2023 ATI RN Leadership Proctored Exam NGN With Answers-100 Solved Questions

NEW GENERATION RN ATI LEADERSHIP PROCTORED EXAM 2023
WITH NGN ALEADY GRADED A+
1. A nurse in an acute care mental health facility is participating in a medication education
group. The leader of the group uses a laissez-faire leadership style. Which of the following
actions should the nurse expect from the leader during the session?
A. The leader allows the group to discuss whatever they would like to regarding their
medications.
Rationale: This reflects a laissez-faire style, where the leader permits open discussion and
encourages self-direction among group members.
B. The leader encourages group members to remain silent until questions are called for.
Rationale: This suggests a more structured approach, which is not characteristic of laissezfaire leadership, as it limits open communication.
C. The leader has group members vote on what they would like to learn about during the
session.
Rationale: While voting is participatory, it still implies some level of direction, which is not
typical of laissez-faire leadership.
D. The leader lectures about medication adverse effects to the group members.
Rationale: This indicates a directive approach, where the leader controls the flow of
information, contradicting the laissez-faire style.
2. A charge nurse is observing a conflict between two nurses who both insist that the charge
nurse favors the other when making assignments. Which of the following conflict-resolution
strategies should the charge nurse use?
A. Encourage collaboration between the two nurses when making the assignments.
Rationale: Promoting collaboration fosters communication and helps resolve
misunderstandings, addressing the root of the conflict.
B. Ask each nurse to take turns making the assignments.
Rationale: This approach can exacerbate feelings of favoritism and does not address the
conflict directly.
C. Tell the nurses that the assignments will be more equitable in the future.
Rationale: Merely promising future equity does not resolve existing concerns or perceptions
of bias.

D. Arrange for the nurses to have as few shifts together as possible.
Rationale: Avoiding scheduling them together does not facilitate resolution or address the
conflict directly, potentially allowing issues to persist.
3. A nurse is preparing an in-service for a group of nurses about malpractice issues in nursing.
Which of the following examples should the nurse include in the teaching as an example of
malpractice?
A. Documenting communication with a provider in the progress notes of the client's medical
record
Rationale: Documenting communication is a necessary part of nursing practice and does not
reflect malpractice.
B. Placing a yellow bracelet on a client who is at risk for falls
Rationale: Placing a fall risk bracelet is a standard safety measure and reflects proper patient
care.
C. Leaving a nasogastric tube clamped after administering oral medication
Rationale: This action can lead to significant harm, showing a failure to adhere to the
standard of care, thus constituting malpractice.
D. Administering potassium via IV bolus
Rationale: Administering potassium via IV bolus requires caution, but this action alone does
not indicate malpractice without further context.
4. A charge nurse is delegating care for a group of clients. Which of the following tasks
should the charge nurse assign to a licensed practical nurse?
A. Complete discharge teaching for a client who has a new diagnosis of diabetes mellitus.
Rationale: Discharge teaching involves complex patient education and is typically reserved
for RNs.
B. Complete the Glasgow Coma Scale for a client who has an evolving stroke.
Rationale: Performing the Glasgow Coma Scale requires higher-level assessment skills that
fall within the RN's scope of practice.
C. Perform a sterile dressing change for a client who has an abdominal wound.
Rationale: LPNs are trained to perform sterile dressing changes, making this an appropriate
task for delegation.
D. Perform an admission assessment for a client who is scheduled for surgery.

Rationale: Admission assessments are comprehensive evaluations that are typically
conducted by RNs, requiring a higher level of critical thinking.
5. A staff nurse is observing a newly licensed nurse suction a client's tracheostomy. Which of
the following actions by the newly licensed nurse requires intervention by the staff nurse?
A. Waits for 2 min between suctions
Rationale: Waiting for 2 minutes between suction sessions is appropriate and ensures patient
safety.
B. Encourages the client to cough during suctioning
Rationale: Encouraging the client to cough while suctioning can increase the risk of trauma
to the airway and is not recommended during the suctioning process. The other actions are
appropriate and within safe practice. Encouraging coughing during suctioning can lead to
airway trauma and should be avoided, making this action incorrect.
C. Applies suction for 15 seconds
Rationale: Applying suction for 15 seconds is within recommended guidelines, promoting
patient safety.
D. Inserts the catheter without applying suction
Rationale: Inserting the catheter without suction is the correct initial step in the suctioning
process, which is acceptable practice.
6. A nurse is planning care for a group of clients and is working with one licensed practical
nurse (LPN) and one assistive personnel (AP). Which of the following actions should the
nurse take first to manage her time effectively?
A. Delegate tasks to the AP.
Rationale: Delegating tasks is important but should come after establishing clear goals to
ensure effective delegation.
B. Determine goals of the day
Rationale: Establishing clear goals is the foundational step in managing time effectively.
Once the goals are set, the nurse can delegate tasks, develop a time frame, and schedule
activities accordingly. Establishing goals first helps in prioritizing tasks and provides a
framework for time management.
C. Develop an hourly time frame for tasks.
Rationale: Developing a time frame for tasks should follow after goals are identified to
ensure they align with the objectives.

D. Schedule daily activities
Rationale: Scheduling activities is useful, but it is more effective once goals are set to direct
those activities.
7. A nurse manager is addressing reports of conflict within a nursing unit. The nurse should
identify which of the following situations as an example of interpersonal conflict?
A. A nurse experiences insulting comments directed at them by another nurse
Rationale: This situation clearly illustrates interpersonal conflict, as it involves direct
negative interactions between individuals. The other options reflect concerns that may
involve conflicts but do not exemplify direct interpersonal conflict. This situation directly
illustrates interpersonal conflict, as it involves negative interactions between two individuals.
B. A nurses expresses concern that another shift works fewer holiday hours.
Rationale: A nurse’s concern about another shift's holiday hours involves workplace
dynamics but does not reflect direct interpersonal conflict.
C. A nurse has a personal difficulty with caring for clients who have HIV.
Rationale: A personal difficulty with caring for specific clients is an internal conflict rather
than a conflict involving another person.
D. A nurse submits a complaint about another department's handoff reporting.
Rationale: Submitting a complaint about another department involves organizational issues
rather than a direct conflict between individuals, hence it is not interpersonal.
8. A nurse is serving on a continuous quality improvement (CQI) committee that has been
assigned to develop a program to reduce the number of medication administration errors
following a sentinel event at the facility. Which of the following strategies should the
committee plan to initiate first?
A. Provide an in service on medication administration to all the nurses.
Rationale: A recommendation for staff education may be indicated, but this does not assist
the committee to identify factors that lead to medication errors.
B. Require staff nurses to demonstrate competency by passing a medication administration
examination.
Rationale: Ensuring competency in medication administration may be indicated, but this
does not assist the committee to identify factors that lead to medication errors.
C. Review the events leading up to each medication administration error.

Rationale: After a sentinel event, the first step the committee should plan to take is to use
root cause analysis to identify the underlying cause or causes that led to the medication
errors.
D. Develop a quality improvement program for nurses involved in medication administration
errors.
Rationale: Although development of a quality improvement program for nurses involved in
medication errors may be indicated, this does not assist the committee to identify factors that
lead to medication errors.
9. A charge nurse has access to the facility’s electronic client records. It is appropriate for the
charge nurse to share her personal password with whom?
A. The nurse manager
Rationale: A nurse manager authorized to have access to a computer will have a personal
password.
B. No one
Rationale: Computer passwords cannot be shared with others for any reason. Any facility
employee authorized to have access to the database on a computer will have a personal
password.
C. A nursing student who is completing a preceptorship on the unit
Rationale: A nursing student who is authorized to have access to the database on a computer
will have a personal password.
D. The unit clerk
Rationale: A unit clerk authorized to have access to a computer will have a personal
password.
10. A nurse on a medical-surgical unit is reconciling a newly admitted client’s medication.
The nurse is reviewing the process of medication reconciliation with a newly licensed nurse.
The nurse should include which of the following information?
A. The American Hospital Association requires accredited facilities to have protocols in place
requiring medication reconciliation.
Rationale: The Joint Commission requires accredited facilities to have protocols in place
requiring medication reconciliation.
B. The purpose of medication reconciliation is to prevent adverse medication reactions.

Rationale: Medication reconciliation includes reviewing an accurate list of all medications
the client is taking and comparing that list to new medications the provider has prescribed.
This action decreases the risk of medication interactions and adverse outcomes.
C. The nurse who performs medication reconciliation is demonstrating the ethical principal of
veracity.
Rationale: This action by the nurse does not demonstrate the ethical principal veracity, which
means telling the truth. The nurse who performs medication reconciliation is demonstrating
the ethical principle beneficence, which means the nurse takes action to promote good, and
nonmaleficence, which means the nurse takes action to prevent harm.
D. The International Council of Nurses Code of Ethics stipulates that the nurse performs
medication reconciliation when a client is admitted to a facility, is transferred to another
facility, and when a client is discharged from a facility.
Rationale: The International Council of Nurses Code of Ethics stipulates that nurses have a
responsibility to promote health and prevent illness, but it does not mandate medication
reconciliation. The Institute for Healthcare Improvement recommends the nurse perform
medication reconciliation when a client is transferred, and The Joint Commission requires
medication reconciliation when a client is admitted and when a client is discharged.
11. A nurse is caring for a client on the medical-surgical unit. The client has been taking
warfarin at home and her laboratory values reveal her INR is 3.5. The client states she is
checking herself out of the hospital and refuses to wait until her provider can discuss the
situation with her. Which of the following actions should the nurse take?
A. Tell the client she will not be permitted to leave the facility until she has signed the against
medical advice (AMA) form.
Rationale: The nurse should attempt to get the client to sign the AMA form because this
measure can help to defend the facility if a lawsuit ensues; however, the nurse should not tell
the client she will not be permitted to leave the facility because this action could lead to
charges of false imprisonment.
B. Tell the client if she leaves without a written prescription for discharge, her insurance will
not pay for the facility visit.
Rationale: This action by the nurse is uncaring and the client could perceive it as a threat.
C. Explain the risk the client faces if she leaves the facility.

Rationale: The expected reference range for INR while a client is taking warfarin is 2 to 3.
The nurse has an obligation to explain to the client that her INR is very high and she is at risk
for bleeding.
D. Ask the security department to guard the room to the client’s door.
Rationale: This action could lead to charges of false imprisonment.
12. A nurse on a medical-surgical unit is planning to delegate tasks to an adult volunteer.
Which of the following tasks should the charge nurse avoid assigning to the volunteer?
A. Delivering meal trays to clients in their rooms
Rationale: Delivering meal trays is an appropriate task to delegate to a volunteer.
B. Assisting a client who has difficulty seeing the foods on the tray while eating
Rationale: Assisting a client who has a vision deficiency to eat is an appropriate task to
delegate to a volunteer.
C. Delivering a routine urine specimen to the laboratory
Rationale: Delivering a routine urine specimen is an appropriate task for a volunteer.
D. Observing a postoperative client who is confused
Rationale: A nurse who uses delegation is responsible for delegating tasks to the right
person. A volunteer does not have the training to intervene if this client tries to get out of bed
or starts pulling at tubes. The observation of this client should be assigned to a member of the
nursing staff.
13. An assistive personnel (AP) tells the nurse manager that she observed a nurse on the unit
removing a small amount of morphine from syringes prior to administering the medication to
clients. Which of the following actions should the nurse manager take first?
A. Gather data about the nurse’s work performance and attendance history.
Rationale: The first action the nurse should take is to conduct an investigation and determine
if the allegations are true.
B. Approach the involved nurse to discuss the behavior.
Rationale: The nurse should approach the involved nurse to discuss the behavior; however,
there is another action the nurse should take first.
C. Notify the risk manager.
Rationale: The nurse should notify the risk manager; however, there is another action the
nurse should take first.
D. Refer the nurse to the board of nursing diversion program.

