Prioritization
1. A nurse is assigned to care for four clients. Which client should the nurse assess first?
- A client scheduled for discharge later today.
- A client who is 2 days post-op and has a fever of 101°F.
- A client with chronic pain requesting pain medication.
- A client who had a minor surgery yesterday and is requesting a dressing change
Correct Answer: B. A client who is 2 days post-op and has a fever of 101°F Explanation: Postoperative fever could indicate an infection, which requires immediate assessment and intervention.
2. A nurse is caring for a client with severe shortness of breath and chest pain. Which action should the nurse take first?
- Administer oxygen via nasal cannula
- Place the client in a high-Fowler’s position
- Notify the healthcare provider
- Administer prescribed nitroglycerin
Correct Answer: B. Place the client in a high-Fowler’s position Explanation: Positioning the client can immediately help alleviate respiratory distress and improve oxygenation.
3. A client with diabetes is found unconscious with a blood glucose level of 45 mg/dL. Which intervention should the nurse implement first?
- Administer 50% dextrose IV
- Call the healthcare provider
- Check the client’s vital signs
- Place the client in a side-lying position
Correct Answer: A. Administer 50% dextrose IV Explanation: Hypoglycemia is a medical emergency that requires immediate administration of dextrose to raise blood glucose levels.
Delegation
4. A nurse is delegating tasks to a nursing assistant. Which of the following tasks is appropriate to delegate to the nursing assistant?
- Administering medication to a client
- Teaching a client how to use an insulin pen
- Measuring and recording a client’s vital signs
- Developing a care plan for a client
Correct Answer: C. Measuring and recording a client’s vital signs Explanation: Measuring and recording vital signs is within the scope of practice for a nursing assistant.
5. Which of the following tasks can a nurse delegate to a licensed practical nurse (LPN)?
- Completing a detailed health assessment
- Administering IV push medications
- Performing a wound dressing change
- Developing a discharge plan
Correct Answer: C. Performing a wound dressing change Explanation: LPNs are trained to perform wound dressing changes, which can be delegated by the nurse.
Legal Responsibilities
6. Question: A nurse discovers that a colleague has been administering medication without documenting it. What is the most appropriate action for the nurse to take?
- Ignore the behavior as long as clients are not harmed
- Confront the colleague directly
- Report the behavior to the nurse manager
- Document the observations in the client’s chart
Correct Answer: C. Report the behavior to the nurse manager Explanation: Failing to document medication administration is a serious violation of legal and ethical standards and must be reported.
7. Question: A client refuses to take a prescribed medication. What should the nurse do next?
- Force the client to take the medication
- Inform the client that they must take the medication
- Document the refusal and notify the healthcare provider
- Leave the medication at the bedside for the client to take later
Correct Answer: C. Document the refusal and notify the healthcare provider Explanation: Clients have the right to refuse medication, and the nurse must document the refusal and notify the healthcare provider.
Ethical Practice
8. Question: A client with terminal cancer asks the nurse to help them end their life. What is the most appropriate response by the nurse?
- Agree to help the client end their life
- Provide emotional support and refer the client to palliative care
- Ignore the client’s request and change the subject
- Inform the client that their request is illegal and unethical
Correct Answer: B. Provide emotional support and refer the client to palliative care Explanation: The nurse should provide emotional support and discuss options for palliative care to address the client’s concerns.
Question 9: A nurse is caring for a client who refuses a blood transfusion due to religious beliefs. What should the nurse do?
- Respect the client’s wishes and document the refusal
- Administer the transfusion without informing the client
- Convince the client to accept the transfusion
- Call a legal representative to overrule the client’s decision
Correct Answer: A. Respect the client’s wishes and document the refusal Explanation: The nurse must respect the client’s autonomy and document the refusal of treatment.
Coordination of Care
Question 10: A nurse is preparing for discharge teaching with a client who had a stroke. Which healthcare professionals should the nurse involve in the discharge planning process?
- Physical therapist
- Social worker
- Speech therapist
- All of the above
Correct Answer: D. All of the above Explanation: A multidisciplinary team, including a physical therapist, social worker, and speech therapist, is essential for comprehensive discharge planning.
Question 11: Which of the following actions best demonstrates effective coordination of care by the nurse?
