A nurse manager conducts a staff meeting on client self-determination. Which statement made by a staff member indicates further teaching on advocacy is required?
Correct answer: A
Answer supplied. The source had no answer line. The rationale identifies making decisions for clients as the statement requiring teaching, the source's own editing label marked this option, and the identical question in Set 15 is keyed A.
A
Correct
Requires teaching. Making decisions for clients, even well-intentioned ethical ones, is paternalism and works directly against self-determination.
B
Incorrect
Accurate. The nurse participates in decision making by informing and supporting the client.
C
Incorrect
Accurate. Presenting all options is what allows an informed choice.
D
Incorrect
Accurate. A client may choose to delegate decisions to someone else, and that choice is itself an exercise of self-determination.
Full rationale from the source
Client self-determination is the ability of the client to make their own decisions regarding their medical care. The nurse’s role is to facilitate challenging decisions for the client, not make the decision for them. A nurse is involved in the client’s decision making by providing and clarifying medical information and listening to the client’s concerns. All treatment options should be presented to the client to allow them to make an informed decision about their medical care. The client has the right to delegate medical decisions to a person they trust.
2
The registered nurse is caring for a client who is diagnosed with type II diabetes and has impaired mobility. Which of the following actions can be delegated to the licensed practical/vocational nurse?
Correct answer: D
A
Incorrect
Cannot be delegated. Developing the plan of care is part of the nursing process.
B
Incorrect
Cannot be delegated. Teaching about hypoglycemia is client education.
C
Incorrect
Cannot be delegated. A comprehensive assessment remains with the registered nurse.
D
Correct
Appropriate to delegate. Administering a prescribed subcutaneous medication is within the licensed practical nurse's scope.
Full rationale from the source
The Five Rights of Delegation are right task, right circumstance, right person, right directions and communication, and right supervision and evaluation. Professional nurses are responsible for delegating nursing activities, but although RNs may delegate elements of care, they do not delegate the nursing process itself. Nursing care or tasks that should never be delegated, except to another RN, include initial and ongoing nursing assessment, determination of the diagnosis and plan of care, evaluation, and client education. LPNs/LVNs can administer subcutaneous medications.
3
The nurse is caring for a client who has diabetes mellitus. Which of the following findings should be reported to the provider immediately?
Correct answer: D
A
Incorrect
Needs attention but not urgent. Low carbohydrate intake is addressed with dietary review.
B
Incorrect
Suggests hyperglycemia. Nocturia reflects osmotic diuresis and warrants follow-up rather than immediate action.
C
Incorrect
Needs exploring but is not a physiological emergency.
D
Correct
Report immediately. New confusion in a client with diabetes suggests hypoglycemia, which can progress to seizure and loss of consciousness within minutes.
Full rationale from the source
Any signs of hypoglycemia, such as new onset confusion, diaphoresis, dizziness, or low capillary glucose levels, should be reported to the provider. The client’s intake and activity level is important but does not need to be reported to the provider. Nocturia is an abnormal finding but is not a cause for concern.
4
The nurse is evaluating a licensed practical nurse’s (LPN) ability to make appropriate decisions while performing assigned tasks. Which statement by the LPN indicates sound judgement?
Correct answer: B
A
Incorrect
Poor decision. Delaying a report of abnormal findings until tasks are finished risks deterioration in the meantime.
B
Correct
Appropriate decision. Reporting an abnormal heart rate promptly gives the registered nurse the information needed to act.
C
Incorrect
Poor decision. Assuming someone else took the observations means they may not have been taken at all.
D
Incorrect
Poor decision. Deferring scheduled medications alters the treatment plan without authorisation.
Full rationale from the source
The LPN should report collected data to the registered nurse in a timely fashion, especially if there are abnormal findings. Delaying tasks until later in the day and stating that they did not complete a task because of an assumption shows poor judgement.
