PNR 207/PNR207 Exam 4 V3 | Transition to PN
Practice - Capstone Q&A with Rationale | Fortis
College
1. A nurse is caring for a group of clients. Which client should the nurse assess first using the
prioritization framework?
A. A client who is 2 days postoperative and reporting pain as 6 on a scale of 0 to 10.
B. A client who has a prescription for a discharge teaching session.
C. A client who is experiencing new-onset shortness of breath and restlessness.
D. A client whose abdominal dressing has a small amount of serosanguinous drainage.
Correct Answer: C
Explanation: According to the ABC (Airway, Breathing, Circulation) framework, the client
with new-onset shortness of breath represents a potential respiratory emergency. This
physiological need takes precedence over stable postoperative pain or discharge
instructions. Immediate assessment is required to prevent further clinical deterioration.
2. A nurse is delegating tasks to an assistive personnel (AP). Which task is appropriate for the
nurse to delegate?
A. Measuring and recording intake and output for a stable client.
B. Performing a sterile dressing change on a central venous catheter.
C. Teaching a client how to use a glucose monitor at home.
,D. Evaluating a client’s response to an antihypertensive medication.
Correct Answer: A
Explanation: Delegation to an AP must involve tasks that are repetitive, non-invasive, and
do not require clinical judgment. Measuring intake and output falls under the standard
scope of an AP’s duties for stable clients. Tasks involving sterile technique, teaching, or
clinical evaluation must be performed by a licensed nurse.
3. A nurse is discussing advance directives with a client. Which statement by the nurse is
correct regarding a Durable Power of Attorney for Healthcare (DPOA)?
A. It allows the client’s physician to make decisions for the client if they are incapacitated.
B. It is only valid if the client has a terminal illness diagnosis.
C. It serves as a legal document that only outlines end-of-life wishes regarding ventilators.
D. It designates a specific person to make medical decisions if the client is unable to do so.
Correct Answer: D
Explanation: A Durable Power of Attorney for Healthcare is a legal document that
identifies a healthcare proxy to speak for the client when they lack decision-making
capacity. Unlike a living will, which outlines specific treatment preferences, the DPOA
focuses on the designation of a surrogate. This ensures the client’s values are represented
even when they cannot communicate.
,4. Which leadership style is characterized by the leader making decisions independently
without input from the staff?
A. Democratic
B. Laissez-faire
C. Transformational
D. Autocratic
Correct Answer: D
Explanation: The autocratic leadership style involves centralized decision-making where
the leader maintains full control. While this style can be effective in emergency situations
requiring rapid action, it often decreases staff morale in routine settings. It differs from the
democratic style, which encourages collaboration and group input.
5. A nurse is witness to an informed consent for a surgical procedure. What is the nurse’s
primary responsibility in this process?
A. Explaining the risks and benefits of the surgery to the client.
B. Describing alternative treatments to the surgical procedure.
C. Ensuring the client understands the specific steps of the operation.
D. Verifying that the client appears competent and the signature is authentic.
Correct Answer: D
, Explanation: The nurse acts as a witness to the signature, confirming that the client is
signing voluntarily and is competent to do so. It is the surgeon’s legal responsibility to
explain the procedure, risks, benefits, and alternatives. If the nurse identifies that the client
has further questions, the nurse must notify the surgeon to return and provide more
information.
6. A nurse discovers a medication error and notifies the provider. Which action should the
nurse take next?
A. Complete an incident report and submit it according to facility policy.
B. Document the error in the client’s medical record including the incident report number.
C. Inform the client’s family about the error immediately.
D. Wait until the end of the shift to notify the nurse manager.
Correct Answer: A
Explanation: Completing an incident report is a critical step in quality improvement and
risk management within the facility. The report should be an objective account of the event
and should not be mentioned in the client’s permanent medical record to protect its status
as a privileged document. The nurse must follow the chain of command to ensure client
safety is maintained.
7. During a mass casualty incident, which color tag is assigned to a client who has a major,
life-threatening injury but has a chance of survival with immediate intervention?