- Performing all care activities independently
- Communicating with the healthcare team and involving the client in care planning
- Limiting family involvement in the care process
- Avoiding delegation of tasks to other team members
Correct Answer: B. Communicating with the healthcare team and involving the client in care planning Explanation: Effective coordination of care involves clear communication with the healthcare team and including the client in decision-making.
Prioritization
Question 12: A nurse receives a shift report on four clients. Which client should the nurse assess first?
- A client with stable vital signs scheduled for discharge today
- A client post-op day 1 requesting pain medication
- A client with a history of hypertension reporting a severe headache
- A client with chronic obstructive pulmonary disease (COPD) who is scheduled for a chest x-ray
Correct Answer: C. A client with a history of hypertension reporting a severe headache Explanation: A severe headache in a hypertensive client could indicate a hypertensive crisis and requires immediate assessment.
Question 13: A nurse is caring for multiple clients. Which client should the nurse see first?
- A client with a new onset of confusion
- A client with a dressing change order
- A client requesting assistance with ambulation
- A client scheduled for physical therapy
Correct Answer: A. A client with a new onset of confusion Explanation: New onset confusion could indicate a serious underlying condition and requires immediate assessment.
Delegation
Question 14: Which of the following tasks can a registered nurse delegate to a licensed practical nurse (LPN)?
- Administering oral medications to a stable client
- Completing the initial assessment of a client
- Developing a care plan for a new admission
- Providing discharge teaching to a client
Correct Answer: A. Administering oral medications to a stable client Explanation: LPNs can administer oral medications to stable clients under the delegation of an RN.
Question 15: A nurse is delegating tasks to a certified nursing assistant (CNA). Which of the following tasks is appropriate for the CNA to perform?
- Assessing a client’s pain level
- Educating a client about diabetes management
- Assisting a client with bathing and grooming
- Performing wound care on a surgical incision
Correct Answer: C. Assisting a client with bathing and grooming Explanation: CNAs can assist clients with activities of daily living, such as bathing and grooming.
Legal Responsibilities
Question 16: A nurse is aware that another nurse is documenting care that was not provided. What is the most appropriate action?
- Confront the nurse about their actions
- Ignore the situation if no harm is done
- Report the behavior to the nurse manager
- Provide the care that was documented
Correct Answer: C. Report the behavior to the nurse manager Explanation: Falsifying documentation is a serious violation that must be reported to ensure client safety and legal compliance.
Question 17: A client demands to leave the hospital against medical advice (AMA). What should the nurse do?
- Restrain the client to prevent them from leaving
- Explain the risks of leaving AMA and have the client sign an AMA form
- Allow the client to leave without any documentation
- Call the police to prevent the client from leaving
Correct Answer: B. Explain the risks of leaving AMA and have the client sign an AMA form Explanation: Clients have the right to leave AMA, but they should be informed of the risks and sign an AMA form.
Ethical Practice
Question 18: A nurse is caring for a terminally ill client who expresses a desire to explore hospice care. What is the nurse’s best response?
- Discourage the client from considering hospice care
- Provide information about hospice services and offer support
- Change the subject to a more positive topic
- Tell the client that hospice care is not an option
Correct Answer: B. Provide information about hospice services and offer support Explanation: The nurse should provide information about hospice care and support the client’s wishes.
Question 19: A nurse is caring for a client who refuses to participate in a prescribed treatment plan. What should the nurse do?
- Respect the client’s decision and document the refusal
- Administer the treatment without the client’s consent
- Convince the client to accept the treatment
- Contact a legal representative to enforce the treatment
Correct Answer: A. Respect the client’s decision and document the refusal Explanation: The nurse must respect the client’s autonomy and document their refusal.
Coordination of Care
Question 20: A nurse is coordinating care for a client who requires physical, occupational, and speech therapy. Which action demonstrates effective coordination?
- Scheduling all therapies for the same day
- Communicating with the therapy team and integrating the therapies into the client’s care plan
- Delegating the coordination of therapies to the client’s family
- Limiting therapy sessions to once a week
Correct Answer: B. Communicating with the therapy team and integrating the therapies into the client’s care plan Explanation: Effective coordination involves clear communication with the therapy team and integrating the therapies into the client’s care plan.