Rationale: The nurse should report the incident to the board of nursing if the suspicion of
drug diversion is founded; however, there is another action the nurse should take first.
14. A nurse is caring for a client who has severe head injuries and is declared brain dead. The
transplant coordinator has spoken with the client’s family about organ donation. The client’s
spouse states she is confused and does not know what she should do. Which of the following
responses by the nurse is appropriate?
A. "There is such a shortage of organs in this country, so I think you should go ahead and
consent to donate your spouse’s organs."
Rationale: The nurse should avoid giving her personal opinion.
B. "What do you think your spouse would have wanted?"
Rationale: Federal law requires facilities to have policies and procedures in place about
making a request for organ and tissue donation at the time of death. The request is made by
an employee, often a social worker, who has advanced training and can request the donations
in a caring, sensitive manner. The role of the nurse is to provide emotional support to the
family. Family members should consider the deceased person’s wishes when making their
decision.
C. "Most religions support organ donation, so don’t let that stand in the way."
Rationale: While it is true that most religions support organ donation, there is no indication
that this is a concern felt by the client’s spouse.
D. "Don’t you think you will feel a little better about the situation if you donate your spouse’s
organs?
Rationale: The nurse should not provide the client’s spouse with false reassurance.
15. A nurse manager is reviewing the Good Samaritan laws with a group of newly licensed
nurses. Which of the following statements by the nurse manager is appropriate?
A. "If you render aid in an accident, do not leave the scene until another competent
person can take over."
Rationale: Once the nurse renders aid, she has entered a nurse-client relationship and must
continue to provide care until competent help arrives.
B. "Good Samaritan laws prohibit the victim from filing a lawsuit against the nurse."
Rationale: Good Samaritan laws require the nurse to render the level of care expected by a
competent, prudent nurse in a similar situation. To win a malpractice suit against the nurse,
the victim must prove the nurse was grossly negligent or careless.

C. "Federal laws require a licensed nurse to render aid in an emergency."
Rationale: Good Samaritan laws are state laws. Only a few states have duty to rescue laws,
for example: Vermont, Minnesota, and Wisconsin. The nurse should know the laws of the
state.
D. "A nurse who volunteers at a summer camp for children is covered by Good Samaritan
laws."
Rationale: Good Samaritan laws protect the nurse in an emergency. Even in volunteer
situations, Good Samaritan laws do not provide protection because in most cases an
emergency does not exist.
16. A nurse is caring for several clients. For which of the following situations should the
nurse complete an incident report?
A. The nurse identifies a broken piece of equipment.
Rationale: This issue should be resolved by removing the equipment from the client care
area and placing a work order for its repair.
B. A staff member does not show up to work her assigned shift.
Rationale: This is a staff problem that should be resolved between the staff member and the
nurse manager.
C. A client discovers that his dentures are missing.
Rationale: This situation represents a variation from the normal standard of care. A change in
the client's plan of care may be necessary if the client has difficulty eating or speaking
without the dentures. In addition, the facility may be liable for replacing the missing dentures.
D. The nurse has a disagreement with the nursing supervisor about inadequate staffing.
Rationale: An incident report is not necessary for this situation.
17. A staff nurse has applied for a promotion. The hiring manager insinuates that if there was
a sexual relationship between the two of them, the nurse's promotion request would get
increased consideration. Which of the following actions should the staff nurse take first?
A. Tell the hiring manager in clear terms that this conduct causes feelings of discomfort
and that the behavior should stop immediately.
Rationale: Sexual harassment is unwanted sexual advances made in the context of a
relationship of unequal power or authority. It is experienced as offensive in nature. The nurse
should first start by taking the most direct measure: confronting the hiring manager and
insisting the harassment stop.

B. Report the behavior to the nurse manager.
Rationale: The nurse should report the behavior to the nurse manager; however, there is
another action the nurse should take first.
C. Create a written document of the incident and store the document in a safe place.
Rationale: The nurse should create a written document of the incident and store the
document in a safe place; however, there is another action the nurse should take first.
D. Seek help from a trustworthy friend.
Rationale: The nurse should seek help from a trustworthy friend; however, there is another
action the nurse should take first.
18. A nurse in a long-term care facility has assigned a task to an assistive personnel (AP). The
AP refuses to perform the task. Which of the following is an appropriate statement for the
nurse to make?
A. "I feel you are being inconsiderate of the other team members."
Rationale: This statement is accusatory and can create barriers to communication.
B. "I have to let the director of nursing know about this situation."
Rationale: Delaying conflict resolution or involving superiors without first attempting to
resolve the situation can create adversarial feelings.
C. "I need to talk to you about the unit policies regarding client assignments."
Rationale: This statement opens the conversation in a nonthreatening way and places the
focus on the issue of policies rather than on any personal desire or characteristic of the
individual.
D. "You always get your choice of assignment and don't work your fair share."
Rationale: This is an inflammatory statement that will only cause more barriers to the
resolution of the conflict.
19. A nurse is caring for a client who is participating in a research study for an experimental
chemotherapy medication. After three treatments, the experimental medication is
discontinued due to evidence of rapidly advancing kidney failure. The nurse should
understand discontinuing this medication demonstrates which of the following ethical
principles?
A. Veracity
Rationale: Veracity is truthfulness. It requires the nurse to tell the truth to every client and to
make sure the client fully understands the message.

B. Autonomy
Rationale: Autonomy is the right to independence and personal freedom, which leads to the
primacy of self-determination.
C. Fidelity
Rationale: Fidelity is the duty to keep promises. It refers to the obligation to be faithful to
agreements, commitments, and responsibilities that are made.
D. Nonmaleficence
Rationale: Nonmaleficence, as a principle in research, is the obligation to do no harm to the
client. Intentionally exposing clients to serious or permanent harm is unacceptable. Should
such a situation emerge during the conduct of a study, the study should be terminated
immediately.
20. A nurse overhears two assistive personnel (AP) from the medical-surgical unit discussing
a hospitalized client while in the cafeteria. Which of the following is the priority nursing
action?
A. Quietly tell the APs that this is not appropriate.
Rationale: The nurse has a professional duty to protect the client’s confidential information.
When using the urgent vs. nonurgent approach to client care, the nurse determines the priority
is to stop the APs before there is an additional breach of confidentiality.
B. Ask the nurse manager to provide an in service program about confidentiality to the staff
on the unit.
Rationale: Although it might be appropriate to ask the manager to review the importance of
maintaining confidentiality with the staff on the unit, there is another action that is the
priority.
C. Complete an incident report.
Rationale: Although the nurse has a responsibility to complete an incident report when there
is an accident or unusual occurrence, there is another action that is the priority.
D. Document the occurrence in a personal log.
Rationale: Although the nurse should keep notes about the occurrence for legal protection,
there is another action that is the priority.
21. A nurse has several tasks to delegate to an assistive personnel (AP). Which of the
following tasks should the nurse ask the AP to perform first?
A. Take an arterial blood gas (ABG) specimen to the laboratory.

Rationale: When using the urgent vs. nonurgent approach to client care, the nurse should
determine the priority action is to take the ABG blood sample to the laboratory. ABG samples
are placed on ice and must be transported to the laboratory immediately or the specimen will
deteriorate, making any results inaccurate.
B. Transport a client to the radiology department for an x-ray.
Rationale: It is appropriate to delegate this task to the AP, but there is another task that is the
priority.
C. Pass fresh water to clients on the unit.
Rationale: It is appropriate to delegate this task to the AP, but there is another task that is the
priority.
D. Obtain a routine urine sample from a newly-admitted client.
Rationale: It is appropriate to delegate this task to the AP, but there is another task that is the
priority.
22. A nurse is caring for an older adult client who has a terminal illness and is ventilator
dependent. The client is alert and oriented and he wants to discontinue use of the ventilator.
The nurse should be aware that continued treatment against the client's wishes is a violation
of which of the following ethical principles?
A. Veracity
Rationale: The ethical principle of veracity requires the nurse to tell the truth and not to
intentionally deceive or mislead clients.
B. Autonomy
Rationale: The issue here is the client's right to choose. The ethical principle of autonomy
applies to an individual's right to choose and control what happens to him. Respecting
autonomy requires the nurse to recognize the client's choice is based on personal values and
those values do not have to be shared by the nurse.
C. Fidelity
Rationale: The ethical principle of fidelity requires the nurse to keep promises by being
faithful to agreements, commitments, and responsibilities.
D. Justice
Rationale: The ethical principle of justice requires the nurse to treat everyone fairly.

23. A nurse and an experienced licensed practical nurse (LPN) are caring for a group of
clients. Which of the following tasks should the nurse delegate to the LPN? (Select all that
apply.)
A. Provide discharge instructions to a confused client's spouse.
Rationale: This task requires comprehensive teaching and assessment skills that are typically
performed by a registered nurse (RN). It is important for the RN to ensure that the
instructions are understood, especially in a potentially confusing situation.
B. Obtain vital signs from a client who is 6 hr postoperative.
Rationale: This is within the LPN's scope of practice, as they are trained to monitor and
report vital signs.
C. Administer a tap-water enema to a client who is preoperative.
Rationale: LPNs are trained to perform this procedure, making it an appropriate task for
delegation.
D. Initiate a plan of care for a client who is postoperative from an appendectomy.
Rationale: This task typically requires the critical thinking and assessment skills of an RN,
as it involves comprehensive evaluation and planning based on the client's condition.
E. Catheterize a client who has not voided in 8 hr.
Rationale: This is a procedure that LPNs are qualified to perform, making it suitable for
delegation.
24. A nurse is caring for a client who is scheduled for surgery. The nurse’s role in regard to
informed consent is which of the following?
A. Ensuring the charge nurse is available to witness the client’s signature on the consent form
Rationale: The nurse caring for the client can witness the client’s signature on the consent
form. It is not necessary to ask the charge nurse to serve as the witness.
B. Explaining the risks involved with the procedure
Rationale: The surgeon must explain the risks involved with the procedure. A nurse who
attempts to explain the risks involved with the procedure faces the possibility of legal action
if the information is incomplete or incorrect. Additionally, the nurse is interfering with the
client provider relationship.
C. Discussing alternate treatment options
Rationale: Discussing alternate treatment options is the responsibility of the surgeon. A nurse
who attempts to discuss alternate treatment options faces the possibility of legal action if the

information is incomplete or incorrect. Additionally, the nurse is interfering with the client
provider relationship.
D. Determining the client’s level of understanding about the procedure
Rationale: In the role of client advocate, the nurse is responsible for ensuring the client
understands the information provided by the surgeon and must notify the surgeon if the client
has questions.
25. A client who fell and broke his hip while being assisted to the bathroom by a nurse states
he plans to sue the nurse. The nurse should know that, in a legal proceeding, the standard that
will be used to determine if the nurse was negligent is which of the following?
A. An expert nurse provides testimony that the nurse should have handled the situation
differently.
Rationale: Although expert nurses can be called to testify by attorneys for both the plaintiff
and the defendant, this is not the standard used to determine the nurse's liability.
B. Another staff nurse provides testimony about how a reasonable, prudent nurse would
have handled the situation.
Rationale: The definition of negligence is practice that is below the standard of care. The
benchmark for standard of care is what a reasonable, prudent person who has similar
background and experience would do. Another staff nurse who has similar background is the
correct person to provide testimony.
C. The client's attorney states that injury to the client could have been prevented.
Rationale: Although the client's attorney can offer an opinion regarding how injury to the
client occurred and could have been prevented, this is not the standard used to determine the
nurse's liability.
D. The client's provider testifies the nurse was at fault for the injury.
Rationale: Although the client's provider can be called to testify about the injury, this is not
the standard used to determine if the nurse was negligent.
26. A nurse in an acute care setting is serving on a committee whose charge is to use the
auditing process to client care. Which of the following aspects of client care is measured by a
process audit?
A. Availability of resources, such as fire extinguishers
Rationale: Structure audits evaluate the availability of resources.
B. Nursing staff ratios

