1
NSG 4800 comps exam 3 All 75 Questions And
Correct Detailed Answers |Already Graded
A+||Already Graded A+.
SECTION 1: Prioritization, Delegation, and Clinical Judgment
This section tests your ability to identify the most urgent patient needs, delegate tasks appropriately,
and use clinical judgment frameworks such as the ABCs (Airway, Breathing, Circulation) and Maslow's
Hierarchy of Needs.
1. A nurse is caring for four clients on a medical-surgical unit. Which client should the nurse assess
first?
A. A client with pneumonia who has an oxygen saturation of 94% on room air.
B. A client with a new diagnosis of diabetes mellitus who has a blood glucose of 220 mg/dL.
C. A client with a chest tube who reports a sudden onset of severe pain at the insertion site.
D. A client who is postoperative day 2 and has not had a bowel movement.
Answer: C. A client with a chest tube who reports a sudden onset of severe pain at the insertion site.
Rationale: Using the ABC (Airway, Breathing, Circulation) and urgent vs. non-urgent frameworks, the
client with a chest tube and new, severe pain is the priority. This could indicate a complication such as
tube dislodgement, a developing pneumothorax, or infection, all of which can rapidly compromise
breathing. The other findings require assessment and intervention but are less acute.
2. A charge nurse is making assignments for the upcoming shift. Which client should be assigned to
the most experienced RN?
A. A client who is 24 hours postoperative following an appendectomy.
B. A client who has a new diagnosis of hypertension.
C. A client who is receiving chemotherapy for the first time.
D. A client who has stable angina and is awaiting discharge.
Answer: C. A client who is receiving chemotherapy for the first time.
Rationale: A client receiving chemotherapy for the first time requires extensive teaching, close
monitoring for hypersensitivity reactions, and potential management of life-threatening adverse effects.
This complex care requires a nurse with experience and strong clinical judgment. The other clients have
more predictable, lower-acuity needs.
,2
3. A nurse is delegating tasks to an assistive personnel (AP). Which of the following tasks is
appropriate for the nurse to delegate to the AP?
A. Assessing a newly admitted client's pain level.
B. Teaching a client how to use an incentive spirometer.
C. Ambulating a stable client who had a stroke 3 days ago.
D. Evaluating a client's response to a diuretic medication.
Answer: C. Ambulating a stable client who had a stroke 3 days ago.
Rationale: Delegation requires the nurse to assign tasks that are routine, have a predictable outcome,
and do not require nursing judgment. Ambulating a stable client is a standard task that can be delegated
to an AP. Assessment (A), teaching (B), and evaluation (D) are core components of the nursing process
that require the clinical judgment and knowledge of a licensed nurse and cannot be delegated.
4. A nurse is supervising a newly licensed nurse who is preparing to administer an IM injection. Which
action by the newly licensed nurse requires intervention?
A. Selecting the ventrogluteal site for an adult client.
B. Aspirating before injecting the medication.
C. Using a 1-inch needle for a client with a BMI of 30.
D. Injecting the medication over 10 seconds.
Answer: C. Using a 1-inch needle for a client with a BMI of 30.
Rationale: A client with a BMI of 30 (obese) requires a longer needle (1.5-2 inches) to reach the muscle.
Using a 1-inch needle may result in subcutaneous injection. The ventrogluteal site is preferred for adults.
Aspiration is no longer recommended for most IM injections (except dorsogluteal), but some facilities
still teach it. The 10-second injection rate is appropriate.
5. A nurse is receiving a handoff report on four clients. Which client should the nurse assess first?
A. A client with pneumonia who has an oxygen saturation of 93% on 2 L/min.
B. A client with a new diagnosis of diabetes who has a blood glucose of 250 mg/dL.
C. A client who has a chest tube and reports pain at the insertion site.
D. A client who is postoperative day 1 and has not voided in 6 hours.
Answer: A. A client with pneumonia who has an oxygen saturation of 93% on 2 L/min.
Rationale: An oxygen saturation of 93% on supplemental oxygen indicates respiratory compromise and
requires immediate assessment. Using the ABC prioritization framework, this client is the priority. The
client may need increased oxygen or other interventions. The other findings require assessment but are
less urgent.
,3
6. A nurse is planning care for a group of clients. Which of the following tasks should the nurse
delegate to a licensed practical nurse (LPN)?