Question 21: Which of the following actions demonstrates effective discharge planning by the nurse?
- Providing the client with discharge instructions only
- Involving the client and family in the discharge planning process
- Limiting discharge planning to the day of discharge
- Notifying the client of the discharge date the day before
Correct Answer: B. Involving the client and family in the discharge planning process Explanation: Effective discharge planning involves the client and family in the planning process to ensure a smooth transition from hospital to home.
Prioritization
Question 22: A nurse is caring for a client with a suspected stroke. Which assessment finding requires immediate intervention?
- Slurred speech and facial droop
- Elevated blood pressure
- Difficulty swallowing
- Nausea and vomiting
Correct Answer: A. Slurred speech and facial droop Explanation: Slurred speech and facial droop are signs of an acute stroke, requiring immediate intervention.
Question 23: A nurse is assigned to care for four clients. Which client should the nurse assess first?
- A client with stable vital signs and no complaints
- A client scheduled for a procedure later in the day
- A client with shortness of breath and low oxygen saturation
- A client receiving IV antibiotics for an infection
Correct Answer: C. A client with shortness of breath and low oxygen saturation Explanation: Shortness of breath and low oxygen saturation are critical findings that require immediate assessment and intervention.
Delegation
Question 24: A nurse is delegating tasks to a nursing assistant. Which of the following tasks is appropriate to delegate to the nursing assistant?
- Performing a sterile dressing change
- Teaching a client about wound care
- Ambulating a client to the bathroom
- Administering oral medications
Correct Answer: C. Ambulating a client to the bathroom Explanation: Ambulating clients is within the scope of practice for a nursing assistant.
Question 25: Which task can a nurse delegate to an LPN?
- Initiating a blood transfusion
- Performing a focused assessment
- Developing a care plan
- Providing discharge instructions
Correct Answer: B. Performing a focused assessment Explanation: LPNs can perform focused assessments under the delegation of an RN.
Legal Responsibilities
Question 26: A nurse accidentally administers the wrong medication to a client. What is the first action the nurse should take?
- Document the incident in the client’s chart
- Notify the healthcare provider
- Report the incident to the nurse manager
- Monitor the client for adverse effects
Correct Answer: D. Monitor the client for adverse effects Explanation: The nurse should first monitor the client for any adverse effects and then notify the healthcare provider.
Question 27: A client requests access to their medical records. What is the appropriate response by the nurse?
- Deny the request for privacy reasons
- Provide the client with the records immediately
- Inform the client of the process to obtain their records
- Allow the client to view the records in the presence of the nurse
Correct Answer: C. Inform the client of the process to obtain their records Explanation: The nurse should inform the client of the appropriate process for obtaining access to their medical records.
Ethical Practice
Question 28: A nurse is caring for a client who expresses the wish to discontinue treatment. What is the most appropriate response by the nurse?
- Respect the client’s decision and inform the healthcare provider
- Convince the client to continue treatment
- Ignore the client’s request and continue treatment
- Call a family member to persuade the client
Correct Answer: A. Respect the client’s decision and inform the healthcare provider Explanation: The nurse must respect the client’s autonomy.
Prioritization
Question 29: A nurse finds a client on the floor. What should be the nurse’s first action?
- Assess the client for injuries
- Call for assistance
- Move the client to the bed
- Document the incident
Correct Answer: A. Assess the client for injuries Explanation: The nurse’s first action should be to assess the client for any injuries before taking further steps.
Question: A nurse is caring for a client who is experiencing an anaphylactic reaction. Which intervention should the nurse perform first?
- Administer epinephrine
- Provide supplemental oxygen
- Start an IV line
- Notify the healthcare provider
Correct Answer: A. Administer epinephrine Explanation: Administering epinephrine is the first-line treatment for anaphylaxis to counteract the allergic reaction.
Delegation
Question: A nurse is delegating tasks to a nursing assistant. Which task can the nursing assistant perform?
- Administering insulin injections
- Performing blood glucose monitoring
- Completing a head-to-toe assessment
- Educating a client about diabetes management
Correct Answer: B. Performing blood glucose monitoring Explanation: Nursing assistants can perform tasks such as blood glucose monitoring under the supervision of a nurse.
