Question set C: ten items, priority and delegation
an answer grid matching pages 68 and 71, with the Client Needs and clinical judgment step columns pre-printed.
Set rules. Twelve minutes. Every option in this set is something a nurse legitimately does. You are choosing order, not choosing right from wrong.
Item type mix: 4 MC · 2 SATA · 2 ORD · 1 MATRIX · 1 DDT · 0 FIB
There is no calculation item in this set, and that is deliberate. Management items are decided by reasoning under ambiguity, not by arithmetic.
1. A nurse receives handoff for four clients on a medical-surgical unit. Which client should the nurse assess first?
- A client 1 day after thyroidectomy who reports a "tight" feeling in the neck and has a hoarse, weak voice
- A client with pancreatitis reporting abdominal pain of 9 out of 10 and requesting the prescribed analgesic
- A client with cellulitis whose intravenous antibiotic dose is 30 minutes overdue
- A client awaiting discharge whose family is asking for teaching about a new prescription
Answer: ______
2. A nurse is caring for a group of clients with the help of unlicensed assistive personnel. Which task may the nurse delegate?
- Repositioning an immobile client every 2 hours and recording the times
- Determining whether a client's reported dizziness means the walk should be stopped
- Reporting whether a client's surgical wound looks infected
- Checking whether a client understands the prescribed low-sodium diet
Answer: ______
3. A charge nurse is making assignments on a unit staffed with registered nurses and one licensed practical/vocational nurse. Which assignments are appropriate for the LPN/VN? Select all that apply.
- Administering oral and subcutaneous medications to stable clients
- Reinforcing teaching the registered nurse has already provided about a low-sodium diet
- Initiating a transfusion of packed red blood cells for a client with anemia
- Performing a sterile dressing change on a stable postoperative wound
- Completing the admission assessment on a newly arrived client
- Monitoring a stable client's nasogastric output and reporting changes to the registered nurse
Answer: ______
4. Four clients arrive on the unit within minutes of one another. Place them in the order the nurse should assess them.
- A client with newly diagnosed leukemia who is crying and asking to speak with someone
- A client with a heart failure exacerbation who is short of breath while speaking, with an oxygen saturation of 89% on room air
- A client with a fractured wrist awaiting closed reduction who reports pain of 7 out of 10
- A client with a gastrointestinal bleed whose heart rate has risen from 92 to 124, with a blood pressure of 92/54
Answer: ______
5. A unit currently holds a neutropenic client and a client with suspected pulmonary tuberculosis. For each placement decision, select whether it is appropriate or not appropriate.
| Decision | APPROPRIATE | NOT APPROPRIATE |
|---|---|---|
| Place the client with suspected tuberculosis in a negative-pressure airborne infection isolation room with the door closed | ☐ | ☐ |
| Place the neutropenic client in a private positive-pressure room with no fresh flowers or plants | ☐ | ☐ |
| Assign the neutropenic client to share a room with a client who has a draining surgical wound | ☐ | ☐ |
| Assign one nurse to care for both the client with suspected tuberculosis and the neutropenic client this shift | ☐ | ☐ |
| Require a fit-tested respirator for every staff entry into the room of the client with suspected tuberculosis | ☐ | ☐ |
| Move a client with influenza into the room with the client who has suspected tuberculosis to conserve isolation rooms | ☐ | ☐ |
Answer: ______
6. While assisting with a sterile dressing change at the bedside, the nurse sees a team member's ungloved hand brush the edge of the sterile field. What should the nurse do first?
- Notify the charge nurse that a break in sterile technique has occurred
- State that the field is contaminated and set up a new sterile field
- Complete the dressing change and document the event afterward
- Ask the team member whether the hand actually made contact
Answer: ______
7. A client falls while walking to the bathroom. Which actions by the nurse are correct? Select all that apply.
- Assess the client and obtain vital signs before moving the client
- Document the objective findings and the client's own statements in the medical record
- Record in the medical record that an incident report was completed
- Complete the facility incident report and route it according to policy
- Report the fall, the assessment findings, and the revised activity plan during the shift handoff
- File a copy of the incident report in the client's medical record
Answer: ______
8. A nurse receives a prescription for a dose that is ten times the usual adult dose. Place the actions in the order the nurse should take them.
- Contact the prescriber to clarify the prescription and state the specific concern.
- Document the concern, the communications, and the outcome in the medical record.
- Hold the medication and do not administer the dose.
- Notify the nursing supervisor through the chain of command if the prescription is not changed.
- Verify the prescription against the original order and the client's record, including allergies, weight, and current medications.
Answer: ______
9. Read the note and complete the sentence by choosing one option from each list.
> 0930. Client scheduled for transfusion of one unit of packed red blood cells for symptomatic anemia states, "I've changed my mind. I don't want the transfusion." Client is alert, oriented, and able to state the reason for the refusal.
"The nurse should first respond, [1], and then [2]."
List 1: "Help me understand what is worrying you about the transfusion." · "Your doctor ordered this because you could become very ill without it." · "I will tell the doctor you are refusing and he will come speak with you." · "Most people find this is much easier than they expect." List 2: document the refusal and notify the provider so the client's decision and the risks can be discussed · cancel the client's remaining prescriptions for the day · administer the transfusion once the client is asleep · ask the family to persuade the client
Answer: [1] ______ [2] ______
10. A registered nurse from a medical-surgical unit is floated to the pediatric intensive care unit and assigned two ventilated infants. The nurse has no pediatric critical care experience. Which action is best?
- Refuse the assignment and return to the medical-surgical unit
- Tell the charge nurse which specific tasks are outside their competence and ask to be assigned clients they can safely care for
- Accept the assignment and ask another nurse to check on them periodically
- Accept the assignment and file an incident report at the end of the shift
Answer: ______
Margin note: "all four are things a nurse does. Only one is next."
> Confidence: ☐1 ☐2 ☐3 ☐4 ☐5 ☐6 ☐7 ☐8 ☐9 ☐10 > → P76 for the scorecard.
Scope of practice for delegation and assignment is set by the Nurse Practice Act of your state and varies. On the exam, answer to the national standard.
Takeaway. Management items are ranking problems wearing the costume of knowledge problems.