A. Developing a plan of care for a newly admitted client.
B. Administering oral medications to a stable client.
C. Performing the initial admission assessment.
D. Teaching a client about a new medication.
Answer: B. Administering oral medications to a stable client.
Rationale: LPNs can administer medications (oral, subcutaneous, intramuscular, and selected IV
piggybacks) to stable clients. They can also perform certain invasive tasks such as dressing changes,
suctioning, and urinary catheterization. However, they cannot perform initial assessments, develop
plans of care, or initiate teaching; these tasks require RN-level clinical judgment.
7. A nurse is caring for a client who is 2 hours postoperative following a total hip arthroplasty. The
client reports a sudden onset of shortness of breath and pleuritic chest pain. Vital signs: HR 118, RR
28, BP 138/86, SpO₂ 88% on room air. What is the priority nursing action?
A. Administer prescribed morphine 2 mg IV.
B. Place the client in Trendelenburg position.
C. Apply oxygen and notify the provider immediately.
D. Encourage the client to cough and deep breathe.
Answer: C. Apply oxygen and notify the provider immediately.
Rationale: The client's presentation (sudden dyspnea, pleuritic chest pain, tachycardia, tachypnea,
hypoxemia) is highly suggestive of pulmonary embolism, a life-threatening postoperative complication.
The priority is to apply oxygen to improve oxygenation and notify the provider immediately for further
diagnostic testing and treatment. Morphine may be given later for pain but does not address the
underlying emergency.
8. A nurse is delegating tasks to an AP. Which of the following tasks should the nurse delegate?
A. Assessing a client's breath sounds.
B. Teaching a client how to use an incentive spirometer.
C. Ambulating a stable client to the bathroom.
D. Evaluating a client's pain level after medication administration.
Answer: C. Ambulating a stable client to the bathroom.
Rationale: Tasks that are routine, have a predictable outcome, and do not require nursing judgment can
be delegated to an AP. Ambulating a stable client is an example. Assessment (A), teaching (B), and
evaluation (D) are components of the nursing process that require the critical thinking and clinical
judgment of a licensed nurse and cannot be delegated.
, 4
9. A nurse is caring for a client who is angry and yelling about the long wait time. Which of the
following is the most therapeutic response by the nurse?
A. "If you would calm down, I can help you faster."
B. "Yelling at me is not going to solve anything."
C. "I can see that you are very upset. Tell me more about what is frustrating you."
D. "It's not my fault. I just started my shift."
Answer: C. "I can see that you are very upset. Tell me more about what is frustrating you."
Rationale: This response uses the therapeutic communication technique of acknowledging the client's
feelings and offering a general lead. It validates the client's emotion and encourages them to express
their concerns. The other options are non-therapeutic, as they are defensive or put the client down.
10. A nurse is preparing to administer medications to a client. The client states, "I've never seen that
yellow pill before." What is the nurse's priority action?
A. Reassure the client that the medication is correct.
B. Verify the medication order against the Medication Administration Record (MAR).
C. Explain the purpose of the medication to the client.
D. Document the client's statement and administer the medication.
Answer: B. Verify the medication order against the Medication Administration Record (MAR).
Rationale: A client's statement that a medication is unfamiliar is a critical safety cue. The nurse's
immediate priority is to stop and verify the "Six Rights" of medication administration, specifically the
right medication. This involves checking the original order against the MAR and the medication label.
Never administer a medication if the client questions it without first verifying its accuracy.
11. A nurse is caring for a client who is receiving a blood transfusion. Fifteen minutes after initiation,
the client reports chills and low back pain. Vital signs: temperature 101.2°F (38.4°C), HR 118, BP 88/54.
What is the priority nursing action?
A. Slow the infusion rate and reassess in 15 minutes.
B. Stop the transfusion and infuse normal saline.
C. Administer acetaminophen as prescribed.
D. Notify the blood bank.
Answer: B. Stop the transfusion and infuse normal saline.
Rationale: Chills, fever, hypotension, and low back pain are classic signs of an acute hemolytic
transfusion reaction. The priority is to immediately stop the transfusion and maintain IV access with
normal saline to support blood pressure and prevent acute kidney injury from hemoglobinuria.
Notification of the provider and blood bank occurs after stopping the infusion.