Question: A nurse is assigning care to a licensed practical nurse (LPN). Which of the following tasks is appropriate to delegate to the LPN?
- Initiating IV therapy
- Conducting a health history
- Administering oral medications
- Developing a nursing diagnosis
Correct Answer: C. Administering oral medications Explanation: LPNs are trained to administer oral medications and can do so under the delegation of an RN.
Legal Responsibilities
Question: A nurse witnesses a coworker diverting narcotics. What should the nurse do first?
- Report the coworker to the nurse manager
- Confront the coworker about the behavior
- Ignore the situation
- Report the incident to the police
Correct Answer: A. Report the coworker to the nurse manager Explanation: The nurse should report the diversion of narcotics to the nurse manager immediately for appropriate action.
Question: A client is preparing to undergo surgery and has not signed the consent form. What should the nurse do?
- Proceed with preoperative preparations
- Inform the surgeon that the consent form is not signed
- Sign the consent form on behalf of the client
- Administer preoperative medications
Correct Answer: B. Inform the surgeon that the consent form is not signed Explanation: The nurse must ensure that the consent form is signed by the client before any surgical procedure.
Ethical Practice
Question: A nurse is caring for a client who refuses a blood transfusion for religious reasons. What is the nurse’s best course of action?
- Respect the client’s decision and document the refusal
- Administer the blood transfusion against the client’s wishes
- Try to convince the client to accept the transfusion
- Contact the client’s family to persuade them
Correct Answer: A. Respect the client’s decision and document the refusal Explanation: The nurse must respect the client’s autonomy and document their refusal of treatment.
Question: A nurse is caring for a client who is nearing the end of life and expresses a desire to discuss advance directives. What should the nurse do?
- Provide information and support the client in discussing advance directives
- Change the subject to avoid causing distress
- Inform the client that it is too late to discuss advance directives
- Delay the conversation until the family is present
Correct Answer: A. Provide information and support the client in discussing advance directives Explanation: The nurse should support the client in discussing advance directives and provide the necessary information.
Coordination of Care
Question: A nurse is coordinating care for a client with a new diagnosis of diabetes. Which healthcare professionals should be involved in the client’s care plan?
- Dietitian
- Endocrinologist
- Diabetes educator
- All of the above
Correct Answer: D. All of the above Explanation: A multidisciplinary team, including a dietitian, endocrinologist, and diabetes educator, is essential for managing diabetes effectively.
Question: A nurse is planning a discharge for a client with chronic obstructive pulmonary disease (COPD). Which action best demonstrates effective discharge planning?
- Providing the client with educational pamphlets only
- Involving the client and family in the discharge planning process
- Limiting discharge planning to the day of discharge
- Arranging for follow-up appointments only after discharge
Correct Answer: B. Involving the client and family in the discharge planning process Explanation: Effective discharge planning involves the client and family in the planning process to ensure a smooth transition from hospital to home.
Prioritization
Question: A nurse is caring for a client with asthma who suddenly develops severe shortness of breath. Which action should the nurse take first?
- Administer a prescribed bronchodilator
- Check the client’s oxygen saturation
- Notify the healthcare provider
- Assist the client to a high-Fowler’s position
Correct Answer: D. Assist the client to a high-Fowler’s position Explanation: Positioning the client in a high-Fowler’s position can immediately help alleviate respiratory distress and improve oxygenation.
Question: A nurse is assigned to care for four clients. Which client should the nurse assess first?
- A client scheduled for a diagnostic test in 2 hours
- A client who reports feeling lightheaded and dizzy
- A client who has stable vital signs and is resting comfortably
- A client requesting assistance with ambulation
Correct Answer: B. A client who reports feeling lightheaded and dizzy Explanation: Lightheadedness and dizziness could indicate a potential underlying issue that requires immediate assessment.
Delegation
Question: A nurse is delegating tasks to a nursing assistant. Which of the following tasks is appropriate to delegate to the nursing assistant?
- Administering an intramuscular injection
- Assisting a client with range-of-motion exercises
- Performing a detailed head-to-toe assessment
- Providing discharge teaching to a client
Correct Answer: B. Assisting a client with range-of-motion exercises Explanation: Assisting with range-of-motion exercises is within the scope of practice for a nursing assistant.
