Solutions Newest
Section 1: Safe and Effective Care Environment – Management of Care (Questions
1–30)
1. A charge nurse is making patient assignments. Which patient should be
assigned to the most experienced RN?
A. Patient with pneumonia requiring IV antibiotics.
B. Patient with new tracheostomy 2 hours post-op.
C. Patient with diabetes needing insulin sliding scale.
D. Patient with urinary tract infection and fever.
Answer: B
Rationale: New tracheostomy poses airway risk; needs experienced RN for
assessment and emergency management.
2. A nurse is providing handoff using SBAR. Which represents the “S” (Situation)?
A. “Patient has a history of hypertension and diabetes.”
B. “I recommend increasing the oxygen to 3 L.”
C. “Mr. Jones, room 204, is having increased shortness of breath.”
,D. “The family is at the bedside.”
Answer: C
Rationale: Situation = what is happening now (concise problem statement).
A: Background; B: Recommendation; D: Not part of formal SBAR.
3. A nurse on a busy med-surg unit is caring for 6 patients. Which task can be
delegated to a UAP?
A. Assess a patient’s pain level.
B. Reapply a patient’s oxygen nasal cannula that has become dislodged.
C. Obtain a blood glucose reading using a glucometer.
D. Teach a patient how to use an incentive spirometer.
Answer: C
Rationale: UAPs can perform capillary blood glucose checks after training.
A: Assessment is RN.
,B: Reapplying oxygen requires assessment of need/placement.
D: Teaching is RN.
4. A nurse witnesses another nurse taking a photo of a patient’s wound on a
personal phone. What is the priority action?
A. Ignore it because no harm was intended.
B. Report the behavior to the nurse manager.
C. Ask the nurse to delete the photo.
D. Document the incident in a personal file.
Answer: B
Rationale: Taking photos on personal devices violates HIPAA; reporting to
management is required to protect patient privacy.
5. A patient is being discharged after a stroke with new dysphagia. Which
interdisciplinary team member should the nurse consult first?
A. Physical therapist.
B. Occupational therapist.
C. Speech-language pathologist (SLP).
, D. Social worker.
Answer: C
Rationale: SLP assesses swallowing and recommends diet consistency/strategies
to prevent aspiration.
6. A nurse is planning care for a patient with a DNR order. The patient codes.
What should the nurse do?
A. Begin CPR while calling a code.
B. Provide comfort measures and do not resuscitate.
C. Ask the family if they want CPR.
D. Administer emergency medications only.
Answer: B
Rationale: DNR means no CPR or advanced cardiac life support; comfort care
continues.
7. A nurse is preparing to witness a surgical consent. The patient says, “I don’t
understand what they’re removing.” What should the nurse do?
A. Explain the procedure to the patient.