Rationale: Structure audits measure staffing ratios.
C. Quality of nursing care provided
Rationale: Process audits evaluate the quality of care nurses provide. They also determine if
the care provided by nurses is consistent with established facility policy.
D. Length of facility stay for a cohort of clients
Rationale: Outcome audits measure the outcome of the care provided and include elements
such as morbidity, mortality, and length of facility stay.
27. Following a tornado, a nurse is determining which of the clients assigned to her care can
be discharged to free up beds for injured clients. Which of the following clients should the
nurse recommend for discharge?
A. A young adult client who has Crohn's disease and is 1 day preoperative for an
ileostomy
Rationale: A client who is scheduled for an elective surgery is medically stable and is not
bedridden; therefore, the nurse should recommend this client for discharge.
B. An adolescent client who was admitted 24 hr ago due to a spontaneous pneumothorax
Rationale: A client who has a pneumothorax is unstable and needs rest, oxygen, and
observation. If the client’s condition becomes worse, a chest tube may be required. Therefore,
the nurse should not recommend this client for discharge.
C. A middle adult who is 36 hr postoperative from an open laminectomy
Rationale: A client who is postoperative from an open laminectomy is at risk for
complications, especially 24 to 48 hr after surgery. Therefore, this client is not stable and the
nurse should not recommend this client for discharge.
D. An older adult client who was admitted for diabetic ketoacidosis and his most recent
ABGs show his pH is now 7.32
Rationale: Diabetic ketoacidosis is a serious complication of diabetes mellitus. It usually
develops in conjunction with an infection, but it can also develop due to poor nonadherence
to prescribed care. This client’s pH is below the expected reference range; therefore, this
client is not stable and the nurse should not recommend this client for discharge.
28. A nurse is caring for a client who is preoperative. The nurse signs as a witness on the
client's consent form. The nurse’s signature on the consent form indicates which of the
following?
A. Determines the client does not have a mental illness

Rationale: Clients who have a mental illness have the right to make decisions about their
health care unless they have been found to be incompetent by a court of law.
B. Confirms the client appears competent to provide consent
Rationale: By signing as a witness on a procedural consent form, the nurse is confirming the
client was the one who signed the consent form and that he seems to be competent to give
consent.
C. Asserts the nurse has explained the risks and benefits of the procedure
Rationale: It is the responsibility of the provider to explain the risks and benefits of the
procedure to the client.
D. Records that the client’s spouse agrees the procedure is necessary
Rationale: Although support from the client’s spouse can be a factor when the client
considers surgery, the ethical principle autonomy is a fundamental principle and it supports
the client’s right to self-determination.
29. A nurse has been reassigned from her regular area of work to a unit that is short staffed.
Which of the following actions should the nurse take first?
A. Ask what she will be assigned to do.
Rationale: Before accepting the assignment, the nurse should clarify the complexity of the
assignment, such as how many clients she will be assigned to care for, what skills are needed,
and what resources are available to her.
B. Determine if she has the skills to complete the assignment.
Rationale: The nurse should perform a self-evaluation to determine if there are discrepancies
between expectations and skills. Discrepancies can lead to unsafe client care.
C. Identify her options.
Rationale: After the nurse gains knowledge about the assignment and completes a selfevaluation, the nurse can either accept or refuse the assignment.
D. Notify the nurse manager about her concerns for client safety.
Rationale: The nurse should not notify the nurse manager about her concerns for client
safety until she has determined she has the skills to safely provide client care.
30. A nurse manager hears a staff nurse on the unit speak openly about her dislike of a recent
policy change regarding client care. When discussing the issue with the nurse, which of the
following statements by the nurse manager is appropriate?
A. “Let’s talk about your concerns about the new policy.”

Rationale: The nurse manager should meet with the nurse to allow an open forum for the
nurse to verbalize the reasons for her reluctance to adopt the new policy.
B. “Why didn’t you voice your concerns before the new policy was implemented?”
Rationale: This statement is accusatory and will likely make the nurse defensive.
C. “Being open to change is an expectation of the nurses who work on this unit.”
Rationale: While being open to change is an expectation of a professional nurse, this
statement does not address the issue. It avoids the issue at hand.
D. “You should support this policy change because it was based on evidence-based practice.”
Rationale: Evidence-based practice is the use of knowledge from research to support
delivery of nursing care. Its use is important when nurses consider a policy change related to
client care; however, this statement does not address the issue. It avoids the issue at hand.
31. A nurse is caring for a client who falls in his room. After the nurse assesses the client,
notifies the client’s provider, and completes an incident report, which of the following actions
should the nurse take?
A. Make a copy of the incident report for the provider.
Rationale: Incidence reports are confidential tools used by the facility to improve client care.
They are never copied.
B. Submit the incident report to the risk manager.
Rationale: The purpose of an incident report is to provide information to the risk manager
who will investigate the incident and work with other members of the health care team to
control risks of client injury.
C. Place the incident report in the client's chart.
Rationale: Incident reports are confidential tools used by the facility to improve client care.
They are never placed in the client's chart. If there is a lawsuit and the incident report is in the
client’s chart, the attorney can subpoena the document and use its contents as evidence.
D. Document in the chart that an incidence report has been filed.
Rationale: Incident reports are confidential tools used by the facility to improve client care.
They are never referred to in a client's chart. If there is a lawsuit and the incident report is
referenced in the client’s chart, the attorney can subpoena the document and use its contents
as evidence.
32. A volunteer assigned to the paediatric unit reports to the charge nurse for an assignment.
Which of the following assignments is unsafe for the volunteer?

A. Transporting a school-age client who is in traction to another department
Rationale: To ensure client safety, the nurse is responsible for delegating tasks to the right
people. The nurse should avoid assigning this task to the volunteer because the individual
who performs this task must understand the principles of traction. A volunteer does not have
the requisite skill to perform this task.
B. Playing a computer video game with an adolescent who has sickle cell disease
Rationale: This is an appropriate and safe assignment for the volunteer. It provides both
socialization and diversional activity to the client in traction.
C. Reading a book to a preschool client who has AIDS
Rationale: This is an appropriate and safe assignment for the volunteer. It provides a
diversional activity for the client.
D. Rocking an infant who was admitted for croup
Rationale: This is an appropriate and safe assignment for the volunteer. It provides comfort
for the client.
33. A coworker puts an arm around a nurse and says, "I bet you are a great lover." Which of
the following is an appropriate response by the nurse?
A. "Let's talk about something else."
Rationale: While this appears to be a response meant to change the subject, this response
does not make it clear that this type of sexually-oriented conversation and physical contact is
undesired by the nurse.
B. "Whether or not I am a good lover is irrelevant."
Rationale: While this appears to be a response meant to change the subject, this response
does not make it clear that this type of sexually-oriented conversation and physical contact is
undesired by the nurse.
C. "Speaking to me like that makes me uncomfortable."
Rationale: This assertive response makes it clear that this type of sexually-oriented
conversation and physical contact is undesired by the nurse.
D. "You need to lower your voice. Others can hear you."
Rationale: This response does not make it clear that this type of sexually-oriented
conversation and physical contact is undesired by the nurse. In fact, it could be considered by
the harasser as encouragement.

34. A nurse in a provider’s office is reviewing the laboratory findings for a client who is
scheduled for surgery. Which of the following findings requires follow up by the nurse?
A. BUN 15 mg/dL
Rationale: This BUN level is within the expected reference range. It does not require follow
up by the nurse.
B. Platelet count 60,000/mm3
Rationale: This platelet count is below the expected reference range. A low platelet count
places the client at risk for bleeding; therefore, the nurse should follow up on this finding.
C. WBC 6,000/mm3
Rationale: This WBC is within the expected reference range and does not require follow up
by the nurse.
D. Haemoglobin 14 g/dL
Rationale: This haemoglobin level is within the expected reference range and does not
require follow up by the nurse.
35. A nurse is working with an assistive personnel (AP) to care for a group of clients on the
paediatric unit. Which of the following tasks should the nurse have the AP perform first?
A. Collect a stool sample for ova and parasites from a school-age child
Rationale: Although the AP should collect a stool sample for ova and parasites, there is
another task the AP should perform first.
B. Engage a toddler in play.
Rationale: Engaging a toddler in play is important because it provides diversion and
promotes the toddler’s sense of security, but there is another task that the AP should perform
first.
C. Wash the hair of an adolescent who reports extreme fatigue and is scheduled for radiation
therapy for the treatment of Hodgkin lymphoma.
Rationale: Although the AP should provide personal hygiene measures for the adolescent,
including washing the client’s hair, there is another task the AP should perform first.
D. Check to see if the elbow restraint is in place for an infant who is postoperative from
a surgical correction of a cleft palate.
Rationale: The infant who is postoperative from a surgical correction of a cleft palate is at
risk for damage to the suture line and an elbow immobilizer decreases the risk of this
complication; therefore, this is the task the AP should perform first.