Question: Which task can a nurse delegate to an LPN?
- Conducting a comprehensive health assessment
- Administering intravenous medications
- Performing wound care on a stable client
- Developing a plan of care for a new admission
Correct Answer: C. Performing wound care on a stable client Explanation: LPNs are trained to perform wound care on stable clients under the delegation of an RN.
Legal Responsibilities
Question: A client refuses to sign an informed consent form for a procedure. What should the nurse do?
- Proceed with the procedure without the consent form
- Inform the healthcare provider and document the client’s refusal
- Sign the consent form on behalf of the client
- Administer preoperative medications without consent
Correct Answer: B. Inform the healthcare provider and document the client’s refusal Explanation: The nurse must inform the healthcare provider and document the client’s refusal to sign the informed consent form.
Question: A nurse is caring for a client who has advanced directives. What is the nurse’s responsibility regarding these directives?
- Follow the advanced directives as written
- Ignore the advanced directives if they conflict with the healthcare provider’s orders
- Convince the client to change their advanced directives
- Allow the family to make decisions that override the advanced directives
Correct Answer: A. Follow the advanced directives as written Explanation: The nurse must follow the client’s advanced directives as written to respect their wishes.
Ethical Practice
Question: A nurse is caring for a client who expresses a desire to refuse further treatment. What should the nurse do?
- Respect the client’s decision and inform the healthcare provider
- Convince the client to continue treatment
- Ignore the client’s request and continue treatment
- Call a family member to persuade the client
Correct Answer: A. Respect the client’s decision and inform the healthcare provider Explanation: The nurse must respect the client’s autonomy and inform the healthcare provider of the client’s decision.
Question: A nurse is caring for a client with a terminal illness who requests assistance with creating a living will. What should the nurse do?
- Provide information and support the client in creating a living will
- Avoid the topic and focus on other aspects of care
- Inform the client that a living will is unnecessary
- Delay the conversation until the healthcare provider arrives
Correct Answer: A. Provide information and support the client in creating a living will Explanation: The nurse should support the client’s wishes and provide information to help them create a living will.
Coordination of Care
Question: A nurse is coordinating care for a client who requires dialysis. Which healthcare professionals should be involved in the client’s care plan?
- Nephrologist
- Dietitian
- Social worker
- All of the above
Correct Answer: D. All of the above Explanation: A multidisciplinary team, including a nephrologist, dietitian, and social worker, is essential for comprehensive dialysis care.
Question: A nurse is preparing to discharge a client with heart failure. Which action demonstrates effective discharge planning?
- Providing the client with educational pamphlets only
- Involving the client and family in the discharge planning process
- Limiting discharge planning to the day of discharge
- Scheduling follow-up appointments only after discharge
Correct Answer: B. Involving the client and family in the discharge planning process Explanation: Effective discharge planning involves the client and family in the planning process to ensure a smooth transition from hospital to home.
Prioritization
Question: A nurse is caring for a client with a history of myocardial infarction who reports chest pain. Which action should the nurse take first?
- Administer prescribed nitroglycerin
- Check the client’s vital signs
- Notify the healthcare provider
- Provide supplemental oxygen
Correct Answer: A. Administer prescribed nitroglycerin Explanation: Administering nitroglycerin can help alleviate chest pain and improve blood flow to the heart.
Question: A nurse is assigned to care for four clients. Which client should the nurse assess first?
- A client scheduled for discharge later today
- A client with a fever of 101°F
- A client with chronic pain requesting pain medication
- A client with shortness of breath
Correct Answer: D. A client with shortness of breath Explanation: Shortness of breath is a critical finding that requires immediate assessment and intervention.
Delegation
Question: Which of the following tasks can a nurse delegate to a licensed practical nurse (LPN)?
- Administering IV push medications
- Teaching a client about wound care
- Performing wound care on a stable client
- Developing a discharge plan
Correct Answer: C. Performing wound care on a stable client Explanation: LPNs can perform wound care on stable clients under the delegation of an RN.
Question: A nurse is delegating tasks to a nursing assistant. Which of the following tasks is appropriate for the nursing assistant to perform?