NSG 4800 comps exam 3 All 75 Questions And
Correct Detailed Answers |Already Graded
A+||Already Graded A+.
SECTION 1: Prioritization, Delegation, and Clinical Judgment
This section tests your ability to identify the most urgent patient needs, delegate tasks appropriately,
and use clinical judgment frameworks such as the ABCs (Airway, Breathing, Circulation) and Maslow's
Hierarchy of Needs.
1. A nurse is caring for four clients on a medical-surgical unit. Which client should the nurse assess
first?
A. A client with pneumonia who has an oxygen saturation of 94% on room air.
B. A client with a new diagnosis of diabetes mellitus who has a blood glucose of 220 mg/dL.
C. A client with a chest tube who reports a sudden onset of severe pain at the insertion site.
D. A client who is postoperative day 2 and has not had a bowel movement.
Answer: C. A client with a chest tube who reports a sudden onset of severe pain at the insertion site.
Rationale: Using the ABC (Airway, Breathing, Circulation) and urgent vs. non-urgent frameworks, the
client with a chest tube and new, severe pain is the priority. This could indicate a complication such as
tube dislodgement, a developing pneumothorax, or infection, all of which can rapidly compromise
breathing. The other findings require assessment and intervention but are less acute.
2. A charge nurse is making assignments for the upcoming shift. Which client should be assigned to
the most experienced RN?
A. A client who is 24 hours postoperative following an appendectomy.
B. A client who has a new diagnosis of hypertension.
C. A client who is receiving chemotherapy for the first time.
D. A client who has stable angina and is awaiting discharge.
Answer: C. A client who is receiving chemotherapy for the first time.
Rationale: A client receiving chemotherapy for the first time requires extensive teaching, close
monitoring for hypersensitivity reactions, and potential management of life-threatening adverse effects.
This complex care requires a nurse with experience and strong clinical judgment. The other clients have
more predictable, lower-acuity needs.
,2
3. A nurse is delegating tasks to an assistive personnel (AP). Which of the following tasks is
appropriate for the nurse to delegate to the AP?
A. Assessing a newly admitted client's pain level.
B. Teaching a client how to use an incentive spirometer.
C. Ambulating a stable client who had a stroke 3 days ago.
D. Evaluating a client's response to a diuretic medication.
Answer: C. Ambulating a stable client who had a stroke 3 days ago.
Rationale: Delegation requires the nurse to assign tasks that are routine, have a predictable outcome,
and do not require nursing judgment. Ambulating a stable client is a standard task that can be delegated
to an AP. Assessment (A), teaching (B), and evaluation (D) are core components of the nursing process
that require the clinical judgment and knowledge of a licensed nurse and cannot be delegated.
4. A nurse is supervising a newly licensed nurse who is preparing to administer an IM injection. Which
action by the newly licensed nurse requires intervention?
A. Selecting the ventrogluteal site for an adult client.
B. Aspirating before injecting the medication.
C. Using a 1-inch needle for a client with a BMI of 30.
D. Injecting the medication over 10 seconds.
Answer: C. Using a 1-inch needle for a client with a BMI of 30.
Rationale: A client with a BMI of 30 (obese) requires a longer needle (1.5-2 inches) to reach the muscle.
Using a 1-inch needle may result in subcutaneous injection. The ventrogluteal site is preferred for adults.
Aspiration is no longer recommended for most IM injections (except dorsogluteal), but some facilities
still teach it. The 10-second injection rate is appropriate.
5. A nurse is receiving a handoff report on four clients. Which client should the nurse assess first?
A. A client with pneumonia who has an oxygen saturation of 93% on 2 L/min.
B. A client with a new diagnosis of diabetes who has a blood glucose of 250 mg/dL.
C. A client who has a chest tube and reports pain at the insertion site.
D. A client who is postoperative day 1 and has not voided in 6 hours.
Answer: A. A client with pneumonia who has an oxygen saturation of 93% on 2 L/min.
Rationale: An oxygen saturation of 93% on supplemental oxygen indicates respiratory compromise and
requires immediate assessment. Using the ABC prioritization framework, this client is the priority. The
client may need increased oxygen or other interventions. The other findings require assessment but are
less urgent.
,3
6. A nurse is planning care for a group of clients. Which of the following tasks should the nurse
delegate to a licensed practical nurse (LPN)?