A. Green
Practice - Capstone Q&A with Rationale | Fortis
College
1. A nurse is caring for a group of clients. Which client should the nurse assess first using the
prioritization framework?
A. A client who is 2 days postoperative and reporting pain as 6 on a scale of 0 to 10.
B. A client who has a prescription for a discharge teaching session.
C. A client who is experiencing new-onset shortness of breath and restlessness.
D. A client whose abdominal dressing has a small amount of serosanguinous drainage.
Correct Answer: C
Explanation: According to the ABC (Airway, Breathing, Circulation) framework, the client
with new-onset shortness of breath represents a potential respiratory emergency. This
physiological need takes precedence over stable postoperative pain or discharge
instructions. Immediate assessment is required to prevent further clinical deterioration.
2. A nurse is delegating tasks to an assistive personnel (AP). Which task is appropriate for the
nurse to delegate?
A. Measuring and recording intake and output for a stable client.
B. Performing a sterile dressing change on a central venous catheter.
C. Teaching a client how to use a glucose monitor at home.
,D. Evaluating a client’s response to an antihypertensive medication.
Correct Answer: A
Explanation: Delegation to an AP must involve tasks that are repetitive, non-invasive, and
do not require clinical judgment. Measuring intake and output falls under the standard
scope of an AP’s duties for stable clients. Tasks involving sterile technique, teaching, or
clinical evaluation must be performed by a licensed nurse.
3. A nurse is discussing advance directives with a client. Which statement by the nurse is
correct regarding a Durable Power of Attorney for Healthcare (DPOA)?
A. It allows the client’s physician to make decisions for the client if they are incapacitated.
B. It is only valid if the client has a terminal illness diagnosis.
C. It serves as a legal document that only outlines end-of-life wishes regarding ventilators.
D. It designates a specific person to make medical decisions if the client is unable to do so.
Correct Answer: D
Explanation: A Durable Power of Attorney for Healthcare is a legal document that
identifies a healthcare proxy to speak for the client when they lack decision-making
capacity. Unlike a living will, which outlines specific treatment preferences, the DPOA
focuses on the designation of a surrogate. This ensures the client’s values are represented
even when they cannot communicate.
,4. Which leadership style is characterized by the leader making decisions independently
without input from the staff?
A. Democratic
B. Laissez-faire
C. Transformational
D. Autocratic
Correct Answer: D
Explanation: The autocratic leadership style involves centralized decision-making where
the leader maintains full control. While this style can be effective in emergency situations
requiring rapid action, it often decreases staff morale in routine settings. It differs from the
democratic style, which encourages collaboration and group input.
5. A nurse is witness to an informed consent for a surgical procedure. What is the nurse’s
primary responsibility in this process?
A. Explaining the risks and benefits of the surgery to the client.
B. Describing alternative treatments to the surgical procedure.
C. Ensuring the client understands the specific steps of the operation.
D. Verifying that the client appears competent and the signature is authentic.
Correct Answer: D
, Explanation: The nurse acts as a witness to the signature, confirming that the client is
signing voluntarily and is competent to do so. It is the surgeon’s legal responsibility to
explain the procedure, risks, benefits, and alternatives. If the nurse identifies that the client
has further questions, the nurse must notify the surgeon to return and provide more
information.
6. A nurse discovers a medication error and notifies the provider. Which action should the
nurse take next?
A. Complete an incident report and submit it according to facility policy.
B. Document the error in the client’s medical record including the incident report number.
C. Inform the client’s family about the error immediately.
D. Wait until the end of the shift to notify the nurse manager.
Correct Answer: A
Explanation: Completing an incident report is a critical step in quality improvement and
risk management within the facility. The report should be an objective account of the event
and should not be mentioned in the client’s permanent medical record to protect its status
as a privileged document. The nurse must follow the chain of command to ensure client
safety is maintained.
7. During a mass casualty incident, which color tag is assigned to a client who has a major,
life-threatening injury but has a chance of survival with immediate intervention?
A. Green
