NUR 210/NUR210 Exam 3 V1 | Transition
to Practice - Capstone Q&A with Rationale
| Fortis College
1. A charge nurse is managing a busy medical-surgical unit. Which task is most appropriate to
delegate to an experienced Unlicensed Assistive Personnel (UAP)?
A. Assisting a client with a new diagnosis of diabetes to select food choices from the menu.
B. Measuring and recording the output from a closed-chest drainage system.
C. Providing basic post-mortem care for a client who has just passed away.
D. Evaluating the effectiveness of a PRN analgesic administered one hour ago.
Correct Answer: C
Expert Explanation: Post-mortem care involves basic tasks that fall within the scope of
practice for a UAP under the supervision of an RN. Tasks involving education, such as meal
selection for a new diabetic, require the specialized knowledge of a nurse. Assessment and
evaluation of chest tube drainage or medication effectiveness are strictly nursing
responsibilities that cannot be delegated.
2. A nurse is preparing to administer an intramuscular injection to a client who refuses the
medication. The nurse proceeds to administer the injection anyway. This action could be
legally defined as:
A. Assault
,B. Battery
C. Malpractice
D. False imprisonment
Correct Answer: B
Expert Explanation: Battery is defined as the intentional and wrongful physical contact
with another person without that person’s consent that causes injury or offensive touching.
In this scenario, the actual act of giving the injection against the client’s will constitutes
battery. Assault would be the threat of performing such an act, whereas malpractice
involves professional negligence.
3. Which clinical scenario should the nurse prioritize first when starting a shift on a telemetry
unit?
A. A client with a history of heart failure who has 2+ pitting edema in the lower extremities.
B. A client who was admitted for syncope and is now asking for assistance to the bathroom.
C. A client who is requesting their morning dose of an antihypertensive medication.
D. A client whose heart rate has increased from 82 to 110 beats/min and is complaining of
chest heaviness.
Correct Answer: D
Expert Explanation: Using the ABC (Airway, Breathing, Circulation) framework, the client
with a rapid increase in heart rate and chest pain is the highest priority as they may be
,experiencing acute myocardial ischemia. While pitting edema and syncope history are
important, they are currently stable compared to active chest pain. Timely intervention in
cardiac events is critical to prevent permanent damage or death.
4. An RN is working with a Licensed Practical Nurse (LPN). Which task is most appropriate to
assign to the LPN?
A. Performing the initial admission assessment for a client with pneumonia.
B. Administering a scheduled subcutaneous insulin injection to a stable client.
C. Updating the nursing care plan for a client with a long-term pressure ulcer.
D. Administering an intravenous bolus of morphine for acute pain.
Correct Answer: B
Expert Explanation: LPNs are trained to administer medications through subcutaneous
and intramuscular routes for stable patients. Initial assessments and IV push medications
are generally reserved for RNs according to most state practice acts. While LPNs can
contribute to the care plan, the RN holds final responsibility for the planning and
evaluation phases of the nursing process.
5. A nurse is advocating for a client who is being pressured by their family to undergo a risky
surgical procedure. Which ethical principle is the nurse primarily supporting?
A. Justice
B. Autonomy
C. Beneficence
, D. Fidelity
Correct Answer: B
Expert Explanation: Autonomy refers to the right of the client to make their own decisions
regarding their healthcare without external coercion. By advocating for the client’s right to
refuse or choose, the nurse is upholding this core ethical principle. Justice refers to fairness,
while beneficence refers to doing good for the patient.
6. A nurse is participating in a root cause analysis (RCA) following a medication error. What is
the primary purpose of an RCA in a healthcare setting?
A. To identify which staff member is responsible for the error and provide disciplinary
action.
B. To determine the underlying system failures that contributed to the adverse event.
C. To satisfy legal requirements from the hospital’s insurance provider.
D. To provide a detailed report to the State Board of Nursing regarding individual
performance.
Correct Answer: B
Expert Explanation: The primary goal of a root cause analysis is to move away from a
‘blame culture’ and instead look at the systemic processes that allowed an error to occur.
