QUESTION 1 (Prioritization)
A nurse in a long-term care facility is receiving a change-of-shift report for four clients.
Which client should the nurse assess first?
A) A client who has COPD and an oxygen saturation of 90%
B) A client who has diabetes mellitus and reports feeling shaky and lightheaded
C) A client who has heart failure and an oral temperature of 37.5°C (99.5°F)
D) A client who has a hip fracture and reports a pain level of 7 on a scale of 0 to 10
ANSWER: B
RATIONALE: Using the Survival Priority Framework, the client reporting shakiness and
lightheadedness is showing classic signs of hypoglycemia, which is an acute,
life-threatening condition requiring immediate glucose monitoring and intervention .
Option A is expected for COPD, C is a low-grade fever, and D requires pain management
but is not life-threatening.
QUESTION 2 (Delegation)
A nurse is preparing to delegate tasks to an unlicensed assistive personnel (UAP).
Which task is appropriate to delegate?
A) Assess a patient's post-operative pain level
B) Ambulate a patient with a walker who has been stable for 24 hours
C) Administer a tube feeding through a nasogastric tube
D) Evaluate the effectiveness of a patient's incentive spirometry use
ANSWER: B
RATIONALE: UAPs are trained to ambulate stable patients . Assessment (A, D) and
administration of tube feedings (C) require the clinical judgment of an RN and are not
delegable. Remember: EAT (Evaluate, Assess, Teach) is what you do NOT delegate to a
UAP .
QUESTION 3 (Safety & Infection Control)
A nurse is caring for a client with active pulmonary tuberculosis. Which type of
precautions is required?
A) Contact precautions
B) Droplet precautions
C) Airborne precautions
D) Standard precautions alone
, ANSWER: C
RATIONALE: TB is transmitted via small droplet nuclei that remain suspended in the air,
requiring Airborne precautions . This includes placing the patient in a negative pressure
room and wearing an N95 respirator .
QUESTION 4 (Restraints)
A nurse is applying wrist restraints to a patient who is pulling at IV lines. Which action is
required?
A) Obtain a written order from the provider before applying restraints
B) Tie the restraints to the bed rail for easy access
C) Release the restraints every hour for range of motion
D) Document the patient's behavior every 2 hours
ANSWER: C
RATIONALE: Restraints must be released at least every 2 hours for range of motion, skin
assessment, toileting, and nutrition . An order should be obtained as soon as possible,
preferably before application in an emergency.
QUESTION 5 (Disaster Triage)
A nurse is participating in a disaster drill. Triage tags are applied using the START
system. A patient who is breathing spontaneously after repositioning the airway but has
a respiratory rate of 35/min and a palpable radial pulse should receive which color tag?
A) Green (minor)
B) Yellow (delayed)
C) Red (immediate)
D) Black (deceased)
ANSWER: C
RATIONALE: In START triage, a patient who is breathing but has a respiratory rate
>30/min is tagged Red (immediate) . This indicates a life-threatening but potentially
survivable injury.
SECTION 3: NGN-STYLE & CLINICAL JUDGMENT QUESTIONS
A nurse in a long-term care facility is receiving a change-of-shift report for four clients.
Which client should the nurse assess first?
A) A client who has COPD and an oxygen saturation of 90%
B) A client who has diabetes mellitus and reports feeling shaky and lightheaded
C) A client who has heart failure and an oral temperature of 37.5°C (99.5°F)
D) A client who has a hip fracture and reports a pain level of 7 on a scale of 0 to 10
ANSWER: B
RATIONALE: Using the Survival Priority Framework, the client reporting shakiness and
lightheadedness is showing classic signs of hypoglycemia, which is an acute,
life-threatening condition requiring immediate glucose monitoring and intervention .
Option A is expected for COPD, C is a low-grade fever, and D requires pain management
but is not life-threatening.
QUESTION 2 (Delegation)
A nurse is preparing to delegate tasks to an unlicensed assistive personnel (UAP).
Which task is appropriate to delegate?
A) Assess a patient's post-operative pain level
B) Ambulate a patient with a walker who has been stable for 24 hours
C) Administer a tube feeding through a nasogastric tube
D) Evaluate the effectiveness of a patient's incentive spirometry use
ANSWER: B
RATIONALE: UAPs are trained to ambulate stable patients . Assessment (A, D) and
administration of tube feedings (C) require the clinical judgment of an RN and are not
delegable. Remember: EAT (Evaluate, Assess, Teach) is what you do NOT delegate to a
UAP .
QUESTION 3 (Safety & Infection Control)
A nurse is caring for a client with active pulmonary tuberculosis. Which type of
precautions is required?
A) Contact precautions
B) Droplet precautions
C) Airborne precautions
D) Standard precautions alone
, ANSWER: C
RATIONALE: TB is transmitted via small droplet nuclei that remain suspended in the air,
requiring Airborne precautions . This includes placing the patient in a negative pressure
room and wearing an N95 respirator .
QUESTION 4 (Restraints)
A nurse is applying wrist restraints to a patient who is pulling at IV lines. Which action is
required?
A) Obtain a written order from the provider before applying restraints
B) Tie the restraints to the bed rail for easy access
C) Release the restraints every hour for range of motion
D) Document the patient's behavior every 2 hours
ANSWER: C
RATIONALE: Restraints must be released at least every 2 hours for range of motion, skin
assessment, toileting, and nutrition . An order should be obtained as soon as possible,
preferably before application in an emergency.
QUESTION 5 (Disaster Triage)
A nurse is participating in a disaster drill. Triage tags are applied using the START
system. A patient who is breathing spontaneously after repositioning the airway but has
a respiratory rate of 35/min and a palpable radial pulse should receive which color tag?
A) Green (minor)
B) Yellow (delayed)
C) Red (immediate)
D) Black (deceased)
ANSWER: C
RATIONALE: In START triage, a patient who is breathing but has a respiratory rate
>30/min is tagged Red (immediate) . This indicates a life-threatening but potentially
survivable injury.
SECTION 3: NGN-STYLE & CLINICAL JUDGMENT QUESTIONS