5
The nurse is developing discharge plans for a client who had a total knee arthroplasty and requires crutches for ambulation. Which statement by the client would indicate to the nurse the need for home health assistance?
Correct answer: C
Flagged — do not use as written. The rationale attached to this question does not match its options. It discusses premedicating before activities of daily living, using a shower chair and performing hygiene in the morning, none of which corresponds to the four choices offered, and the same mismatch appears in Set 15. The keyed answer is nevertheless sound: a two-storey home means negotiating stairs on crutches after a total knee replacement, which is the clearest indication for home health assistance.
A
Incorrect
Indicates support is available. Family transport reduces rather than creates need.
B
Incorrect
Indicates the home is adapted. A shower chair in a walk-in shower supports safe hygiene.
C
Correct
Indicates the need for assistance. Negotiating stairs on crutches after a total knee replacement is the clearest barrier to managing at home.
D
Incorrect
A consideration rather than a barrier. Being alone during the day matters, though it does not by itself make the home unsafe.
Full rationale from the source
It is recommended that the client premedicates prior to activities of daily living (ADL) to ease the pain that may be associated after a total knee arthroplasty (TKA). Post-medication treatment will not help the client endure the pain that may be associated with the ADL. This statement would require further review with the nurse. It is recommended that the client initially ask for assistance/support when bathing and use a shower chair. In addition, the client should perform hygiene in the morning instead of the evening when they have more energy.
6
The preoperative nurse is witnessing a client sign consents for surgery. The client states, “I am not sure if I should have the surgery.” Which statement would be appropriate for the nurse to make?
Correct answer: D
A
Incorrect
Deflects. Directing the client to family avoids the doubt they have raised with the nurse.
B
Incorrect
Premature. The provider is informed, but only after the nurse understands what the concern is.
C
Incorrect
Acknowledges feeling without exploring it, so the doubt remains unresolved.
D
Correct
Best response. Consent is not informed while the client is unsure, so the nurse explores the doubt before witnessing any signature.
Full rationale from the source
The nurse’s role with informed consent is to the witness the client’s signature of the consent. If the client expresses concerns, the nurse should gather more information about the client’s feelings. The nurse should alleviate the client’s anxiety by allowing the client to discuss their feelings and concerns. The nurse should notify the healthcare provider if the client refuses the surgery or has specific questions about the surgery.
7
A precepting nurse tells a graduate nurse, “A client may ask you how many years of experience you have.” Which response by the graduate nurse indicates an understanding of client rights?
Correct answer: C
A
Incorrect
Inaccurate. Clients are entitled to know who is providing their care and at what level.
B
Incorrect
Evasive. Redirecting the question avoids information the client has a right to.
C
Correct
Correct. A client has the right to know the identity and title of those caring for them, including that a nurse is new to practice.
D
Incorrect
True in general but not the point. It sidesteps the question about disclosure of experience.
Full rationale from the source
A client has a right to know the identity and title of their healthcare providers. A graduate nurse has the knowledge competency that can be shared with the client. A client can request to know the experience of their healthcare providers. Ignoring a client’s question does not build rapport. Clients have a right to express their concerns. However, requesting a new provider does not address the scenario.
8
The nurse is assisting a client who is on strict bedrest off a bedpan. The nurse notes the client’s skin on the coccyx is reddened and non-blanchable. The nurse should collaborate with which member of the healthcare team for this client?
Correct answer: A
A
Correct
Best referral. A certified wound care nurse has specialist preparation in assessing and managing wounds, including pressure injury.
B
Incorrect
Supports healing through nutrition but does not manage the wound itself.
C
Incorrect
Addresses mobility rather than the skin finding.
D
Incorrect
Coordinates the unit rather than providing wound expertise.