36. A nurse is caring for a group of clients. The nurse demonstrates adherence to the ethical
principle of fidelity by doing which of the following?
A. Keeping an appointment with a client
Rationale: Fidelity is the duty to keep one's promises or word. Keeping an appointment the
nurse has made with the client is an example of fidelity.
B. Allowing a new mother to hold her stillborn infant
Rationale: Beneficence is the duty to do good for others. Allowing a grieving mother an
opportunity to spend time with her infant helps her to process her loss and is an example of
beneficence.
C. Confirming that a client going for surgery has signed a consent form
Rationale: The ethical principle of autonomy describes an individual's right to choose. In
health care, autonomy is the principle underlying informed consent, the right to refuse
treatment, and the right to appoint a surrogate decision maker.
D. Refusing to disclose information about a client to the media
Rationale: Confidentiality is not disclosing a client's personal health care information to
unauthorized individuals or other entities.
37. A nurse is participating in a disaster simulation in which a toxic substance is released into
a crowded stadium. Multiple clients are transported to the facility. Which of the following
activities would be the lowest priority for the nurse?
A. Preventing cross-contamination of clients
Rationale: In a disaster, the nurse must be able to segregate clients to prevent contamination
of a nonexposed client with an exposed client, and thereby limiting the spread of the
unknown toxin.
B. Performing concise client assessment
Rationale: In the triage setting, the nurse provides essential care; therefore, the nurse must
conduct concise client assessments for triage purposes.
C. Transferring a client to the discharge location
Rationale: Nursing care in a disaster setting focuses on essential care. The nurse should
recognize nonskilled interventions, such as transferring a client to the discharge location, can
be performed by nonmedical personnel.
D. Maintaining a client tracking system
Rationale: It is imperative for the nurse to maintain a client tracking system in a disaster
situation. Disaster tags are numbered and include information such as triage priority, name,

address, medications given, and treatments provided. These tags should remain with the
client throughout his movement within the facility.
38. A nurse on a medical-surgical unit is providing care for a group of clients. The nurse
should delegate collection of which of the following specimens to the assistive personnel
(AP)?
A. Wound drainage for culture
Rationale: Collecting drainage from a wound for culture requires the use of sterile technique;
therefore, the nurse should not delegate this task to the AP.
B. Urine from an indwelling catheter
Rationale: Urine from an indwelling catheter requires the use of sterile technique; therefore,
the nurse should not delegate this task to the AP.
C. Blood for PaCO2
Rationale: PaCO2 is one component of arterial blood gases (ABGs). Only individuals who
are specially trained to draw blood from a radial, brachial, or femoral artery, such as nurses,
medical technicians, and respiratory therapists, should perform this task; therefore, the nurse
should not delegate this task to the AP.
D. Random stool specimen
Rationale: The nurse should delegate collection of a random stool specimen to the AP
because it does not require the skills of a licensed nurse. However, the nurse, not the AP,
should collect a stool specimen if a culture using a sterile swab is required.
39. A nurse on a medical-surgical unit is preparing to contact a provider about a client’s
condition. The client is 6 hr postoperative from a total hysterectomy. The nurse notes the
client’s postoperative oxygen saturation is 94% and her apical heart rate is 110. The nurse
should include information about the client’s oxygen saturation level and heart rate in which
component of the SBAR report?
A. Situation
Rationale: The nurse should state his name, the client’s name, the name of the facility, the
client’s medical diagnosis, and a general description of what is going on in this section of the
report.
B. Background
Rationale: The nurse should provide information about the client’s postoperative status in
this section of the report.

C. Assessment
Rationale: The nurse should include his assessments in this level of the report. For example,
the client’s oxygen saturation level and the client’s apical heart rate. The nurse can also
include the amount of vaginal bleeding and the appearance of the wound dressing.
D. Recommendation
Rationale: The nurse makes a recommendation on how to resolve the problem in this section
of the report.
40. A nurse manager is reviewing the admission history of four adults who were admitted to
the medical-surgical unit during the shift. Which of the following situations is the nurse
required to disclose information to an outside agency about the client or the client's
circumstances?
A. A dependent adult admitted for the treatment of a spiral fracture
Rationale: Physical signs of dependent adult abuse include skeletal fractures, as well as
burns, bruises, welts, and lacerations. Nurses are responsible for reporting suspicion of
dependent adult abuse to the proper legal authorities within the state. It is important for the
nurse to note that a competent older adult has the right to make his or her own decisions
about pursuing legal action. Unless a client has been found to be legally incompetent, he or
she is not classified as a dependent adult.
B. A young adult client admitted for asthma and has track marks that may indicate IV drug
abuse
Rationale: Although the use of street drugs is illegal, the track marks may be present from
scarring due to prior use. The nurse would not be required to report this finding to law
enforcement.
C. A young adult client admitted for acute glomerulonephritis following a viral infection
Rationale: The nurse is responsible for reporting a number of infections as identified by the
Centers for Disease Control as reportable to health authorities; however, acute
glomerulonephritis following a viral infection is not a reportable infection.
D. An emancipated minor who has acute appendicitis and wants to leave the facility without
treatment
Rationale: An emancipated minor has the legal authority to make decisions about his health
care. Although the client’s decision to leave the facility without treatment can place him at
risk for a poor outcome, the nurse should not report this situation to an outside agency.

41. A nurse is preparing to administer a soap suds enema to a client who has constipation. As
the nurse explains the procedure, the client states, "The doctor didn't tell me I was supposed
to receive an enema." Which of the following nursing actions is appropriate at this time?
A. Check the client's medical record for the provider's prescription.
Rationale: The nurse should use the client’s medical record to verify the provider prescribed
an enema for the client.
B. Explain to the client that the provider prescribed the procedure.
Rationale: This option ignores the client’s concern about whether or not an enema is
prescribed.
C. Assure the client that enemas are commonly prescribed for constipation.
Rationale: This option ignores the client’s concern about whether or not an enema is
prescribed.
D. Inform the charge nurse that the client refused the enema.
Rationale: The client did not refuse the enema; therefore, this action is not appropriate.
42. A nurse suspects that a coworker is diverting opioid analgesics. Which of the following is
an adverse effect of opioid medications?
A. Euphoria
Rationale: Euphoria is an adverse effect of opioid analgesics and is due to activation of mu
receptors.
B. Rhinorrhea
Rationale: Rhinorrhea can occur with opiate withdrawal, but it is not an effect from the
medication.
C. Hallucinations
Rationale: Hallucinations are an adverse effect of cannabis.
D. Dilated pupils
Rationale: Constricted pupils are an adverse effect of opioid analgesics.
43. A nurse is caring for a client who has advanced lung cancer. The client’s provider has
recommended hospice services for the client. Which of the following statements by the client
indicates a correct understanding of hospice care?
A. “I will have to be admitted to a long-term care facility in order to receive hospice care.”

Rationale: Hospice care is provided in a long-term care facility; however, hospice care is
also provided in a number of other settings, including the client’s home and in an assisted
living facility.
B. “I should expect the hospice team to help me manage my dyspnea.”
Rationale: Dyspnea is a manifestation of terminal lung cancer. The primary purpose of
hospice care is to provide relief of symptoms related to a terminal illness.
C. “Hospice care services are available to patients who are terminally ill regardless of their
life expectancy.”
Rationale: Hospice care is available to clients who have a prognosis of 6 months or fewer to
live.
D. “My oncologist will continue to look for a cure for my cancer while I am receiving
hospice care.”
Rationale: Hospice care provides comfort care for the client, but does not include curative
treatment.
44. A nurse manager has received information from the facility’s risk management
department that a former client is pursuing a lawsuit. The nurse manager should anticipate a
deposition will be required during which phase of the legal process?
A. Complaint phase
Rationale: During the complaint phase, the plaintiff files a document alleging the defendant
failed to provide the expected level of safe care.
B. Discovery phase
Rationale: During the discovery phase, both attorneys for the plaintiff and the defendant
obtain relevant information about the case. This includes witnesses’ depositions.
C. Decision phase
Rationale: During the decision phase, the judge or jury issues a verdict.
D. Trial phase
Rationale: During the trial phase, the facts are presented to the judge or jury.
45.A nurse is caring for a client who is scheduled to have surgery. In preparing the client for
surgery, which of the following actions is considered outside the nurse’s responsibilities?
A. Assessing the current health status of the client
Rationale: This action is a nursing responsibility. The nurse should collect baseline data from
the client and participate as a member of the interdisciplinary team.

B. Explaining the operative procedure, risks, and benefits
Rationale: Explaining the procedure and any risks that may be associated with it is the
responsibility of the person performing the procedure. This is not a nursing responsibility.
C. Reviewing preoperative laboratory test results
Rationale: This action is a nursing responsibility. Reviewing preoperative laboratory test
results determines if any values outside the expected reference range could cause surgical
complications.
D. Ensuring that a signed surgical consent form was completed
Rationale: This action is a nursing responsibility. A signed surgical consent form ensures
proper surgical protocol is carried out.
46. An assistive personnel (AP) comes to work with a new set of artificial nails. The nurse
takes the AP to a private location to discuss the issue. Which of the following statements by
the nurse is appropriate?
A. “There is a higher risk of infection for our clients associated with artificial nails.”
Rationale: Short, natural nails are less likely to harbor pathogens that can be harmful to
clients. The CDC recommends health care workers avoid wearing artificial nails when caring
for clients who are at risk for infection. Additionally, guidelines from the World Health
Organization prohibit artificial nails for caregivers in every setting.
B. “You should know that artificial nails have a very unprofessional appearance.”
Rationale: This is not the reason that artificial nails are prohibited in the health care setting.
Additionally, this statement is aggressive and condescending.
C. “I want you to review the facility’s policy on personal attire before you begin the shift.”
Rationale: This statement is passive and does not directly address the issue.
D. “Why would you wear artificial nails to work when you know it’s against the rules?”
Rationale: This statement is aggressive and condescending.
47. A nurse in the emergency department is caring for a client who has a compression fracture
of a spinal vertebra. During transport to the facility, the client was medicated with
intravenous morphine. On arrival, the neurosurgeon determined urgent surgical intervention
is indicated for the fracture. Staff members have been unable to reach the client’s family.
Which of the following actions should the nurse anticipate the neurosurgeon taking?
A. Invoking implied consent

Rationale: The client is unable to sign the consent form because he is sedated from the
morphine. The neurosurgeon has the legal right to invoke implied consent and proceed with
the surgery if it is determined an emergency and surgery is in the client’s best interest. The
neurosurgeon should document the specifics of the situation in the client’s medical record.
B. Delaying the surgery until a member of the client’s family is reached
Rationale: This action places the client at risk for a poor outcome; therefore, this is not the
action the nurse should anticipate.
C. Asking the client to sign the surgical consent form
Rationale: The neurosurgeon should not ask the client to sign the consent form because he is
sedated from the morphine. A client who is disoriented or unable to function because of the
administration of a medication, such as morphine, is not competent to sign the surgical
consent form.
D. Prescribing naloxone to reverse the effects of the morphine
Rationale: The purpose of naloxone is to reverse the effects of opioid toxicity. The
neurosurgeon should not prescribe naloxone for the client because it can reverse the analgesic
effects of morphine.
48. A nurse is triaging clients in an urgent care clinic. Which of the following clients should
the nurse have the provider care for immediately?
A. An adolescent female client who is belligerent and has slurred speech
Rationale: This client is displaying the effects of excessive alcohol intake and needs care.
However, there is another client who has a higher priority need and should be cared for by the
provider first.
B. A toddler who has a laceration on his forehead and is screaming
Rationale: The nurse should apply pressure to the site of laceration and work with the parent
to decrease the toddler’s anxiety. However, there is another client who has a higher priority
need and should be cared for by the provider first.
C. A middle adult male who is diaphoretic and reports epigastric pain
Rationale: When using the urgent vs. nonurgent approach to client care, the nurse should
determine that caring for this client is the highest priority because diaphoresis and epigastric
pain are manifestations of an acute myocardial infarction.
D. A young adult with a painful sunburn of his face and arms

