NCSBN
1.** A nurse is preparing to delegate tasks to unlicensed assistive personnel
(UAP) on a medical-surgical unit. Which task is appropriate to delegate to the
UAP?
A) Performing an initial admission assessment
B) Administering oral medications to stable patients
C) Assisting a patient with ambulation using a gait belt
D) Evaluating the effectiveness of patient education
**Correct Answer:** C) Assisting a patient with ambulation using a gait belt
**Rationale:** Delegation requires assigning tasks that are within the scope
of practice of the delegate. Assisting with ambulation using a gait belt is a
routine task within the UAP's scope. Assessment, medication administration,
and evaluation require licensed nursing judgment and cannot be delegated
to UAP.
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**2.** A charge nurse is assigning patient care for the shift. Which patient
should be assigned to the most experienced RN?
A) A patient requiring routine postoperative vital signs
B) A patient with a new tracheostomy and unstable respiratory status
C) A patient needing assistance with activities of daily living
D) A patient being discharged with home care instructions
,**Correct Answer:** B) A patient with a new tracheostomy and unstable
respiratory status
**Rationale:** The most complex and unstable patient requires the most
experienced nurse. A patient with a new airway and instability needs
advanced assessment skills, clinical judgment, and the ability to respond
rapidly to changes in condition.
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**3.** A nurse is providing a handoff report using the SBAR communication
tool. Which statement is an example of the "Assessment" component?
A) "The patient is a 65-year-old male admitted with pneumonia."
B) "The patient's oxygen saturation is 88% on room air, and crackles are
audible in the lung bases."
C) "I recommend that the provider be notified and the patient be assessed
for possible intubation."
D) "The patient was admitted 2 days ago and has been on IV antibiotics."
**Correct Answer:** B) "The patient's oxygen saturation is 88% on room air,
and crackles are audible in the lung bases."
**Rationale:** In SBAR, the Assessment component describes the nurse's
clinical judgment and findings. Option B provides objective assessment data
and clinical findings. Situation describes the current issue; Background
provides relevant history; Recommendation states what is needed.
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, **4.** A nurse is caring for a patient who is refusing a prescribed blood
transfusion. The patient is competent and has been informed of the risks and
benefits. What is the nurse's appropriate action?
A) Administer the transfusion despite the refusal to prevent harm
B) Honor the patient's refusal and document it in the medical record
C) Ask the family to convince the patient to accept the transfusion
D) Notify security to restrain the patient
**Correct Answer:** B) Honor the patient's refusal and document it in the
medical record
**Rationale:** Respect for patient autonomy requires honoring a competent
patient's refusal of treatment. The nurse should ensure informed refusal,
document thoroughly, notify the provider, and continue to monitor the
patient.
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**5.** A nurse is developing a care plan for a patient with impaired mobility.
Which goal statement follows SMART criteria?
A) "Patient will walk more."
B) "Patient will ambulate 50 feet with a walker by discharge."
C) "Patient will improve mobility."
D) "Nurse will assist patient with walking daily."
**Correct Answer:** B) "Patient will ambulate 50 feet with a walker by
discharge."