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Question 1
A nurse is caring for a client who is scheduled for surgery and
has signed the informed consent. The client states, "I have
changed my mind and do not want the surgery." Which of the
following actions should the nurse take?
A) Explain the risks of refusing the surgery
B) Inform the client that they have the right to refuse the
procedure
C) Notify the surgeon of the client's decision
D) Ask the client to discuss the decision with their family
1
,Correct Answer: B – Inform the client that they have the right
to refuse the procedure
Rationale: Clients have the legal and ethical right to refuse
treatment, even after signing informed consent. The nurse should
first acknowledge the client's right to refuse and then notify the
surgeon. This respects patient autonomy. The nurse should not
attempt to persuade the client or involve family without permission .
Question 2
A nurse is preparing to delegate tasks to an assistive personnel
(AP). Which of the following tasks should the nurse delegate to
the AP?
A) Perform a sterile dressing change
B) Administer a tube feeding
C) Measure a client's intake and output
D) Assess a client's pain level
2
,Correct Answer: C – Measure a client's intake and output
Rationale: APs can measure and record intake and output, assist
with activities of daily living, and obtain vital signs. Sterile
procedures, medication administration, tube feedings, and
assessments must be performed by licensed nursing personnel (RN
or LPN) .
Question 3
A nurse is providing discharge teaching to a client who speaks a
different language. An interpreter is not available. Which of the
following actions should the nurse take?
A) Use hand gestures to explain the instructions
B) Provide written instructions in the client's language
C) Ask a family member to translate
D) Use a translation app on a hospital device
3
, Correct Answer: B – Provide written instructions in the client's
language
Rationale: When an interpreter is unavailable, written materials in
the client's preferred language should be provided. Family members
should not be used as interpreters due to confidentiality and
accuracy concerns. Hand gestures and translation apps may not
accurately convey medical information .
Question 4
A nurse is caring for a client who has a new diagnosis of terminal
cancer. The client asks, "Why is this happening to me?" Which of
the following responses should the nurse make?
A) "I understand this must be very difficult for you."
B) "Everything happens for a reason."
C) "You should focus on staying positive."
D) "Let me call the chaplain for you."
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