Rationale: A sunburn is a superficial burn and the client needs to be cared for by the
provider. However, there is another client who has a higher priority need and should be cared
for by the provider first.
49. A nurse is preparing to bathe a client. Which of the following actions should the nurse
plan to take?
A. Pull the curtain around the client’s bed.
Rationale: The nurse should close the door to the client’s room and pull the curtain around
the client’s bed to ensure the client’s right to privacy.
B. Wash the client’s arms and hands first.
Rationale: The nurse should wash the cleanest area of the body, the client’s face, first.
C. Use a washcloth to wipe the client’s eyes from the outer canthus to the inner canthus.
Rationale: The nurse should use a clean washcloth to wipe the client’s eyes from the inner
canthus to the outer canthus.
D. Fill the bath basin with tap water that is 39° C (102.2° F).
Rationale: The nurse should maintain warmth for the client by filling the bath basin with
water that is between 43° C and 46° C (110° F and 115° F).
50. A nurse on a medical-surgical unit has accepted a transfer to the intensive care unit (ICU).
Prior to transfer to the ICU, the nurse completes an online critical care and emergency
nursing course. The nurse is demonstrating which of the following ethical principles?
A. Veracity
Rationale: Veracity is the duty to tell the truth. A nurse who tells her client the truth is
demonstrating the principle veracity.
B. Autonomy
Rationale: Autonomy is the client’s right to make his own decisions about health care. When
the nurse supports the client’s right to make decisions about health care, the nurse is
demonstrating the ethical principle autonomy.
C. Fidelity
Rationale: Fidelity is the duty to keep one’s promises or word. When the nurse keeps her
promise to the client, she is demonstrating the ethical principle fidelity.
D. Nonmaleficence

Rationale: Nonmaleficence consists of actions taken to prevent client harm. When the nurse
completes an advanced education program that will prepare her to provide safer care in the
ICU, the nurse is demonstrating the ethical principle nonmaleficence.
51. A charge nurse is working with an assistive personnel (AP) who provides excellent care to
clients and is an effective team member. Which of the following actions should the nurse take
first to recognize the AP’s contributions to client care?
A. Give positive feedback directly to the AP.
Rationale: Positive reinforcement is one of the most effective ways to recognize an
employee’s ability and to motivate the employee.
B. Tell other nurses what an effective team member the AP is.
Rationale: Although it is important to share information about the excellent care the AP
provides, there is another action the charge nurse should take first.
C. Nominate the AP for the Employee of the Month award.
Rationale: Although offering rewards is an effective way to recognize an employee’s ability,
there is another action the charge nurse should take first.
D. Detail the AP's contributions to the nurse manager.
Rationale: Although it is important to share information about the excellent care the AP
provides, there is another action the charge nurse should take first.
52. A nurse is caring for a client who is dying. The nurse should incorporate the principle of
nonmaleficence into practice by taking which of the following actions?
A. Discussing advance directives with the client and the client's family
Rationale: Discussing advance directives with the client and the client's family is an example
of promoting client autonomy by respecting the client's right to self-determination.
B. Providing comfort care measures to the client
Rationale: Providing comfort care measures to a client who is dying is an example of the
principle of beneficence, which is a moral obligation to act to benefit others.
C. Withholding a dose of narcotic pain medication when the client has respiratory
depression
Rationale: The principle of nonmaleficence is an obligation not to inflict harm. It is
customary to ease a client's pain via the administration of narcotics. However, if the nurse
believes the dose is potentially lethal or could hasten the client's death, the nurse should not
administer the medication on the grounds of nonmaleficence.

D. Allowing the client's family unlimited visitation at the time of death
Rationale: Allowing the client's family unlimited visitation at the time of death is an example
of the principle of beneficence, which is the moral obligation to act in the interest of others.
53. A nurse is assessing a group of clients for hospice services. The nurse should recommend
hospice care for which of the following clients?
A. A client who has diabetes mellitus and is having difficulty self-administering insulin
because of poor eye sight
Rationale: Having a chronic disease does not make a client eligible for hospice services. The
nurse should recommend home health services for this client.
B. A client who has terminal cancer and needs assistance with pain management
Rationale: A client who has a terminal disease and who is deemed to have less than 6 months
to live is eligible for hospice services. Hospice care provides the client with physical and
psychological support, which includes management of symptoms, such as pain and dyspnea.
C. A client who is recovering from a stroke and needs someone to provide care while his
spouse is at work
Rationale: Having a stroke with no one to care for him during the day does not make a client
eligible for hospice services. The nurse should recommend adult day care services for this
client.
D. A client who has dementia and needs help with activities of daily living
Rationale: Having dementia and needing help with ADLs does not make a client eligible for
hospice services. The nurse should recommend assisted living for this client.
54. A nurse is caring for a client who is confused and uncooperative. The client hit the nurse
when she attempted to give him his medication. The nurse asks the charge nurse if she can
restrain the client. The charge nurse should tell the nurse this action is a violation of the
client’s rights and is an example of which of the following?
A. Slander
Rationale: Making false statements that damage a client’s reputation is slander.
B. Invasion of privacy
Rationale: Violating a client’s confidentiality is an invasion of privacy.
C. Defamation of character
Rationale: Writing derogatory statements about a client’s refusal of treatment is defamation
of character.

D. False imprisonment
Rationale: Unlawfully restraining a client is false imprisonment. Clients have the right to
refuse treatment.
55.A nurse is planning care for four clients and is assigning tasks to a licensed practical nurse
(LPN) and an assistive personnel (AP). Which of the following should the nurse assign to the
LPN?
A. Complete an admission assessment for a client who has COPD.
Rationale: It is not within the scope of practice for an LPN to complete an admission
assessment. The LPN can contribute data, but the RN must complete the plan of care.
B. Measure I&O for a client who has an indwelling urinary catheter.
Rationale: Even though measuring I&O is within the scope of practice of an LPN, this task
does not require a licensed personnel to perform it; therefore, the RN should delegate this
task to the AP.
C. Reinforce teaching to a client to begin taking enoxaparin at home following a hip
arthroplasty.
Rationale: Reinforcing teaching with a client is within the scope of practice of a LPN;
therefore, the RN should delegate this task to the LPN.
D. Develop a plan of care for a client who has cholecystitis.
Rationale: It is not within the scope of practice for an LPN to develop a plan of care. The
LPN can contribute to the plan of care, but the RN is responsible for the development of the
plan.
56. A nurse on a medical-surgical unit is assigning tasks to an assistive personnel (AP).
Which of the following tasks should the nurse delegate to the AP? (Select all that apply.)
A. Demonstrate the technique to in still eye drops.
Rationale: This task requires knowledge and understanding of the procedure, which is
typically beyond the scope of practice for APs. It should be performed by a nurse.
B. Ambulate a client who has a cane.
Rationale: This is an appropriate task for an AP, as they can assist clients in ambulating
safely.
C. Irrigate a wound.
Rationale: This procedure requires sterile technique and clinical judgment, which are outside
the scope of practice for an AP. It should be performed by a nurse.

D. Transfer a client to a stretcher.
Rationale: This is a physical task that an AP can perform safely, provided they follow proper
protocols for client safety.
E. Record urinary output.
Rationale: This task is appropriate for an AP, as they can measure and document output
accurately.
57. A nurse is triaging clients in the emergency department. Which of the following clients
should the nurse ask the provider to care for first?
A. A toddler who has asthma and has a pulse oximetry reading of 95% while receiving
oxygen at 2 L/min
Rationale: A client who has a pulse oximetry reading of 95% while receiving oxygen at 2
L/min is stable; therefore, there is another client the nurse should have the provider care for
first.
B. A toddler who has otitis media, a temperature of 39.2° C (102.6° F), and purulent ear
discharge
Rationale: A client who has otitis media, a temperature of 39.2° C (102.6° F), and purulent
ear discharge is stable; therefore, there is another client the nurse should have the provider
care for first.
C. A school-age child who has acute epiglottitis, is drooling, and has an absence of
spontaneous cough
Rationale: A client who has acute epiglottitis, is drooling, and has an absence of spontaneous
cough is unstable and requires immediate medical attention; therefore, this client is the
priority and the nurse should have the provider care for this client first.
D. An adolescent who has sickle cell disease, reports pain as 7 on a scale of 0 to 10, and
requests pain medication
Rationale: A client who has sickle cell disease and reports pain is stable; therefore, there is
another client the nurse should have the provider care for first.
58. A nurse is assessing four clients on a medical-surgical unit. Which of the following clients
should the nurse care for first?
A. A client who has diarrhea and requests clear liquids for breakfast
Rationale: Although this client is at risk for fluid volume deficit and needs fluid
replacement, there is another client who has a higher priority need.

B. A client who has a cast on the left leg and reports numbness and paresthesia
Rationale: The client who has a cast is at risk for acute compartment syndrome (ACS).
Numbness and paresthesia are manifestations of ACS; therefore, when using the airway,
breathing, circulation (ABC) approach to client care, the nurse should care for this client first.
C. A client who has type 1 diabetes mellitus and has a fasting blood glucose level of 150
Rationale: Although this client’s blood glucose is not within the expected reference range
and the nurse might need to administer hypoglycemic medication, there is another client who
has a higher priority need.
D. A client who has pneumonia and has an axillary temperature of 38° C (101° F)
Rationale: Although this client’s temperature is above the expected reference range and the
nurse might need to administer an antipyretic, there is another client who has a higher priority
need.
59. A nurse is planning to use the SBAR communication tool when calling a provider. Which
of the following statements should the nurse include in the B step?
A. "The client should be seen by a neurologist."
Rationale: This statement is the recommendation for action, which is the R step in the SBAR
tool.
B. "The client was found unconscious on the floor in her home."
Rationale: This statement is the background or context of the situation, which is the B step in
the SBAR tool. The background portion should provide information that is pertinent to the
current situation.
C. "There are no provider’s prescriptions available."
Rationale: This statement is the situation as it relates to the client, which is the S step in the
SBAR tool.
D. "The client is disoriented. Pupils are slow to respond to light."
Rationale: This statement is the assessment as it relates to the identified problem, which is
the A step in the SBAR tool.
60 .A charge nurse is making assignments for nursing personnel who will be caring for clients
during the oncoming shift. Which of the following factors should the charge nurse consider?
A. The most experienced nurse receives the more complex clients

Rationale: The charge nurse does not need to assign all the complex clients to the most
experienced nurse. If there is an increase in supervision, a complex client can be assigned to a
less experienced nurse to increase the nurse's confidence and skill level.
B. Personal comfort level in making the assignments
Rationale: The charge nurse's role requires her to be adequately prepared and make
appropriate assignments.
C. Social relationships between nurses working the oncoming shift
Rationale: The charge nurse should be aware of the right person doing the right task on the
right person. Social relationships between the nurses should not be considered when making
assignments.
D. The physiologic status of the clients on the unit
Rationale: Making assignments requires knowing the physiologic status of the clients on the
unit, such as the stability of the clients' vital signs, the amount of health education they need,
and the complexity of care involved. Clients who have an unstable physiologic status may
require a higher level of skilled care.
61. A charge nurse is delegating tasks to nursing personnel on a 10-bed medical-surgical
nursing unit. Which of the following assignments is an example of over delegation?
A. Assigning two assistive personnel (AP) to ambulate all clients
Rationale: Assigning two APs to ambulate 10 clients follows the rights of delegation and
expectations of the APs. It is not an example of over delegation.
B. Assigning a new graduate nurse to perform a wet-to-dry dressing change
Rationale: Assigning a new graduate nurse to perform a wet-to-dry dressing change follows
the rights of delegation and expectations of the nurse. It is not an example of over delegation.
C. Assigning the most efficient AP to perform glucometer monitoring for each client
Rationale: Asking the most efficient AP to perform glucometer testing based on her
efficiency in performing this task is an example of over delegation. This can result in the AP
becoming overworked and tired, thus decreasing productivity.
D. Assigning the most competent RN to perform a central line dressing change
Rationale: Assigning the most competent RN to perform a central line dressing change
follows the rights of delegation and expectations of the nurse. It is not an example of over
delegation.