This process helps implement changes that prevent the same error from happening again
in the future. It focuses on environmental, procedural, and communication factors rather
than individual punishment.
to Practice - Capstone Q&A with Rationale
| Fortis College
1. A charge nurse is managing a busy medical-surgical unit. Which task is most appropriate to
delegate to an experienced Unlicensed Assistive Personnel (UAP)?
A. Assisting a client with a new diagnosis of diabetes to select food choices from the menu.
B. Measuring and recording the output from a closed-chest drainage system.
C. Providing basic post-mortem care for a client who has just passed away.
D. Evaluating the effectiveness of a PRN analgesic administered one hour ago.
Correct Answer: C
Expert Explanation: Post-mortem care involves basic tasks that fall within the scope of
practice for a UAP under the supervision of an RN. Tasks involving education, such as meal
selection for a new diabetic, require the specialized knowledge of a nurse. Assessment and
evaluation of chest tube drainage or medication effectiveness are strictly nursing
responsibilities that cannot be delegated.
2. A nurse is preparing to administer an intramuscular injection to a client who refuses the
medication. The nurse proceeds to administer the injection anyway. This action could be
legally defined as:
A. Assault
,B. Battery
C. Malpractice
D. False imprisonment
Correct Answer: B
Expert Explanation: Battery is defined as the intentional and wrongful physical contact
with another person without that person’s consent that causes injury or offensive touching.
In this scenario, the actual act of giving the injection against the client’s will constitutes
battery. Assault would be the threat of performing such an act, whereas malpractice
involves professional negligence.
3. Which clinical scenario should the nurse prioritize first when starting a shift on a telemetry
unit?
A. A client with a history of heart failure who has 2+ pitting edema in the lower extremities.
B. A client who was admitted for syncope and is now asking for assistance to the bathroom.
C. A client who is requesting their morning dose of an antihypertensive medication.
D. A client whose heart rate has increased from 82 to 110 beats/min and is complaining of
chest heaviness.
Correct Answer: D
Expert Explanation: Using the ABC (Airway, Breathing, Circulation) framework, the client
with a rapid increase in heart rate and chest pain is the highest priority as they may be
,experiencing acute myocardial ischemia. While pitting edema and syncope history are
important, they are currently stable compared to active chest pain. Timely intervention in
cardiac events is critical to prevent permanent damage or death.
4. An RN is working with a Licensed Practical Nurse (LPN). Which task is most appropriate to
assign to the LPN?
A. Performing the initial admission assessment for a client with pneumonia.
B. Administering a scheduled subcutaneous insulin injection to a stable client.
C. Updating the nursing care plan for a client with a long-term pressure ulcer.
D. Administering an intravenous bolus of morphine for acute pain.
Correct Answer: B
Expert Explanation: LPNs are trained to administer medications through subcutaneous
and intramuscular routes for stable patients. Initial assessments and IV push medications
are generally reserved for RNs according to most state practice acts. While LPNs can
contribute to the care plan, the RN holds final responsibility for the planning and
evaluation phases of the nursing process.
5. A nurse is advocating for a client who is being pressured by their family to undergo a risky
surgical procedure. Which ethical principle is the nurse primarily supporting?
A. Justice
B. Autonomy
C. Beneficence
, D. Fidelity
Correct Answer: B
Expert Explanation: Autonomy refers to the right of the client to make their own decisions
regarding their healthcare without external coercion. By advocating for the client’s right to
refuse or choose, the nurse is upholding this core ethical principle. Justice refers to fairness,
while beneficence refers to doing good for the patient.
6. A nurse is participating in a root cause analysis (RCA) following a medication error. What is
the primary purpose of an RCA in a healthcare setting?
A. To identify which staff member is responsible for the error and provide disciplinary
action.
B. To determine the underlying system failures that contributed to the adverse event.
C. To satisfy legal requirements from the hospital’s insurance provider.
D. To provide a detailed report to the State Board of Nursing regarding individual
performance.
Correct Answer: B
Expert Explanation: The primary goal of a root cause analysis is to move away from a
‘blame culture’ and instead look at the systemic processes that allowed an error to occur.
This process helps implement changes that prevent the same error from happening again
in the future. It focuses on environmental, procedural, and communication factors rather
than individual punishment.
