PNR 207/PNR207 Exam 2 V3 | Transition to PN
Practice - Capstone Q&A with Rationale | Fortis
College
1. A nurse is preparing to delegate tasks to an Unlicensed Assistive Personnel (UAP). Which
task is most appropriate for the nurse to delegate?
A. Assessing a client’s pain level after medication administration
B. Teaching a client how to use an incentive spirometer
C. Measuring and recording the intake and output of a stable client
D. Evaluating the effectiveness of a new diet plan for a diabetic client
Correct Answer: C
Explanation: The UAP scope of practice includes tasks that are routine and do not require
clinical judgment or complex decision-making. Measuring and recording intake and output
is a standard data collection task that can be safely delegated to assistive personnel.
Assessment, teaching, and evaluation are responsibilities that remain strictly with the
licensed nurse.
2. A nurse manager is discussing the ‘Five Rights of Delegation’ during a staff meeting. Which
of the following is one of the five rights?
A. Right circumstance
B. Right supervisor
,C. Right cost of care
D. Right documentation time
Correct Answer: A
Explanation: The Five Rights of Delegation are Right Task, Right Circumstance, Right
Person, Right Direction/Communication, and Right Supervision/Evaluation. ‘Right
circumstance’ ensures that the client’s condition is stable and the setting is appropriate for
delegation. Other options like cost or documentation time are not part of the formal five
rights framework.
3. A nurse is assigned to four clients. Which client should the nurse assess first after receiving
the change-of-shift report?
A. A client who is postoperative following a thyroidectomy and reports tingling in the toes
B. A client with chronic obstructive pulmonary disease (COPD) and an oxygen saturation of
91%
C. A client with diabetes who is scheduled for discharge in 2 hours
D. A client who is 2 days postoperative and reporting a pain level of 4 on a scale of 0 to 10
Correct Answer: A
Explanation: Tingling in the extremities (paresthesia) following a thyroidectomy can
indicate hypocalcemia, which is a medical emergency due to potential laryngospasm. The
nurse must prioritize this client using the ABC and safety framework to prevent further
, complications. The other clients are stable or experiencing expected symptoms related to
their conditions.
4. Which ethical principle is a nurse demonstrating when they respect a client’s decision to
refuse a recommended chemotherapy treatment?
A. Autonomy
B. Justice
C. Fidelity
D. Non-maleficence
Correct Answer: A
Explanation: Autonomy refers to the right of the client to make their own decisions
regarding their healthcare, even if those decisions conflict with the healthcare team’s
recommendations. The nurse supports autonomy by ensuring the client is informed and
respecting their final choice. Principles like justice relate to fairness, while fidelity relates to
keeping promises.
5. A nurse witnesses a provider obtaining informed consent for a surgical procedure. What is
the nurse’s primary responsibility in this process?
A. Explaining the risks and benefits of the procedure to the client
B. Describing alternative treatments to the client
C. Answering specific questions about the surgical technique
Practice - Capstone Q&A with Rationale | Fortis
College
1. A nurse is preparing to delegate tasks to an Unlicensed Assistive Personnel (UAP). Which
task is most appropriate for the nurse to delegate?
A. Assessing a client’s pain level after medication administration
B. Teaching a client how to use an incentive spirometer
C. Measuring and recording the intake and output of a stable client
D. Evaluating the effectiveness of a new diet plan for a diabetic client
Correct Answer: C
Explanation: The UAP scope of practice includes tasks that are routine and do not require
clinical judgment or complex decision-making. Measuring and recording intake and output
is a standard data collection task that can be safely delegated to assistive personnel.
Assessment, teaching, and evaluation are responsibilities that remain strictly with the
licensed nurse.
2. A nurse manager is discussing the ‘Five Rights of Delegation’ during a staff meeting. Which
of the following is one of the five rights?
A. Right circumstance
B. Right supervisor
,C. Right cost of care
D. Right documentation time
Correct Answer: A
Explanation: The Five Rights of Delegation are Right Task, Right Circumstance, Right
Person, Right Direction/Communication, and Right Supervision/Evaluation. ‘Right
circumstance’ ensures that the client’s condition is stable and the setting is appropriate for
delegation. Other options like cost or documentation time are not part of the formal five
rights framework.
3. A nurse is assigned to four clients. Which client should the nurse assess first after receiving
the change-of-shift report?
A. A client who is postoperative following a thyroidectomy and reports tingling in the toes
B. A client with chronic obstructive pulmonary disease (COPD) and an oxygen saturation of
91%
C. A client with diabetes who is scheduled for discharge in 2 hours
D. A client who is 2 days postoperative and reporting a pain level of 4 on a scale of 0 to 10
Correct Answer: A
Explanation: Tingling in the extremities (paresthesia) following a thyroidectomy can
indicate hypocalcemia, which is a medical emergency due to potential laryngospasm. The
nurse must prioritize this client using the ABC and safety framework to prevent further
, complications. The other clients are stable or experiencing expected symptoms related to
their conditions.
4. Which ethical principle is a nurse demonstrating when they respect a client’s decision to
refuse a recommended chemotherapy treatment?
A. Autonomy
B. Justice
C. Fidelity
D. Non-maleficence
Correct Answer: A
Explanation: Autonomy refers to the right of the client to make their own decisions
regarding their healthcare, even if those decisions conflict with the healthcare team’s
recommendations. The nurse supports autonomy by ensuring the client is informed and
respecting their final choice. Principles like justice relate to fairness, while fidelity relates to
keeping promises.
5. A nurse witnesses a provider obtaining informed consent for a surgical procedure. What is
the nurse’s primary responsibility in this process?
A. Explaining the risks and benefits of the procedure to the client
B. Describing alternative treatments to the client
C. Answering specific questions about the surgical technique