62. A nurse is planning care for a group of clients at the beginning of the shift. Which of the
following tasks should the nurse assign to the licensed practical nurse (LPN)?
A. Developing the plan of care for a client who has an amputation
Rationale: Developing a plan of care is not within the LPN's scope of practice.
B. Evaluating the outcomes of a new postoperative client
Rationale: Evaluating a client’s progress is not within the LPN's scope of practice.
C. Analyzing data to identify issues for a client who has uncontrolled diabetes mellitus
Rationale: Establishing client goals based on data analysis is not within the LPN's scope of
practice.
D. Assisting a client with crutch walking following knee replacement surgery
Rationale: Assisting a client with crutch walking is within the LPN's scope of practice.
63. A nurse is working with a limited staff because of a severe storm in the area. The facility
incident commander has initiated disaster protocols. Which of the following actions should
the nurse take?
A. Focus on providing care that prevents life-threatening emergencies.
Rationale: The triage method in a disaster focuses on providing care to clients who have any
immediate threat to life.
B. Reinforce discharge teaching to clients.
Rationale: In the event of a disaster, the nurse should focus on urgent client care. Discharge
teaching should not be the nurse’s focus at this time.
C. Instruct the assistive personnel (AP) to focus on clients’ ADLs.
Rationale: The triage method in a disaster focuses on meeting critical needs, which does not
include having the AP assist clients with ADLs.
D. Stock additional unit supplies.
Rationale: In a disaster, facilities implement the triage method, which calls for ancillary
personnel to stock additional unit supplies for nursing personnel. The nurse should focus on
urgent client care needs.
64. A nurse in an acute care setting is planning care for a group of clients at the beginning of
the shift. Which of the following tasks should the nurse assign to the assistive personnel
(AP)?
A. Application of antibiotic ointment to the arm of a client who has dermatitis

Rationale: A nurse cannot delegate a task that requires medication administration, such as
application of antibiotic ointment to an infected area.
B. Obtaining medical history information from a stable client who is being admitted
Rationale: A nurse cannot delegate a task that requires assessment, such as obtaining
information about a client’s medical history.
C. Monitoring vital signs of a client who had an appendectomy 12 hr ago
Rationale: Delegating the monitoring of vital signs of a stable client 12 hr after surgery is an
appropriate task for the AP because it does not involve assessment, specialized knowledge, or
judgment.
D. Removal of the nasogastric tube of a client who has been receiving enteral feedings
Rationale: A nurse cannot delegate a task that requires assessment and specialized skills or
training, such as removing a nasogastric tube.
65. A charge nurse delegates to a licensed practical nurse (LPN) the task of changing a
client’s dressing. Several hours later the client reports the dressing has not been changed.
Which of the following actions should the charge nurse take?
A. Change the client’s dressing.
Rationale: Changing the client’s dressing does not clarify the reason for lack of action by the
assigned LPN.
B. Reassign the task to another nurse.
Rationale: Reassigning the task to another nurse does not clarify the reason for lack of action
by the LPN.
C. Verify the LPN knows how to do a dressing change.
Rationale: The charge nurse should attempt to see the delegated task from the perspective of
the individual being delegated to. This approach clarifies the reason for lack of action by the
LPN.
D. Report the issue to the unit manager.
Rationale: Reporting the issue to the unit manager does not clarify the reason for lack of
action by the LPN.
66. A nurse is planning to delegate tasks to a licensed practical nurse (LPN). Which of the
following entities is important for the nurse to understand when delegating tasks to the LPN?
A. The state Nurse Practice Act

Rationale: The state Nurse Practice Act identifies the skill or education level needed by a
nurse to complete a task, as well as indicating items that can and cannot be delegated from a
legal perspective.
B. The National Association for Practical Nurse Education and Services
Rationale: This association promotes and defends the practice and education of practical
nursing, but does not define tasks that can be delegated in each state.
C. The National Council of State Boards of Nursing Decision Tree
Rationale: The decision tree focuses on a step-by-step analysis that nurses can use to decide
if a task can be delegated to assistive personnel.
D. The Omnibus Budget Reconciliation Act of 1987
Rationale: This act established regulations for the education and certification of assistive
personnel.
67. A nurse is assisting a newly licensed nurse with delegating tasks to an assistive personnel
on the unit. Which of the following statements by the nurse explains the purpose of
delegation?
A. "Delegation provides appropriate resources for the client."
Rationale: Delegation allows work to be done by others. It does not determine if the
appropriate resources are being provided for clients.
B. "Delegation permits a designated individual to meet a goal on your behalf."
Rationale: Delegation is defined as directing the performance of others to accomplish goals
of the nurse and the facility.
C. "Delegation promotes discharge teaching activities for clients."
Rationale: Delegation allows work to be done by others. Teaching activities should not be
delegated by nurses because they require specialized knowledge.
D. "Delegation decreases health care costs."
Rationale: Reducing the cost of health care can be a result of appropriate delegation, but this
is not the purpose of delegation.
68. A nurse is caring for four postoperative clients. The nurse can delegate obtaining vital
signs to an assistive personnel (AP) for which of the following clients?
A. A client who is 1 hr postoperative following a thyroidectomy

Rationale: The client’s physiologic status and stability of vital signs are considerations when
assigning vital signs to an AP. A client immediately following a thyroidectomy would not be
stable and would require the assessment of an RN.
B. A client who is 2 hr postoperative following an abdominal hysterectomy
Rationale: The client’s physiologic status and stability of vital signs are considerations when
assigning vital signs to an AP. A client immediately following an abdominal hysterectomy
would not be stable and would require the assessment of a RN.
C. A client who is 3 days postoperative following gastric bypass surgery
Rationale: The client’s physiologic status and stability of vital signs are considerations when
assigning vital signs to an AP. This client is 3 days postoperative and his condition would
have stabilized by this time.
D. A client who is 3 days postoperative following a craniotomy
Rationale: The client’s multisystem involvement following a craniotomy is a consideration
when assigning vital signs to an AP; this client requires assessment by the RN.
69. A nurse is planning client care for herself and an assistive personnel (AP) working with
her. Which of the following tasks should the nurse plan to perform?
A. Administration of an enema
Rationale: Administration of an enema is a task that is within the scope of practice for an AP.
B. Application of antiembolic stockings
Rationale: Application of antiembolic stockings is a task that is within the scope of practice
for an AP.
C. Assessing a client’s sacrum for edema
Rationale: Assessment requires the nurse's specialized knowledge and cannot be delegated to
an AP.
D. Assisting a client to cough and deep breathe
Rationale: Assisting a client to cough and deep breathe is a task that is within the scope of
practice for an AP.
70. A nurse has received change-of-shift report and is delegating tasks to the assistive
personnel (AP). The nurse should tell the AP to complete which of the following tasks first?
A. Perform blood glucose monitoring of a client who has a prescription for short-acting
insulin prior to breakfast.

Rationale: When using the urgent vs. nonurgent approach to client care, the nurse should
determine the priority task to delegate is the blood glucose monitoring for the client who has
an insulin prescription. This task is time sensitive and should be completed first.
B. Apply a condom catheter to a client who is incontinent.
Rationale: Applying a condom catheter to an incontinent client is a nonurgent task. The
client will need to have this task completed for comfort; however, there is another task that is
the priority.
C. Feed a client who has bilateral casts due to upper arm fractures.
Rationale: Feeding a client who has bilateral casts is a nonurgent task. The client will need to
have this task completed for nutritional needs; however, there is another task that is the
priority.
D. Deliver a clean voided urine specimen to the laboratory.
Rationale: Delivering a specimen to the laboratory is a nonurgent task. This task will need to
be completed for diagnostic purposes; however, there is another task that is the priority.
71. An assistive personnel (AP) reports to the nurse that a client who is 3 days postoperative
following an abdominal hysterectomy has a dressing that is saturated with blood. Which of
the following tasks should the nurse delegate to the AP?
A. Change the abdominal dressing.
Rationale: Changing the abdominal dressing requires assessment by the nurse; therefore, the
nurse cannot delegate this task.
B. Obtain vital signs.
Rationale: Obtaining vital signs is a skill within the scope of practice for an AP; therefore,
the nurse can delegate this task to the AP.
C. Palpate for possible bladder distention.
Rationale: Palpating the client’s bladder requires assessment by the nurse; therefore, the
nurse cannot delegate this task.
D. Observe the incision site.
Rationale: Observing the incision site requires assessment of the client’s condition;
therefore, the nurse cannot delegate this task.
72. A nurse is planning care for a client who has anorexia nervosa. The nurse should make
which of the following client goals the priority?
A. Attain a weight that is greater than the 75th percentile for age and height.

Rationale: When using Maslow’s hierarchy of needs, the nurse should determine the priority
goal is to meet the physiological need for adequate nutrition. This means working with the
client to attain an increase in weight.
B. Make positive statements about improvements in body image.
Rationale: Making positive statements about improvement in body image is important
because the client needs to attain positive self-esteem; however, there is another goal that is
the priority.
C. Feel in control of her behavior.
Rationale: Having the client feel she is in control of her behavior is important because the
client needs to attain the goal of safety; however, there is another goal that is the priority.
D. Identify changes within the family unit that promote the client’s autonomy.
Rationale: The client needs to identify changes that promote autonomy because it is
important for the client to attain the goal of love and belonging; however, there is another
goal that is the priority.
73. A charge nurse has assigned a group of clients to a licensed practical nurse (LPN). The
charge nurse receives reports from her assigned clients about the LPN's lack of care. Which
of the following actions should the charge nurse take?
A. Review the LPN’s personnel file.
Rationale: Reviewing the LPN’s personnel file assists in understanding the LPN's
educational background, but it does not address the clients' concerns.
B. Discuss the LPN’s behavior with other nurses on the unit.
Rationale: Discussing the LPN’s behavior with other nurses on the unit violates the LPN’s
privacy and is not an action the nurse should take.
C. Talk with the clients who have reported the LPN’s lack of care.
Rationale: The charge nurse should investigate the allegations of misconduct to determine if
disciplinary action is warranted.
D. Reassign some of the LPN’s client care to assistive personnel.
Rationale: Reassigning some of the LPN’s client care to others does not clarify the LPN’s
lack of care. Attempting to work around the situation often causes resentment with other
employees and does not address the clients' concerns.
74. A nurse is planning a community diabetes mellitus management program. Which of the
following goals should the nurse include for the program?

A. Proper foot care will be demonstrated to clients during the program.
Rationale: A goal is the desired result toward which effort is directed. Demonstrating proper
foot care is an objective because it identifies how the goal will be met.
B. Clients will have a decreased incidence of foot amputations.
Rationale: A goal is the desired result toward which effort is directed. A reduced incidence of
foot amputations is an appropriate, measurable, and realistic goal for a community diabetes
management program.
C. A facility will be reserved for the program.
Rationale: A goal is the desired result toward which effort is directed. Reserving a facility to
ensure a location for the program is secure is an objective because it identifies how the goal
will be met.
D. Handouts and teaching materials will be distributed at the program.
Rationale: A goal is the desired result toward which effort is directed. Handing out
educational materials is an objective because it identifies how the goal will be met.
75. A nurse is caring for a group of clients. She plans to delegate obtaining morning vital
signs to an assistive personnel (AP) on her team. Which of the following actions should the
nurse plan to take?
A. Verify the AP’s educational preparation prior to delegating the task.
Rationale: The right person is one of the five rights of delegation. This AP is a participating
team member; verification of the AP’s educational preparation would be done by the facility
at the time of hiring.
B. Determine the time frame the AP should report the results.
Rationale: The right communication is one of the five rights of delegation. The nurse should
communicate with the AP and provide direction as to when the AP should report the findings
of the vital signs.
C. Observe the AP as she obtains the vital signs of each client.
Rationale: The right level of supervision is one of the five rights of delegation. Obtaining
vital signs is within the AP's scope of practice; therefore, the nurse does not need to directly
observe the AP taking vital signs for each client.
D. Ask the AP to take the vital signs of the client returning from surgery first.
Rationale: The right circumstance is one of the five rights of delegation. The nurse should
assess the client returning from surgery to ensure the client’s stability prior to delegating the
AP to obtain the vital signs.