Full rationale from the source
A certified wound care nurse is a nurse that has become certified in treating wounds (CWCN), continence care (CCCN), ostomies (COCN), or all three, making them a fully certified wound ostomy and continence nurse (CWOCN). They receive consultations for treatment and monitoring of wounds/ostomies, provide direct care, educate patients, families, and nurses, and manage wound care programs. The primary nurse should collaborate with the wound care nurse to develop a plan of care that is evidence-based and in accordance with facility protocol.
9
The nurse is caring for a client who is scheduled to have a surgical procedure. The client states that they don’t know if they want to have the surgery. Which action by the nurse is appropriate at this time?
Correct answer: A
A
Correct
Correct action. Uncertainty means the consent is not informed, and only the surgeon can resolve it by discussing the procedure again.
B
Incorrect
Pressuring. Reassuring the client that they need it overrides the doubt.
C
Incorrect
Invalid. A signature obtained while the client is unsure does not represent informed consent.
D
Incorrect
Too late. Concerns must be resolved before the client leaves for theatre.
Full rationale from the source
If a client states that they are unsure if they want to go through with a surgical procedure, the nurse should notify the provider of the client’s wishes. The surgeon is responsible for discussing treatment options, risks, and benefits with the client. The nurse can educate the client, but should not push a client to have a procedure that they do not want to have. Putting off the client’s concerns and stating that someone else will address them is not appropriate.
10
The nurse is conducting a telehealth visit for a client in their home. During the assessment, the client’s neighbor joins the conversation and asks, “What’s wrong with my friend? Should I take her to the hospital now?” What is the most appropriate response by the nurse?
Correct answer: B
A
Incorrect
A breach, and false reassurance. Commenting on the neighbour's condition discloses protected information.
B
Correct
Correct response. It states plainly that the information cannot be shared, which protects the other client's confidentiality.
C
Incorrect
Still a breach. Confirming the neighbour is a client and directing the question elsewhere discloses information.
D
Incorrect
Avoids the question without addressing the confidentiality principle.
Full rationale from the source
The nurse must remember that the client has a right to confidentiality, and information should only be shared with the client’s consent. The nurse should tell the neighbor that the nurse cannot say anything about the client’s condition. Asking the neighbor to call the nurse for information or to ask the client’s spouse are not the correct responses as they do not maintain HIPAA protocol or the client’s right to confidentiality and privacy.
11
The nurse is caring for client in acute respiratory distress who had an atrial blood gas level collected. . When reviewing the results, the nurse should understand that PAO2 indicates which finding?
Correct answer: B
A
Incorrect
Not what PaO2 measures. Alveolar oxygen tension is a calculated value, not the blood gas result.
B
Correct
Correct. PaO2 is the partial pressure of oxygen dissolved in arterial blood.
C
Incorrect
Describes PCO2 generally rather than the arterial value.
D
Incorrect
Describes PaCO2, which is a different component of the same blood gas.
Full rationale from the source
Arterial blood gas is a common diagnostic modality ordered for clients in respiratory distress. The abbreviation of PO2 refers to partial alveolar oxygen pressure.
12
The nurse is reviewing the plan of care for assigned clients. Which client should the nurse identify as having the risk for endocarditis?
Correct answer: C
A
Incorrect
Some risk, but hypertension with a peripheral line is not the principal route to endocarditis.
B
Incorrect
Not an infection risk. A positive stress test indicates ischemia rather than infective risk.
C
Correct
Greatest risk. A non-tunneled dialysis catheter gives organisms direct, repeated access to the bloodstream, which is the classic route to infective endocarditis.
D
Incorrect
Lower risk. Oral therapy does not breach the vascular system.
Full rationale from the source
Endocarditis is an infection of the endocardium layer of the heart and heart valves. The infectious organism enters the bloodstream which flows through the heart, infecting the valves or endothelial tissue. A client with invasive devices, such as a non-tunneled dialysis catheter that is placed in the subclavian, have a high risk for developing endocarditis. Other risk factors include clients with congenital heart defects, cardiomyopathy, prior valve disease, or IV drug use.
