, stable client who just returned from an MRI
to rule out a kidney mass
C. a client whose IV pump has started beeping, indicating
that the antibiotic has completed infusing
D. a client complaining of sudden warmth and pain at an
appendectomy incision site 48 hours after surgery
6. The nurse is working triage in the ED when four clients present
at the same time. Which client should be seen first ?
A. a 45-year-old female on oral contraceptives with
unusually heavy menstrual bleeding
B. a 24-year-old with a dog bite to the leg from the family
dog who is current on rabies shots
C. an irritable 4-month-old with a petechial rash, nuchal
rigidity, and temperature of 103.4°F
D. a 16-year-old football player with a twisted ankle who
has no deformity and a pedal pulse
7. The nurse is caring for clients on a medical-surgical floor.
Which tasks related to pain management can be delegated to
unlicensed assistive personnel (UAP)? Select all that apply.
A. assessing the pain level on a scale of 1 – 10
B. reminding clients to report pain immediately
C. reporting facial grimacing in unresponsive clients
D. asking clients directly, “Are you having any pain right
now?”
E. giving acetaminophen (Tylenol) after the nurse obtains
the medication but is interrupted to attend a code blue
before she administers it
8. A newly graduated nurse is working in the pediatric unit. Which
client assignment is most appropriate for this nurse?
A. a 2-year-old with hemophilia A who has suddenly
become less responsive