76. An RN is making nursing staff assignments for his team consisting of himself, two
licensed practical nurses (LPNs), and an assistive personnel (AP). Which of the following
clients should he assume responsibility for?
A. The client who requires frequent ambulation
Rationale: An LPN can assume responsibility for this client. Ambulation can be delegated
further to the AP.
B. The client who is in protective isolation
Rationale: An LPN can assume responsibility for a client who is in protective isolation. This
client will be more time-consuming than others; therefore, the nurse should take this into
consideration when making assignments.
C. The client who is actively dying and requires IV pain medication
Rationale: The nurse should assume responsibility of this client because IV pain medications
should be administered by RNs. Although this client may require less physical care, he may
require more emotional care. The nurse should plan to spend extensive time with both the
client and his family.
D. The client who is 3 days postoperative and requires a dressing change
Rationale: An LPN can assume responsibility for this client. Postoperative dressing changes
are within the scope of practice for an LPN.
77. A charge nurse is planning to conduct a performance appraisal of a staff member on her
unit. Which of the following actions should the nurse take?
A. Inform the staff member of her appraisal time for that day prior to change-of-shift report.
Rationale: The charge nurse should give the employee 2 to 3 days advance notice of the
appraisal conference time so the staff member can be prepared for the interview.
B. Schedule the appraisal interview as early in the shift as possible.
Rationale: The charge nurse should schedule the appraisal interview at a time when it is not
busy at work and when it is convenient for the staff member so she can have time to fully
participate in the conference.
C. Provide a chair directly across the desk for the staff member to sit in.
Rationale: The charge nurse should arrange the chairs so they are side by side to denote
collegiality. Placing the chairs across from one another denotes a power status position.
D. Provide the staff member with a copy of the appraisal form in advance.

Rationale: The charge nurse should ensure the staff member knows the standards by which
her work will be evaluated and that she has a copy of the appraisal form.
78. An RN is delegating care activities to a licensed practical nurse (LPN). Which of the
following is the priority criterion the RN should consider when delegating?
A. Agency policies for the LPN
Rationale: The nurse should consider the agency policies for the LPN to ensure delegation
within the right circumstance; however, evidence-based practice indicates another criterion is
the priority.
B. The documented experience level of the LPN
Rationale: The nurse should consider the documented experience of the LPN to ensure
delegation to the right person; however, evidence-based practice indicates another criterion is
the priority.
C. The documented skill level of the LPN
Rationale: The nurse should consider the documented skill level of the LPN to ensure
delegation to the right person; however, evidence-based practice indicates another criterion is
the priority.
D. State Nurse Practice Act for the LPN
Rationale: According to evidence-based practice, the nurse should first consider the state
Nurse Practice Act for the LPN. This act guides agency policies and provides the legal
authority for nursing practice, including delegation.
79. A nurse is planning to assign care activities to the assistive personnel (AP) on her team.
Which of the following activities can the nurse assign to the AP? (Select all that apply.)
A. Accompany a client who has depression to occupational therapy.
Rationale: Yes, this can be assigned to the AP. It involves supporting the client and does not
require clinical judgment.
B. Assess a client who has hypomania for exhaustion.
Rationale: No, this should not be assigned to the AP. Assessment requires nursing judgment
and skills.
C. Check the position of a client in soft wrist restraints.
Rationale: Yes, this can be assigned to the AP. They can monitor physical positioning but
should report any concerns.
D. Set limits with a client who has mania.

Rationale: No, this should not be assigned to the AP. Setting limits requires specific
therapeutic communication skills and nursing judgment.
E. Sit with a client who has alcohol use disorder and whose last drink was five days ago.
Rationale: Yes, this can be assigned to the AP. Providing companionship and support is
appropriate.
80. A nurse is receiving change-of-shift report at the start of the shift. Which of the following
statements by the nurse giving report indicates to the oncoming nurse that she should assume
total care for the client, rather than assigning tasks to the assistive personnel (AP)?
A. "The client’s family members have been present most of the day."
Rationale: The presence of family members is not a consideration in the decision to delegate
tasks to the AP.
B. "The client’s blood pressure and pulse have been fluctuating throughout the day."
Rationale: Knowing the client and the stability of his condition is a criterion to consider
when delegating to the AP. To promote client safety, the more stable clients should be chosen
when delegating tasks to APs.
C. "The client discussed having prior thoughts of suicide."
Rationale: The client having a history of suicidal ideation is not a criterion to consider when
delegating tasks to the AP.
D. "The client works in the hospital radiology department."
Rationale: The client being an employee is not a criterion to consider when delegating tasks
to the AP.
81. A nurse has assigned client care activities to an assistive personnel (AP). Which of the
following statements by the AP indicates a need for assistance in establishing priorities?
A. "I have my assignment and will start with room 1, then work my way to room 10."
Rationale: The AP’s statement does not include consideration of the tasks that need to be
performed for each client, any time restrictions, or equipment to be organized.
B. "I will give this client his meal tray first, as he is going early to physical therapy."
Rationale: This statement reflects the AP is establishing priorities and considering the time
frame of the client leaving the floor early.
C. "After breakfast, I will pack the belongings of clients who will be discharged this
morning."

Rationale: This statement reflects the AP is establishing priorities and recognizing this task
can wait until after breakfast.
D. "I will start by providing partial baths before breakfast."
Rationale: This statement reflects the AP is establishing priorities and recognizing care that
can be initiated early with minimal time required before breakfast.
82. A nurse manager is providing an in service program about delegation to assistive
personnel (AP) with staff nurses on the unit. Which of the following statements by a staff
nurse indicates an understanding of the teaching?
A. "The nurse relinquishes accountability for client outcomes when care is delegated to an
AP."
Rationale: The nurse who delegates a task retains accountability for client outcomes.
B. "The AP can provide client education about how to perform basic self-care to the client."
Rationale: Client education, along with assessment of client status and data interpretation, is
the responsibility of the nurse.
C. "The nurse should consider the AP’s level of experience when making delegation
decisions."
Rationale: When delegating a task, the nurse should delegate the task to the right person. The
nurse should consider the AP’s job description, level of knowledge, and individual level of
experience.
D. "The AP can re-delegate a task to another AP who has similar work experience."
Rationale: It is the nurse’s responsibility to make delegation decisions, including selecting
the right person to whom the task can be delegated; therefore, the AP cannot re-delegate a
task.
83. A nurse checks with assistive personnel on the unit throughout the shift to determine if
they are completing tasks. The nurse is demonstrating which of the following rights of
delegation?
A. Right circumstances
Rationale: The right circumstances include delegating tasks that do not require independent
nursing judgment.
B. Right communication
Rationale: The right communication includes providing clear explanations about the tasks,
client outcomes, and when the delegate should report to the nurse.

C. Right person
Rationale: The right person means delegating to the individual who is competent and
qualified.
D. Right supervision
Rationale: The nurse is demonstrating the right supervision when she assesses how the tasks
are being accomplished and if any improvements are needed.
84. A nurse is assigned a group of clients at the start of the shift. Which of the following
clients should the nurse plan to care for first?
A. A client who needs assistance with a bath
Rationale: Although the nurse should assist the client who needs assistance with a bath,
when using the priority setting framework of urgent vs. nonurgent, this is not the client the
nurse should care for first.
B. A client requesting a referral for home health services
Rationale: Although the nurse should help the client who needs a referral, when using the
priority setting framework urgent vs. nonurgent, this is not the client the nurse should care for
first.
C. A client asking about his PCA pump that contains morphine
Rationale: Clients who are administered morphine are at risk for respiratory distress. When
using the urgent vs. nonurgent approach to client care, this is the client the nurse should care
for first.
D. A client who has questions about his new prescription
Rationale: Although the nurse should answer the client’s questions about his new
prescription, when using the priority setting framework of urgent vs. nonurgent, this is not the
client the nurse should care for first.
85. At the beginning of the shift, an RN is preparing assignments for a licensed practical
nurse (LPN) and an assistive personnel (AP). Which of the following tasks should the nurse
assign to the LPN?
A. Providing postmortem care for a client
Rationale: Using principles of cost containment, the RN should avoid assigning tasks to the
LPN that can be completed by an AP.
B. Measuring a client’s I&O

Rationale: Using principles of cost containment, the RN should avoid assigning tasks to the
LPN that can be completed by an AP.
C. Obtaining a client’s weight
Rationale: Using principles of cost containment, the RN should avoid assigning tasks to the
LPN that can be completed by an AP.
D. Inserting a nasogastric tube for a client
Rationale: This is an appropriate task to assign to the LPN. It is not appropriate to assign this
task to the AP.
86. A nurse on the paediatric unit is providing room assignments for children who are to be
admitted to the unit. The nurse should plan to place a child who is postoperative from an
appendectomy with which of the following clients?
A. A child who is experiencing sickle cell crisis
Rationale: The nurse should not place these clients together. The child who is experiencing
sickle cell crisis requires rest and pain management, and the child who is postoperative from
an appendectomy requires frequent assessments and interventions.
B. A child who has streptococcal pharyngitis
Rationale: The nurse should not place these clients together. A child who has streptococcal
pharyngitis requires contact precautions and a private room.
C. A child who has a head injury
Rationale: The nurse should not place these clients together. The child who has a head injury
requires a quiet, low stimulus environment, and the child who is postoperative from an
appendectomy requires frequent assessments and interventions.
D. A child who has a new diagnosis of type 1 diabetes mellitus
Rationale: The nurse should place these clients together. It is appropriate because the child
who has diabetes requires monitoring and teaching and the child who is postoperative from
an appendectomy requires frequent assessments and interventions.
87. An RN from the maternal-newborn unit is being floated to a medical-surgical unit. Which
of the following clients should the charge nurse on the medical-surgical unit plan to assign to
the RN?
A. A client who has terminal end-stage renal disease

Rationale: The nurse who floats to another unit must have the skills to provide safe care to
clients. This client is unstable and his condition could change rapidly. This is not an
appropriate assignment for the RN.
B. A client who has acute pancreatitis
Rationale: The nurse who floats to another unit must have the skills to provide safe care to
clients. This client is unstable and his condition could change rapidly. This is not an
appropriate assignment for the RN.
C. A client who is one-day postoperative following a total abdominal hysterectomy
Rationale: The nurse who floats to another unit must have the skills to provide safe care to
clients. This client is stable. This is an appropriate assignment for the RN.
D. A client who had a stroke and is to be admitted
Rationale: The nurse who floats to another unit must have the skills to provide safe care to
clients. This client is expected to be unstable. This is not an appropriate assignment for the
RN.
88. A nurse on a paediatric unit is reviewing her client assignment following the shift report.
Which of the following clients should the nurse plan to assess first?
A. A school-age child who has diabetes mellitus and requires blood glucose monitoring
Rationale: The nurse should provide care to a child who requires blood glucose monitoring;
however, the nurse should assess another client first.
B. An infant who has pertussis and is receiving oxygen via nasal cannula
Rationale: Using the airway, breathing, circulation (ABC) approach to prioritizing client
care, this infant should be assessed first because the infant has a compromised airway and
requires oxygen.
C. An adolescent who was admitted to the unit in sickle cell crisis and is ready for discharge
instructions
Rationale: The nurse should assess the adolescent who was admitted in sickle cell crisis;
however, since this client is stable and ready for discharge, the nurse should assess another
client first.
D. A toddler who has both arms in casts and needs to be fed his breakfast
Rationale: The nurse should feed the toddler; however, the nurse should assess another client
first.