A. Developing a plan of care for a newly admitted client.
B. Administering oral medications to a stable client.
C. Performing the initial admission assessment.
D. Teaching a client about a new medication.
Answer: B. Administering oral medications to a stable client.
Rationale: LPNs can administer medications (oral, subcutaneous, intramuscular, and selected IV
piggybacks) to stable clients. They can also perform certain invasive tasks such as dressing changes,
suctioning, and urinary catheterization. However, they cannot perform initial assessments, develop
plans of care, or initiate teaching; these tasks require RN-level clinical judgment.
7. A nurse is caring for a client who is 2 hours postoperative following a total hip arthroplasty. The
client reports a sudden onset of shortness of breath and pleuritic chest pain. Vital signs: HR 118, RR
28, BP 138/86, SpO₂ 88% on room air. What is the priority nursing action?
A. Administer prescribed morphine 2 mg IV.
B. Place the client in Trendelenburg position.
C. Apply oxygen and notify the provider immediately.
D. Encourage the client to cough and deep breathe.
Answer: C. Apply oxygen and notify the provider immediately.
Rationale: The client's presentation (sudden dyspnea, pleuritic chest pain, tachycardia, tachypnea,
hypoxemia) is highly suggestive of pulmonary embolism, a life-threatening postoperative complication.
The priority is to apply oxygen to improve oxygenation and notify the provider immediately for further
diagnostic testing and treatment. Morphine may be given later for pain but does not address the
underlying emergency.
8. A nurse is delegating tasks to an AP. Which of the following tasks should the nurse delegate?
A. Assessing a client's breath sounds.
B. Teaching a client how to use an incentive spirometer.
C. Ambulating a stable client to the bathroom.
D. Evaluating a client's pain level after medication administration.
Answer: C. Ambulating a stable client to the bathroom.
Rationale: Tasks that are routine, have a predictable outcome, and do not require nursing judgment can
be delegated to an AP. Ambulating a stable client is an example. Assessment (A), teaching (B), and
evaluation (D) are components of the nursing process that require the critical thinking and clinical
judgment of a licensed nurse and cannot be delegated.
, 4
9. A nurse is caring for a client who is angry and yelling about the long wait time. Which of the
following is the most therapeutic response by the nurse?
A. "If you would calm down, I can help you faster."
B. "Yelling at me is not going to solve anything."
C. "I can see that you are very upset. Tell me more about what is frustrating you."
D. "It's not my fault. I just started my shift."
Answer: C. "I can see that you are very upset. Tell me more about what is frustrating you."
Rationale: This response uses the therapeutic communication technique of acknowledging the client's
feelings and offering a general lead. It validates the client's emotion and encourages them to express
their concerns. The other options are non-therapeutic, as they are defensive or put the client down.
10. A nurse is preparing to administer medications to a client. The client states, "I've never seen that
yellow pill before." What is the nurse's priority action?
A. Reassure the client that the medication is correct.
B. Verify the medication order against the Medication Administration Record (MAR).
C. Explain the purpose of the medication to the client.
D. Document the client's statement and administer the medication.
Answer: B. Verify the medication order against the Medication Administration Record (MAR).
Rationale: A client's statement that a medication is unfamiliar is a critical safety cue. The nurse's
immediate priority is to stop and verify the "Six Rights" of medication administration, specifically the
right medication. This involves checking the original order against the MAR and the medication label.
Never administer a medication if the client questions it without first verifying its accuracy.
11. A nurse is caring for a client who is receiving a blood transfusion. Fifteen minutes after initiation,
the client reports chills and low back pain. Vital signs: temperature 101.2°F (38.4°C), HR 118, BP 88/54.
What is the priority nursing action?
A. Slow the infusion rate and reassess in 15 minutes.
B. Stop the transfusion and infuse normal saline.
C. Administer acetaminophen as prescribed.
D. Notify the blood bank.
Answer: B. Stop the transfusion and infuse normal saline.
Rationale: Chills, fever, hypotension, and low back pain are classic signs of an acute hemolytic
transfusion reaction. The priority is to immediately stop the transfusion and maintain IV access with
normal saline to support blood pressure and prevent acute kidney injury from hemoglobinuria.
Notification of the provider and blood bank occurs after stopping the infusion.