13
A nurse is assisting a charge nurse who has attempted to start an IV multiple times on a client unsuccessfully. The client states, “My arm is in a lot of pain. Please stop.” The charge nurse disregards the client’s statement and continues to attempt IV access. Which action does the nurse take?
Correct answer: B
A
Incorrect
Sides against the client. Insisting on necessity pressures someone already distressed.
B
Correct
Correct action. Suggesting a pause advocates for the client while addressing the colleague respectfully, and repeated failed attempts warrant a different approach.
C
Incorrect
Escalates prematurely and leaves the client mid-procedure.
D
Incorrect
Complicit. Comforting while continuing does not stop the distress.
Full rationale from the source
The nurse should suggest to the charge nurse to stop the IV attempts. The nurse must advocate for the client and respect their request to stop the procedure. Telling the client that the procedure is necessary for medical treatment disregards the client’s pain and refusal to continue providing consent. Leaving the room to inform the nurse manager leaves the client unattended and allows the charge nurse to continue the IV attempts against the client’s wishes. Comforting the client and continuing to assist the charge nurse disregards the client’s concerns and refusal of treatment.
14
The nurse provides a brochure with discharge instructions for a client with a limited understanding of English. When asked if the client has any questions, the client responds in a different language. How does the nurse respond?
Correct answer: B
A
Incorrect
Unlikely to help. Reviewing the same brochure again does not overcome a language barrier.
B
Correct
Best response. An interpreter allows the nurse to confirm understanding and answer questions accurately.
C
Incorrect
Unsafe. A signature does not establish comprehension, and obtaining one here documents something untrue.
D
Incorrect
Not appropriate. Family members are not qualified interpreters and using them risks error and breaches confidentiality.
Full rationale from the source
The nurse recognizes that the client may or may not understand the teaching due to the response in a different language. The best response by the nurse would be to reach out for assistance after review of facility protocol with aid of an interpreter. Due to the language barrier, reviewing the brochure with the client may not be effective and not the best response. Having the client sign the patient education document to confirm understanding would not confirm client understanding. It is not acceptable to have another family member to be responsible for translating pertinent medical information.
15
The nurse working with an unlicensed personal assistant (UAP) to care for a client who has soft, bilateral wrist restraints placed. Which task should the nurse the perform?
Correct answer: C
A
Incorrect
Can be delegated as observation. Assistive personnel may observe and report capillary refill, though the nurse interprets it.
B
Incorrect
Can be delegated. Assisting the client to the bathroom is within the assistant's scope.
C
Correct
The nurse performs this. Assessing the skin beneath restraints requires nursing judgement about integrity and circulation, and it cannot be delegated.
D
Incorrect
Can be delegated. Setting up trays and assisting with eating is routine care.
Full rationale from the source
A client who is in soft wrist restraints will require an assessment of skin and circulation, which is the responsibility of the nurse. The nurse can delegate to the UAP assisting the client to the bathroom and with eating and drinking.
16
The nurse is providing an SBAR shift report on a client who is postoperative right knee replacement. Which of the following information should the nurse include in the assessment section of the report?
Correct answer: D
A
Incorrect
Belongs to Recommendation. A prescription for ambulation is part of what should happen next.
B
Incorrect
Belongs to Background. A history of hypertension is relevant prior information.
C
Incorrect
Belongs to Recommendation. A home health referral is a proposed action.
D
Correct
Belongs to Assessment. A dry and intact dressing is the nurse's current finding about the client's status.
Full rationale from the source
SBAR is the standard format for providing and receiving a report on client care, which organizes client care into sections: situation, background, assessment, and recommendation. The situation section focuses on what is occurring with the client, such as prescriptions or interventions that need to be implemented. The background provides information on what caused the current situation and includes the client’s past history. Assessment includes information about the nurse’s impression of the problem, such as findings observed or measured by the nurse. Recommendation explains what would need to be done for the client, such as further referrals or follow-up care.