89. A nurse asks the assistive personnel (AP) to take a specimen to the laboratory and the AP
refuses. Which of the following actions should the nurse take?
A. Take the specimen to the laboratory.
Rationale: Taking the specimen to the laboratory is avoiding confrontation. This action does
not determine the underlying problem.
B. Report the AP to the charge nurse.
Rationale: Reporting the AP to the charge nurse does not clarify the reason for the AP’s lack
of action. This action does not determine the underlying problem.
C. Complete an incident report.
Rationale: An incident report is required when there is an accident or unusual occurrence. It
is not required in this situation.
D. Ask the AP about her concerns with the assignment.
Rationale: Reviewing the incident with the AP allows the nurse to understand the delegated
task from the AP’s perspective. The nurse should attempt to determine the underlying
problem the AP has with the assignment.
90. A charge nurse is reviewing the list of tasks that have been delegated to the assistive
personnel (AP) by the staff nurse. Which of the following tasks should the charge nurse
reassign to a licensed nurse?
A. Transporting a client who experienced a stroke 72 hr ago to the radiology department
Rationale: APs are trained on how to use transfer techniques; therefore, this task is within
their range of function and does not have to be reassigned.
B. Providing a back rub to a client who has right-sided paralysis
Rationale: APs are trained on how to properly turn a client and perform a back rub;
therefore, this task is within their range of function and does not have to be reassigned.
C. Removing and cleaning the cannula of a client who has a new tracheostomy
Rationale: Removing and cleaning the cannula of a client who has a new tracheostomy
requires use of the nursing process, specialized knowledge, and clinical judgment; therefore,
this task should be reassigned to a licensed nurse.
D. Performing oral hygiene for a client who is 1 day postoperative following an amputation
of the right arm
Rationale: APs are trained on oral hygiene techniques; therefore, this task is within their
range of function and does not have to be reassigned.

91. A nurse manager is preparing an in service program for the nurses on the unit about the
use of a new infusion pump. Which of the following teaching strategies is the most effective
way to ensure that the staff can use the device correctly?
A. Provide a written procedure for the use of the device for the staff to review.
Rationale: This strategy might be useful for learners who wish to prepare beforehand or
check a detail afterward, but it does not ensure the staff can use the device correctly.
B. Demonstrate using the device and observe the staff returning the demonstration.
Rationale: The most effective strategy to ensure the staff nurses can perform a psychomotor
skill, such as using an infusion pump, is to show them how to use the device and provide the
opportunity for a return demonstration.
C. Remind the staff to review the procedure manual prior to using the new pump.
Rationale: This strategy might be useful for learners who wish to accept responsibility for
learning, but it does not ensure the staff can use the device correctly.
D. Identify the differences and new features of the device in a written brochure.
Rationale: This strategy might be useful for learners who wish to accept responsibility for
learning, but it does not ensure the staff can use the device correctly.
92. A nurse enters a client’s room and finds the client pulseless. The family has requested a
do-not-resuscitate (DNR) order from the provider, but he has not written the order yet. Which
of the following actions should the nurse take?
A. Call the emergency response team.
Rationale: Unless the provider writes a DNR order, the nurse should make every effort to
revive the client. The nurse should follow the facility’s protocol for enacting the emergency
response procedure.
B. Seek immediate help from the risk manager.
Rationale: The nurse does not have time to wait for a response from the risk manager. The
nurse should follow the facility’s protocol for this type of situation.
C. Call the provider for a stat DNR order.
Rationale: The nurse should follow the facility’s protocol for this type of situation.
D. Respect the family’s wishes and do nothing.
Rationale: The nurse should follow the facility’s protocol for this type of situation. Without a
DNR order, the nurse cannot follow the family’s wishes.

93. A nurse and an assistive personnel (AP) are providing care for four clients who were
admitted to the medical surgical unit on the previous shift. The nurse should delegate meal
assistance for which of the following clients to the AP?
A. A client who has a lumbosacral spinal tumor
Rationale: The nurse should delegate a task to the AP that is safe for a specific client. The
client who has a lumbosacral spinal tumor is not at risk for dysphagia; therefore, the nurse
should delegate meal assistance to the AP for this client.
B. A client who has Guillain-Barre syndrome
Rationale: The nurse should delegate a task to the AP that is safe for a specific client. A
client who has Guillain-Barre syndrome is at risk for aspiration during swallowing; therefore,
it is unsafe for the nurse to delegate this task to the AP.
C. A client who has amyotrophic lateral sclerosis (ALS)
Rationale: The nurse should delegate a task to the AP that is safe for a specific client. A
client who has ALS is at risk for aspiration during swallowing; therefore, it is unsafe for the
nurse to delegate this task to the AP.
D. A client who has systemic sclerosis
Rationale: The nurse should delegate a task to the AP that is safe for a specific client. A
client who has systemic sclerosis is at risk for aspiration during swallowing; therefore, it is
unsafe for the nurse to delegate this task to the AP.
94. A nurse who is leading a team of nurse managers is planning to make a major
announcement. The nurse should use which of the following nonverbal communication
techniques to enhance the importance of the announcement?
A. Sit in front of the group for the meeting and then stand for the announcement.
Rationale: The weight of a message increases when the sender stands.
B. Cross her arms over her chest when beginning the announcement.
Rationale: Crossing the arms over the chest suggests defensiveness or aggressiveness and
will detract from the importance of the message the nurse is sending.
C. Stare at the people the announcement will affect the most.
Rationale: Staring impedes connecting with others emotionally and might change the impact
of the message the nurse is sending.
D. Lean gently over the back of a chair sitting to one side of the room when making the
announcement.

Rationale: Slouching or non-erect posture suggests indifference and changes the impact of
the message the nurse is sending.
95. A client who is terminally ill tells a nurse on the medical-surgical unit that she feels
hopeless. Which of the following statements by the nurse is appropriate?
A. "Tell me why you feel hopeless."
Rationale: Asking why questions is nontherapeutic and the client may not be able to put her
feelings of hopelessness into words.
B. "I am sure these feelings will pass once you go home."
Rationale: This statement is false reassurance and does not encourage the client to talk about
her feelings.
C. "If I were you, I would ask for a referral to hospice care."
Rationale: Although referral to hospice may be helpful for the client, the nurse should avoid
giving the client her personal opinion.
D. "Tell me what you understand about your illness."
Rationale: The nurse should use this statement to encourage the client to express her feelings
and concerns.
96.A nurse on a paediatric unit is caring for a child and his family. His parents define family
as a husband, wife, and child. This definition is which type of family form?
A. Extended family
Rationale: An extended family includes aunts, uncles, grandparents, and cousins.
B. Blended family
Rationale: A blended family occurs when two families are brought together to create a new
family form.
C. Nuclear family
Rationale: A nuclear family consists of parents and offspring.
D. Intergenerational family
Rationale: An intergenerational family consists of a family form of two or more generations,
such as grandparents caring for children or adult children living with their parents.
97. A nurse is caring for four clients on a medical-surgical unit. Which of the following
clients should the nurse assess first?

A. A client who has a nasogastric tube for decompression and the gastric aspirate is green
with a pH of 5.3
Rationale: Gastric aspirate that is green with a pH of 5.3 for a client who has a nasogastric
tube for decompression is nonurgent because it is an expected finding; therefore, this client
should not be assessed first.
B. A client who had an indwelling urinary catheter removed 5 hr ago and has not voided
Rationale: After removal of an indwelling urinary catheter, the client should void within 4 hr.
If the client has not voided in 4 hr, the nurse may need to reinsert the catheter; therefore,
when using the priority-setting framework of urgent vs. nonurgent, this client should be
assessed first because he has not voided for 5 hr.
C. A client who has COPD and the capillary refill time on both hands is 4 seconds
Rationale: A capillary refill time of 4 seconds is nonurgent for a client who has COPD
because it is an expected finding; therefore, this client should not be assessed first.
D. A client who has late-stage cirrhosis and whose breath has a fruity odor
Rationale: Breath that has a fruity or musty odor, known as fetor hepaticas, is nonurgent
because it is an expected finding for a client who has late stage cirrhosis; therefore, this client
should not be assessed first.
98. A nurse is planning to delegate a task to an assistive personnel (AP). Which of the
following actions should the nurse plan to take?
A. Assess the AP’s ability to follow the client’s teaching plan.
Rationale: The nurse cannot delegate teaching to an AP; therefore, the nurse does not need to
assess the AP’s ability to follow the client's teaching plan.
B. Determine the social skills of the AP.
Rationale: Knowing the AP's skills is important when planning to delegate a task; however,
the social skills of the AP are not essential when planning to delegate a task.
C. Evaluate the ability of the AP to work with peers.
Rationale: Knowing the AP's skills is important when planning to delegate a task; however,
the ability of the AP to work with peers is not essential when planning to delegate a task.
D. Provide a clear description of the task to the AP.
Rationale: Providing a clear, concise description of the task, as well as the expected
outcome, is essential when planning to delegate a task to the AP.

99. A nurse is obtaining informed consent from a client who is preoperative. Which of the
following actions should the nurse take? (Select all that apply.)
A. Establish that the client is able to pay for the surgical procedure.
Rationale: This is not part of the informed consent process. Consent is focused on the
understanding of the procedure and its risks, not on the client's ability to pay.
B. Explain the surgical procedure to the client.
Rationale: This responsibility typically lies with the surgeon or the physician, not the nurse.
The nurse can provide general information but should ensure the client has received adequate
information from the surgeon.
C. Validate the signature is authentic.
Rationale: The nurse should ensure that the consent form is properly signed and that the
signature matches the client's identity.
D. Verify the client understands the surgical procedure.
Rationale: It is crucial for the nurse to ensure that the client comprehends the procedure, its
risks, and benefits, which is part of the informed consent process.
E. Confirm that the consent is voluntary.
Rationale: The nurse must ensure that the client is consenting freely, without coercion or
undue influence.
100. A nurse is teaching a class on torts. The nurse should instruct the class that administering
an antibiotic medication to a competent client after the client has refused it is an example of
which of the following torts?
A. Assault
Rationale: Assault is the act of verbally threatening a client. A nurse who verbally threatens
to give a medication to a client without the client’s consent is committing assault.
B. False imprisonment
Rationale: False imprisonment is detaining a client against her will without legal warrant. A
nurse who administers a chemical restraint without the client’s consent is committing false
imprisonment.
C. Negligence
Rationale: Negligence is a breach of duty that results in harm to the client. A nurse who
administers an incorrect medication to a client is committing professional negligence.
D. Battery

Rationale: Battery is physical contact without the client’s consent. Administering a
medication against a client’s wishes is an example of battery.