- Performing a head-to-toe assessment
- Measuring and recording a client’s vital signs
- Administering oral medications
- Developing a care plan
Correct Answer: B. Measuring and recording a client’s vital signs Explanation: Measuring and recording vital signs is within the scope of practice for a nursing assistant.
Legal Responsibilities
Question: A nurse discovers that a client has signed a consent form for a procedure without understanding the risks. What should the nurse do?
- Proceed with the procedure
- Notify the healthcare provider
- Explain the risks to the client
- Cancel the procedure
Correct Answer: B. Notify the healthcare provider Explanation: The nurse should notify the healthcare provider to ensure the client understands the risks before proceeding.
Question: A client refuses a scheduled treatment. What should the nurse do?
- Force the client to undergo the treatment
- Respect the client’s decision and document the refusal
- Administer the treatment without informing the client
- Ignore the client’s refusal
Correct Answer: B. Respect the client’s decision and document the refusal Explanation: The nurse must respect the client’s autonomy and document their refusal of treatment.
Ethical Practice
Question: A nurse is caring for a client who expresses a desire to discuss advance directives. What should the nurse do?
- Provide information and support the client in discussing advance directives
- Change the subject to avoid causing distress
- Inform the client that it is too late to discuss advance directives
- Delay the conversation until the family is present
Correct Answer: A. Provide information and support the client in discussing advance directives Explanation: The nurse should support the client in discussing advance directives and provide the necessary information.
Question: A nurse is caring for a client who requests to discontinue life-sustaining treatment. What is the nurse’s best response?
- Respect the client’s wishes and inform the healthcare provider
- Convince the client to continue treatment
- Ignore the client’s request
- Contact a legal representative to enforce the treatment
Correct Answer: A. Respect the client’s wishes and inform the healthcare provider Explanation: The nurse must respect the client’s autonomy and inform the healthcare provider of the client’s decision.
Coordination of Care
Question: A nurse is coordinating care for a client who requires physical therapy, occupational therapy, and speech therapy. Which action demonstrates effective coordination?
- Scheduling all therapies for the same day
- Communicating with the therapy team and integrating the therapies into the client’s care plan
- Delegating the coordination of therapies to the client’s family
- Limiting therapy sessions to once a week
Correct Answer: B. Communicating with the therapy team and integrating the therapies into the client’s care plan Explanation: Effective coordination involves clear communication with the therapy team and integrating the therapies into the client’s care plan.
Question: Which of the following actions demonstrates effective discharge planning by the nurse?
- Providing the client with discharge instructions only
- Involving the client and family in the discharge planning process
- Limiting discharge planning to the day of discharge
- Notifying the client of the discharge date the day before
Correct Answer: B. Involving the client and family in the discharge planning process Explanation: Effective discharge planning involves the client and family in the planning process to ensure a smooth transition from hospital to home.
Prioritization
Question: A nurse is caring for a client with a suspected stroke. Which assessment finding requires immediate intervention?
- Slurred speech and facial droop
- Elevated blood pressure
- Difficulty swallowing
- Nausea and vomiting
Correct Answer: A. Slurred speech and facial droop Explanation: Slurred speech and facial droop are signs of an acute stroke, requiring immediate intervention.
Question: A nurse is assigned to care for four clients. Which client should the nurse assess first?
- A client with a new onset of confusion
- A client with stable vital signs and no complaints
- A client scheduled for physical therapy
- A client who reports chronic pain
Correct Answer: A. A client with a new onset of confusion Explanation: New onset confusion could indicate a serious underlying condition and requires immediate assessment.
Delegation
Question: A nurse is delegating tasks to a nursing assistant. Which task can the nursing assistant perform?
- Administering insulin injections
- Assisting a client with activities of daily living (ADLs)
- Performing a detailed head-to-toe assessment
- Providing discharge teaching to a client
Correct Answer: B. Assisting a client with activities of daily living (ADLs) Explanation: Assisting clients with ADLs is within the scope of practice for a nursing assistant.
Question: Which task can a nurse delegate to an LPN?
- Conducting a comprehensive health assessment
- Administering intravenous medications
- Performing wound care on a stable client
- Developing a plan of care for a new admission
Correct Answer: C. Performing wound care on a stable client Explanation: LPNs are trained to perform wound care on stable clients under the delegation of an RN.