17
The nurse is currently evaluating COPD readmission rates in the Emergency Department. After identifying that most of the clients do not read discharge instructions, the nurse suggests which next step?
Correct answer: C
A
Incorrect
Addresses medication supply rather than the communication barrier identified.
B
Incorrect
Useful generally but does not address why this group is returning.
C
Correct
Best action. Keeping language preference current means every subsequent step, from teaching to discharge instructions, reaches the client in a form they understand.
D
Incorrect
Partial. Translated instructions help only if the client's language is recorded accurately in the first place.
Full rationale from the source
Proper discharge planning should begin on admission. Avoiding reactionary discharge planning is one way to improve the effectiveness of discharge planning. Educating the staff to update language preferences on admission would identify any language barriers. Educating the client in the native language helps to decrease miscommunication. The discharge instructions should be given in the client’s preferred language as well as medication labels from the pharmacy, if possible. Making follow up appointments for clients may prove to be difficult due to social issues, such as transportation.
18
A client has been referred to a skilled nursing facility for long-term medical care. The facility is requesting information on the client’s pharmacological history and current treatment. Which will the nurse provide?
Correct answer: D
A
Incorrect
Records what was given in hospital rather than the full picture.
B
Incorrect
Excessive. Sending the whole record breaches the principle of sharing only what is needed.
C
Incorrect
Incomplete. Home medications alone omit what was started or stopped during admission.
D
Correct
Best document. Medication reconciliation sets out what the client took before, what changed and what they are to continue, which is what prevents error at transfer.
Full rationale from the source
A medication reconciliation form provides information on the client’s history of medications and current prescriptions. A medication reconciliation form should be provided with every referral or transfer to another facility or unit. The medication administration record only provides documentation of the current medications. The medical record provides information on the client’s entire treatment. The facility is only requesting information on pharmacological treatment. A list of the client’s home medications only provides pharmacological history, not current treatment.
19
The healthcare provider has identified the need for an infusion of packed red blood cells. When obtaining informed consent, what information should be included?
Correct answer: A
A
Correct
Required element. The client must understand the risks of transfusion, including febrile, allergic and haemolytic reactions and infection.
B
Incorrect
Not disclosed. Donor identity is confidential and irrelevant to consent.
C
Incorrect
Not a required element. Detail about blood components is not needed for informed consent.
D
Incorrect
Not a required element. Crossmatching is a laboratory process rather than part of the consent discussion.
Full rationale from the source
In all health care facilities, informed and voluntary consent is needed for admission, for each specialized diagnostic or treatment procedures, and for any experimental treatments or procedures. The following are the required elements for documentation of the informed consent discussion: (1) the nature of the procedure, (2) the risks and benefits and the procedure, (3) reasonable alternatives, (4) risks and benefits of alternatives, and (5) assessment of the patient's understanding of elements 1 through 4. The identity of the donor is not available and is not shared. The client does not require a lesson on the components of blood during the informed consent process nor how blood is crossmatched.
20
The nurse is admitting a new client to the emergency room who states that they have a large amount of cash in their wallet and valuable jewelry on them. Which action by the nurse is appropriate?
Correct answer: D
A
Incorrect
Not the priority, and the valuation is not the nurse's role.
B
Incorrect
Unsafe. Leaving valuables in the client's possession in an emergency department invites loss.
C
Incorrect
Insufficient. Bagging items without documenting or witnessing them leaves no record of what was received.
D
Correct
Correct action. A valuables inventory records each item, which protects both the client and the facility, and the items are then secured.
Full rationale from the source
When a client has personal items, it is important to document what items they have with them and store them appropriately. In the event that a client states that they are missing an item, the nurse can look back on the valuables inventory to determine what items the client had upon admission. Items should either be in the client’s view or safely stored after inventory. Asking the total value of the items is not appropriate.
